Every finding on record at Columbia Post Acute

Based on observation, interview, and record review, facility staff failed to obtain physician ordered settings for Continuous Positive Airway Pressure (CPAP) machine (non-invasive mechanical ventilation device) for three residents (Residents #66, #22 and #30) of three sampled residents who required the use of a CPAP. The facility census was 62.1. Review of the facility's policy titled CPAP/Bi-level positive airway pressure (BiPAP), non-invasive mechanical ventilation machine, Support, dated March 2015, showed staff to document the following in the resident's medical record: -Time CPAP started and duration; -Mode and settings for CPAP; -How resident tolerates CPAP therapy; -Oxygen saturation during CPAP therapy. Review of the facility's policy titled Medication and Treatment Orders, dated July 2016, showed orders for medications must include: -Start and stop date, or specific duration of therapy; -Dosage and frequency of administration; -Route of administration. 2. Review of Resident #66's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/02/26, showed staff assessed the resident as: -Intact cognition; -Did not require CPAP; -admitted [DATE]; -Required continuous Oxygen; -Diagnoses of Chronic Obstructive Pulmonary Disease ((COPD) lung disease that makes it hard to breathe), Respiratory Failure, Acute and Chronic Respiratory Failure with Hypoxia (worsening of breathing), Acute and Chronic Respiratory Failure with Hypercapnia (a sudden worsening of ventilation) and Sleep Apnea (disorder where breathing repeatedly stops and starts during sleep). Review of the resident's care plan, dated 04/21/26, showed the care plan did not contain use of CPAP, or settings of the CPAP. Review of the resident's Physician Order Sheet (POS), dated May 2026, showed a physician order directed staff to use home settings for CPAP therapy for sleep apnea. Review showed the POS did not contain settings for CPAP use. The POS did not contain an order for the oxygen amount to be used for the CPAP machine. Observation on 05/04/26 at 10:38 A.M., showed the resident CPAP machine on the nightstand, by the bed. The resident oxygen concentrator in the bathroom, with green oxygen tubing running from the oxygen concentrator into the side of CPAP machine. Observation on 05/07/26 at 9:00 A.M., showed the resident CPAP machine on his/her nightstand, by the bed. The resident oxygen concentrator in the bathroom, with green oxygen tubing running from the oxygen concentrator into the side of CPAP machine. During an interview on 05/07/26 at 9:03 A.M., the resident said staff help him/her put the CPAP mask on at night. The resident said he/she does have oxygen that goes from his/her oxygen concentrator to his/her CPAP machine. 3. Review of Resident #22's admission MDS, dated [DATE], showed staff assessed the resident with mild cognitive impairment and required CPAP. Review of the resident's POS, dated May 2026, showed an order for CPAP at bedtime for sleep apnea. Review showed the orders did not contain CPAP settings. Review of the resident's care plan, dated 05/05/26, showed the care plan did not contain direction for CPAP use. Observation on 05/04/26 at 11:15 A.M., showed the resident's CPAP on the nightstand. The CPAP mask had white debris throughout. During an interview on 05/05/26 at 9:26 A.M., the resident said he/she uses his/her CPAP when he/she is not nauseous. Observation on 05/05/26 at 9:36 A.M., showed the resident's CPAP on his/her nightstand. The CPAP mask had white debris throughout and is not in a bag. Observation on 05/06/26 at 9:09 A.M., showed the resident's CPAP on his/her nightstand. During an interview on 05/07/26 at 9:15 A.M., Registered Nuse (RN) K said CPAP orders should include instructions on how to use, when to apply, and to check water level. He/She said the resident has been wearing his/her CPAP at night. He/She said he/she does not mess with the settings, and they are not required in orders. He/She said if there was a hard reset of the equipment or the settings were not the same, he/she would call his/her supervisor and/or the provider. 4. Review of Resident #30's admission MDS, dated [DATE], showed staff assessed the resident cognitive and did not require a CPAP. Review of the resident's care plan, dated 04/12/26, showed staff documented resident required a CPAP due to sleep apnea. Review of the resident's POS, dated May 2026, showed a physician order for CPAP at bedtime for Sleep Apnea. Did not contain settings for CPAP use. Observation on 05/04/26 at 11:29 A.M., showed the resident in his/her room, in bed. The resident had a CPAP machine on his/her nightstand. Observation on 05/06/26 at 8:46 A.M., showed the resident had a CPAP machine on his/her nightstand. During an interview on 05/07/26 at 10:55 A.M., the resident said he/she had the CPAP machine for a long time before coming to the facility. He/She said he/she does not know what the settings are, he/she just turns it on at night and puts the mask on. 5. During an interview on 05/07/26 at 11:18 A.M., the Director of Nursing (DON) said the evening staff assist the residents with applying their CPAPs at night. The DON said staff don't mess with the CPAP machine, the CPAP machines have the settings set before the machines arrive at the facility. The DON said he/she is aware the CPAP machines can be adjusted manually. The DON said he/she has not asked the nurses what they do to check the settings on the residents' CPAP machines. The DON said the residents' CPAP orders are in batch orders the Medical Director approves. The DON said he/she would expect the resident's CPAP settings to be in the Physicians Orders. The DON said if the resident has oxygen bleed in for CPAP, it should be identified on the POS. The DON said he/she is responsible for making sure the POS has those things, but he/she really doesn't look at all the orders. During an interview on 05/07/26 at 12:53 P.M., Stadium admission Nurse said he/she completes the admissions for the stadium side of the building, he/she gets the orders for new admissions and transcribes the orders to the POS. The Stadium admission Nurse said for residents with oxygen the flow rate must be in orders, if not he/she would have to call the discharging facility to get the order. The Stadium admission Nurse said he/she accepts the order for CPAP and the order should have pressure settings. The Stadium admission Nurse said facility staff recently discussed CPAPs and staff should be contacting the ordering agency and getting those setting. The Stadium admission Nurse said the residents' POS does not have the settings but should. The Stadium admission Nurse said technically the CPAPs need to come to the facility with pressure settings, as it could be considered invasive, if something is being placed into the body with pressure. The Stadium admission Nurse said the nurses should put the CPAPs on the residents at night and check the seal and pressure and should be checking the settings. The Stadium admission Nurse said he/she does not know what the facility's policy on CPAPs says. The Stadium admission Nurse said the residents' POS should have oxygen bleed in for the CPAP and it should be documented on the POS. The Stadium admission Nurse said he/she is responsible to ensure those settings are in orders upon admission.

Based on record review and interview, facility staff failed to ensure one resident (Resident #1) remained free of significant medication errors when facility staff administered an incorrect dosage of Morphine to the resident. The census was 67. 1. Review of the facility's Administering Medications policy, dated 04/2019, showed staff are directed as follows: -Medications are administered in accordance with prescribed orders; -Medication errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to inform process changes and or the need for additional staff training; -The individual who administers the medication should check the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before medication is administered. 2. Review of Resident #1's Entry Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Received as needed pain medications; -Fracture of shaft of left fibula. Review of the resident's Physician Order Sheet (POS), dated [DATE], showed the physician orders directed staff as follows: -Morphine (opioid pain medication) Sulfate Oral tablet 15 milligrams (mg) every four hours as needed for pain; -Naloxone Hydrochloride (used to reverse opioid effect) Nasal Liquid 4 mg/0.1 milliliters (ml) as needed for opioid reversal; -Generic equivalent/liquid equivalent items may be used unless otherwise specified/indicated. Review of resident's progress note, dated [DATE], showed Registered Nurse (RN) A documented resident requested morphine 15 mg Immediate Release (IRC) for intense pain. The only morphine in the Omnicell (automatic system for medication management) was morphine liquid 100 mg in 20 ml which equaled 20 mg per one milliliter. RN A documented he/she felt it was still immediate release and he/she could administer it as a liquid. He/She and Licensed Practical Nurse (LPN) D both read the bottle as 20 mg per five ml, and calculated to give 3.75 ml of the liquid morphine. RN A drew 3.7 ml of morphine up in a syringe and took to the resident and administered into his/her mouth. LPN D returned to inform RN A the correct dosage should have been 0.75 ml, so the resident received 75 mg of Morphine instead of the 15 mg as ordered. RN A called the Nurse Practitioner who ordered Narcan 4 mg/0.1 ml nasal spray to be given. Within three minutes the resident was yelling in much pain all over and having diarrhea and nausea. Oxygen down to 89% with respirations up to 24 breaths per minute with yelling. Nurse Practitioner communicated to send resident to emergency room for monitoring. Resident taken to emergency room. Review of the hospital emergency services note, dated [DATE], showed hospital staff documented resident presented to emergency department after he/she received morphine 75 mg instead of the prescribed 15 mg. Hospital staff documented the admission diagnosis as accidental morphine overdose. During an interview on [DATE] at 12:57 P.M., RN A said the resident had recently been admitted to the facility and he/she did not have resident's Morphine yet at the time resident was requesting Morphine for pain. RN A said he/she thought the liquid would be the same as the pill. RN A said he/she and LPN D both saw the concentrated part on the morphine vial as 20 mg/five ml instead of the one ml. He/She said directly after administering the medication into the resident's mouth, LPN D came and informed him/her about the incorrect dosage. RN A said he/she stayed with the resident to monitor and notified the Nurse Practitioner and received the order to administer Nasal Narcan. He/She said the resident had no side effects after the morphine or prior to receiving the Narcan dosage and then after the Narcan was administered the resident started having nausea and diarrhea. He/She said the Nurse Practitioner gave order to send resident to emergency room for monitoring. He/She said it was an honest mistake that shouldn't have happened. During an interview on [DATE] at 7:45 A.M., RN B said he/she was taking report from LPN D since he/she had just come on shift. He/She said RN A was in the background saying a newly admitted resident needed pain medication that they had not yet been received from the pharmacy. He/She said RN A obtained liquid morphine from the omnicell because that is all they had. LPN D said he/she was not sure if an order from the doctor was obtained, but thought it was since RN A had got the liquid morphine out of omnicell to administer. He/She said while still getting report they calculated the morphine dosage and RN A went down to give the morphine to the resident. LPN D said he/she then looked at the morphine vial and checked the residents order and realized the concentration was off for what was drawn up. He/She said he/she went down to the resident room and RN A had already administered the morphine. He/She said the Nurse Practitioner was contacted and received order to give Narcan which was obtained from the omnicell and given within five minutes. He/She said an order was obtained to send resident to the emergency room for monitoring. He/She knows the five rights of medication administration. He/She said, I was not paying as much attention as I should have when the morphine was being calculated because I was trying to receive report at the same time. During an interview on [DATE] at 2:20 P.M., the Nurse Practitioner said with the amount of morphine that was administered, the resident could have died because of suppressed respirations. He/She said that is the reason he/she prescribed the Narcan at that time. During an interview on [DATE] at 2:50 P.M., the Director of Nursing (DON) said there is a standing order in the chart the nurses can given the liquid equivalent of the prescribed medication. The DON said he/she felt the nurses took the correct steps once they realized it was the incorrect dosage and a medication error had occurred. The DON said he/she talked with the medical director afterwards and it was agreed the standing order was in the chart and it was a mistake on the dosage calculation by the nurse. The DON said he/she did an investigation after it occurred and has talked with RN A and counseled on medication errors. During an interview on [DATE] at 3:22 P.M., the administrator said he/she agrees what happened was a medication error because the wrong dosage was given. He/She said when a medication error occurs the staff should first ensure resident is safe, notify the physician, DON, administrator, and family. MO00249293

Based on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the residents' needs for seven residents (Resident's #5, #13, #14, #27, #29, #35, and #40) out of 25 sampled. The census was 66. 1. Review of the facility's policy Care Plans, Comprehensive Person Centered, dated March 2022, showed care plans are developed within seven days of completion of the required MDS (Minimum Data Set), a federally mandated assessment tool (Admission. Annual, or Significant Change of Status), and no more than 21 days after admission. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of residents is ongoing and care plans are revised as information about the resident and the residents' conditions change. 2. Review of Resident #5's Admission MDS, dated [DATE], showed staff assessed the resident as moderately Cognitively Impaired and required an indwelling urinary catheter (tube placed directly in the bladder to drain urine). Review of the Physician Order Sheet (POS), dated November 2024, showed staff documented the resident's foley catheter had been discontinued on 11/03/24. Review of the care plan, dated 10/13/24, showed staff were directed to use enhanced barrier precautions due to the presence of an indwelling urinary catheter. 3. Review of Resident #13's Admission MDS dated [DATE], showed staff assessed the resident as mild to moderately cognitively impaired, received anticoagulant (thins the blood) medication and required partial to moderate assist from staff for sitting on the side of the bed. Review of resident's medical record showed a signed consent, dated 10/1/24, for bed rail use to assist with mobility. Review of the POS, dated November 2024, showed an order for Eliquis (blood thinner) 5 milligrams (mg) daily and a bed enabler. Review of the resident's care plan, revised 11/11/24, showed it did not contain direction for staff in regard to the resident's use of an anticoagulant medication or the use of bed rails. Observation on 11/12/24 at 12:45 P.M., showed bed rails up on both sides of the resident's bed. During an interview on 11/12/24 at 12:45 P.M., the resident said the rails help him/her move around in bed. Observation on 11/13/24 at 02:36 P.M., showed bed rails up on both sides of the resident's bed. During an interview on 11/15/24 at 2:41 P.M., the Director of Nursing (DON) said blood thinners should be on the care plan due to the risk of bleeding. The DON said he/she did not know why blood thinners were not on the resident's care plan. During an interview on 11/15/24 at 3:33 P.M., the MDS Coordinator said blood thinners should be included on the care plan and he/she does not know why it is not on the resident's care plan. 4. Review of Resident #14's Admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and required partial/moderate assistance for bed mobility. Review of the resident's care plan, dated 10/03/24, showed it did not contain direction for staff in regard to bed rail or enabler use. Review of the POS, dated November 2024, showed an order for staff to assess the resident at admission for the use of a one-eighth type enabler on bed for positioning/transfer assistance, if indicated and/or with resident request. Observation on 11/12/24 at 1:38 P.M., showed the resident in bed with bed rails raised on both sides. Observation on 11/13/24 at 12:31 P.M., showed the resident in bed with bed rails raised on both sides. During an interview on 11/13/24 at 12:31 P.M., the resident said he/she utilized the bed rails to assist with mobility. 5. Review of Resident's #27's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderate cognitive impairment, diarrhea, and frequently incontinent of bowel. Review of the resident's care plan, dated 7/4/24, showedteh care plan did not contain documentation of frequent bowel incontinence. Review of the resident's POS, dated November 2024, showed an order for Diphenoxylate-Atropine (a medication used to treat diarrhea) 2.5-0.024 mg, one tablet four times a day. Review of the resident's Bowel Incontinence log, dated 10/17/24 through 11/15/24 showed staff documented the resident has 15 episodes of bowel incontinence. 6. Review of Resident #29's Admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and required substantial/maximal assistance for bed mobility. Review of the resident's POS, dated November 2024, showed an order for staff to assess the resident at admission for use of one-eighth type of enabler on bed for positioning/transfer assistance, if indicated and/or with resident request. Review of the care plan, revised 11/08/24, showed it did not contain direction for staff in regard to bed rail or enabler use. Observation on 11/12/24 at 1:44 P.M., showed the resident in the room with both bed rails in the raised position. Observation on 11/13/24 at 12:16 P.M., showed the resident in the room with both bed rails in the raised position. During an interview on 11/13/24 at 12:16 P.M., the resident said he/she utilized the bed rails to assist with mobility. 7. Review of Resident #35's Quarterly MDS dated [DATE] showed staff assessed the resident as mild cognitive impairment, diagnosis of hemiplegia or hemiparalysis (partial or total paralysis of one side of the body), and required partial to moderate assistance for sitting on the side of the bed. Review of the medical record showed a bed rail consent, signed 8/11/23. Review of the POS showed an order, dated 8/16/24, for one-eighth type of enabler on bed for positioning/transfer assistance if indicated and /or with resident request. Review of the care plan, dated 10/25/24, showed it did not contain direction for staff in regard to the resident's bed rail use. 8. Review of Resident #40's Admission MDS, dated [DATE], showed staff assessed the resident with moderate cognitive impairment and diagnosis of dementia. Review of the medical record, showed staff documented the resident had a diagnosis of dementia. Review of the care plan, dated 11/14/24, showed it did not contain direction for staff in regard to the resident's dementia. 9. During an interview on 11/15/24 at 2:05 P.M., Certified Nurse Aide (CNA) H said he/she knew where to find care plans but did not use them. CNA H said the basic care instructions for residents are on the white boards in the residents' rooms. During an interview on 11/15/24 at 2:11 P.M., Licensed Practical Nurse (LPN) J said care plans should include everything about a resident, however staff use the white boards in the residents' rooms in addition to report from therapy to be informed about the residents. During an interview on 11/15/24 at 2:15 P.M., LPN F said he/she has never been told about care plans and does not know how to access them. The LPN said nurses do not really work with care plans, and they are more for therapy. The LPN is is the responsibility of the case worker and social worker to update the care plans. During an interview on 11/15/24 at 2:36 P.M., CNA G said he/she knows how to care for residents by reviewing the hospital paperwork, and by using the white board at the nurses' station. During an interview on 11/15/24 at 2:41 P.M., the DON said chronic diarrhea should be on the care plan, as it poses a risk for skin breakdown. The DON said he/she did not know why it was not care planned for Resident #27. The DON said if a resident has bed enablers, it should be care planned. The DON said care plans are discussed at daily clinical meetings. The MDS Coordinator is responsible for developing the care plans. During an interview on 11/15/24 at 3:33 P.M., the MDS Coordinator said care plan changes can be made by anyone, but usually are not. Care plans are completed within 14 days of admission. The information is gathered from hospital records, staff, the chart, providers, family and the resident. The care plans should be updated when something changes. Chronic diarrhea and bed rails should be on the care plan and he/she does not know how diarrhea had been missed for Resident #13. The MDS Coordinator did not know why bed rails were missed for Residents #13, 14, #29 and #35. He/She said all staff know where to find care pans and should be using them to give the right care to residents. 42484 Surveyor: [NAME], [NAME] 50432

Based on observation, interview and record review, facility staff failed to conduct regular entrapment assessments for seven (Resident #5, #13, #14, #17, #29, #35 and #40) out of seven sampled residents who used bed rails . The facility census was 66. 1. Review of the facility's Bed Safety and Bed Rails policy, dated August 2022, showed the use of bed rails is prohibited unless the criteria for use of bed rails have been met. Regardless of mattress, type, width, length and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are with the safety dimensions established by the Food and Drug Administration (FDA). Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including entrapment risks. The maintenance department provides a copy of inspection to the administrator. 2. Review of the maintenance department records showed it did not contain a completed entrapment assessment since June 2024. 3. Review of Resident #5's Admission Minimum Data Set (MDS), a federally mandated assessment tool, showed staff assessed the resident as: -admitted on [DATE]; -Moderately Cognitively Impaired; -Required supervision or touch assistance for bed mobility. Review of the Physician Order Sheet (POS), dated November 2024, showed an order for staff to assess the resident at admission for the use of a one-eighth type of enabler on the bed for positioning/transfer assistance, if indicated and/or with resident request. Review of the medical record showed it did not contain an entrapment assessment. Observation on 11/12/24 at 1:21 P.M., showed the resident in bed with bed rails raised on both sides. Observation on 11/13/24 at 3:14 P.M., showed the resident in bed with bed rails raised on both sides. 4. Review of Resident #13's Admission MDS, dated [DATE], show staff assessed the resident as: -admitted on [DATE]; -Mild to moderate cognitive impairment; -Partial to moderate assistance for lying to sitting side of bed. Review of the POS, dated November 2024, showed an order for staff to assess the resident at admission for use of a one-eighth type of enabler on bed for positioning/transfer assistance, if indicated and/or with resident request. Review of the care plan, dated 10/4/24, showed it did not contain documentaion of bed rail use. Review of the resident's medical record did not contain an entrapment assessment. Observation on 11/12/24 at 12:45 P.M., showed the resident in bed with bed rails raised on both sides. Observation on 11/13/24 at 2:36 P.M., showed the resident in bed with bed rails raised on both sides. 5. Review of Resident #14's Admission MDS, dated [DATE], showed staff assessed the resident as: -admitted on [DATE]; -Cognitively intact; -Required partial/moderate assistance for bed mobility. Review of the resident's POS, dated November 2024, showed an order for staff to assess the resident at admission for use of one-eighth type of enabler on bed for positioning/transfer assistance, if indicated and/or with resident request. Review of resident's medical record did not contain an entrapment assessment. Observation on 11/12/24 at 1:38 P.M., showed the resident in bed with bed rails raised on both sides. Observation on 11/13/24 at 12:31 P.M., showed the resident in bed with bed rails raised on both sides. 6. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -admitted on [DATE]; -Severely Cognitively Impaired; -Required substantial/maximal assistance for bed mobility. Review of the resident's (POS), dated November 2024, showed an order for staff to assess the resident at admission for use of one-eighth type of enabler on bed for positioning/transfer assistance, if indicated and/or with resident request. Review of the resident's medical record did not contain an entrapment assessment. Observation on 11/13/24 at 8:21 A.M., showed the resident in bed with bed rails raised on both sides. Observation on 11/14/24 at 2:01 P.M., showed the resident in bed with bed rails raised on both sides. 7. Review of Resident #29's Admission MDS, dated [DATE], showed staff assessed the resident as: -admitted on [DATE]; -Cognitively intact; -Required substantial/maximal assistance for bed mobility. Review of the POS, dated November 2024, showed an order for staff to assess the resident at admission for use of one-eighth type of enabler on bed for positioning/transfer assistance, if indicated and/or with resident request. Review of the resident's medical record did not contain an entrapment assessment. Observation on 11/12/24 at 1:44 P.M., showed the resident's bed with bed rails raised. Observation on 11/13/24 at 12:16 P.M., showed the resident's bed with bed rails raised. 8. Review of Resident #35's Quarterly MDS dated [DATE], showed staff assessed the resident as: -Mild cognitive impairment; -Required partial/moderate assistance for bed mobility; -Diagnosis of hemiplegia (partial or total paralysis on one side of the body) or hemiparesis (weakness or inability to move one side of the body). Review of the care plan, dated 7/20/24, showed staff documented the resident used bed rails for mobility. Review of the POS, dated November 2024, showed an order dated 8/16/24 for staff to assess the resident at admission for use of one-eighth type enabler on bed for positioning/transfer assistance, if indicated and/or with resident request. Review of the resident's medical record did not contain an entrapment assessment. Observation on 11/12/24 12:15 P.M., showed the resident in bed with bed rails raised on both sides. Observation on 11/13/24 at 2:19 P.M., showed the resident in bed with bed rails raised on both sides. 9. Review of Resident #40's Admission MDS, dated [DATE], showed staff assessed the resident as: -admitted on [DATE]; -Moderately Cognitively Impaired; -Required partial/moderate assistance for bed mobility. Review of the resident's POS, dated November 2024, showed it did not contain an order for bed rails. Review of the resident's medical record showed it did not contain an entrapment assessment. Observation on 11/13/24 at 9:00 A.M., showed the resident in bed with bed rails raised on both sides. Observation on 11/14/24 at 2:31 P.M., showed the resident in the room with bed rails in the raised position. 10. During an interview on 11/14/24 at 10:38 A.M., the administrator said the staff member who had been responsible for completing the entrapment assessments had been terminated in June of this year. The administrator said entrapment assessments had not been completed since June 2024. The administrator said the new maintenance director had been out and the assessments had not been completed. 42484 50432

Based on interview and record review, facility staff failed to accurately transcribe one resident's (Resident #18) eye drop medication orders from the hospital which resulted in the resident not receiving necessary medications during their stay at the facility. The facility census was 66. 1. Review of the facility's policy titled Reconciliation of Medications on Admission, revised July 2017, showed medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous Medication Administration Record (MAR), and the admitting orders (sources). 2. Review of Resident #18's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/15/24, showed staff assessed the resident as: -Moderately cognitively impaired; -Vision moderately impaired; limited vision, not able to see newspaper headlines but can identify objects; -Diagnosis of Cataracts, Glaucoma or Macular Degeneration (an age-related eye disease that causes gradual loss in the center of the visual field). Review of the resident's medical record, dated October through November 2024, showed staff documented the resident has diagnoses of Primary open-angle glaucoma and Presence of intraocular lens (a clear, artificial lens that replaces the eye's natural lens to improve vision). Review of the resident's Physician Order Sheet (POS), dated 10/31/24, showed an order to admit to facility with hospital discharge orders. Review of the resident's hospital discharge orders, dated 10/31/24, showed orders for: -Atropine Ophthalmic 1% solution (used to relieve pain caused by swelling and inflammation of the eye), one drop in the right eye two times a day; -Brimonidine Ophthalmic 0.2% solution (used for lowering intraocular pressure (IOP) with open-angle glaucoma or ocular hypertension), one drop in the left two times a day; -Difluprednate Ophthalmic 0.05% Solution (used to treat eye pain, redness, and swelling caused by eye surgery. It is also used to treat an eye condition called endogenous anterior uveitis (eye inflammation), one drop in the right eye four times a day; -Latanoprost 0.005% Ophthalmic Solution (used to treat glaucoma), one drop in the left eye twice a day. Review of the resident's POS, dated October and November 2024, showed orders for: -Atropine Ophthalmic Solution 1%, instill one drop in right eye every 12 hours as needed for eye irritation; -Brimonidine Tartrate Ophthalmic Solution 0.2%, instill one drop in left eye every 12 hours as needed for eye irritation; -Difluprednate Ophthalmic Emulsion; instill one drop in right eye every 8 hours as needed for eye irritation; -Latanoprost Ophthalmic Solution, instill one drop in left eye every 12 hours as needed for eye irritation. Review of the resident's MAR, dated October and November 2024, showed staff did not document the resident received the eye medications as ordered on the hospital discharge orders. During an interview on 11/15/24 at 11:55 A.M., Pharmacist M said when a resident has a diagnosis of glaucoma eye drops are usually given as scheduled and not as needed. Pharmacist M said the facility orders should match the hospital discharge orders. During an interview on 11/15/24 at 12:09 P.M., Physician L said the orders received from the hospital should have been the orders followed by the facility. The physician said he/she did not know why the medication orders were not entered correctly. The physician said a resident with glaucoma could be harmed if eye drops are not given as ordered. During an interview on 11/15/24 at 2:11 P.M., Licensed Practical Nurse (LPN) J said when a resident is admitted , the charge nurse reviews the medication list, and enters the medications. The social worker reviews the list with the family, and another nurse will audit the orders. LPN J did not know why the medications were not administered according to the hospital discharge summary. LPN J said the resident's glaucoma could become worse if the eye drops were not administered correctly. During an interview on 11/15/24 at 2:41 P.M., the Director of Nursing (DON) said when a resident is admitted from the hospital a medication list is always provided. The list is double checked by multiple staff members. The DON did not know how these medications were entered incorrectly since it had been checked by multiple staff. MO00245028

Based on observation, interview, and record review, facility staff failed to maintain a medication administration error rate of less than 5% out of 38 opportunities observed, two errors occurred resulting in a 5.26%, which effected one residents (Resident #35) out of 21 sampled residents. The facility census was 66. 1. Review of the facility's policy titled Administering Medications, dated April 2019, showed the Director of Nursing (DON) supervises and directs all personnel who administer medications. Medications are administered in accordance with prescribe orders. The individual administering medications verifies the right resident, right medication, right dosage, right time, and right route before giving the medication. Review of the manufacturer's recommendations for insulin (a medication used to control blood sugars) pens, dated 09/11/15, showed prime the pen with two units (U) before each injection. Priming the pen removes the air from the needle and cartridge that may collect and ensures the pen is working correctly. If you do not prime the pen before each injection, you may get too much or too little insulin. 2. Review of Resident #35's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/10/24, showed staff documented the resident had a diagnosis of diabetes and received insulin injections. Review of the resident's Physician's Order Sheet (POS), dated November 2024, showed orders for: -Humalog Lispro Insulin 100 units U/milliliter (ml), give per sliding scale according to the resident's blood sugar, inject subcutaneously (SQ) with meals: -Glargine Insulin 100 U/ml, inject 10 units SQ once a day. Observation on 11/13/24 at 8:00 A.M., showed Registered Nurse (RN) A administered Humalog Insulin two units per the sliding scale orders but did not prime the insulin pen Observation showed the RN administered Glargine Insulin 10 units but did not prime the insulin pen. During an interview on 11/13/24 at 2:35 P.M., RN A said the proper way to administer insulin from a pen is to prime the pen with two units before giving each dose of insulin. RN A said he/she realized after he/she gave the insulin he/she failed to prime the pens and should have. RN A said the reason the pen should be primed before administering the insulin is to ensure an accurate dose is given as the pens can get air bubbles. RN A said not priming the pens is a medication error. 3. During an interview on 11/14/24 at 1:00 P.M., the Unit Manager N said the proper way to administer insulin using a pen is to prime the insulin pen with two units each time before setting the dose of insulin to give. This ensures the accuracy of the dose given as insulin pens can get air bubbles in them. If staff do not prime the pen each time it is considered a medication error. During an interview on 11/14/24 at 1:25, the DON said the nurses and CMT's are responsible to administer medications per the physician's orders accurately. The DON said the proper way to administer insulin using a pen is to prime the insulin pen with two units each time before setting the dose of insulin. The DON said this ensures the accuracy of the dose given as insulin pens can get air bubbles in them. The DON said if staff do not prime the pen each time this would be considered a medication error. During an interview on 11/14/24 at 2:22 P.M., the administrator said he/she expects staff to follow the standards of practice and facility policies regarding medication administration. 48982

Based on interview and record review, facility staff failed to ensure the activities program was directed by a qualified professional. The facility census was 66. 1. Review of facility records showed they did not have a policy in regard to qualifications for the Activity Director (AD) position. Review of the facility's Activity Director Job Description, undated, showed the primary purpose of the AD position is to plan, organize, develop, and direct the overall operation of the Activity Department in accordance with current federal, state, local and corporate standards, regulations, and guidelines to assure than an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and physical, mental, and psychosocial needs of each resident. Keep current of federal and state regulations, as well as professional standards. The job description did not include the necessity for certification. 2. Review of the AD's employee file showed the file did not contain documentation the AD completed a state approved training course. During an interview on 11/15/24 at 10:29 A.M., the AD said he/she did not know the position required certification. The AD said he/she had not been directed to take any courses by facility staff. During an interview on 11/14/24 at 3:22 P.M., the administrator said the AD is not certified. The administrator said he/she did not know the activity director position required certification.

Based on observation, interviews, and record reviews, the facility staff failed to wear hairnets and beard guards, to ensure the ice machine drained through an air gap, to maintain the kitchen in a clean and sanitary manner, to store food in a manner to prevent outdated usage and cross contamination, and to perform handwashing when appropriate. These failures had the potential to affect all residents. The census was 64. 1. Review of the facility's Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy, dated November 2022, showed hairnets and beard guards are worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens. Observation on 8/8/23 at 11:15 A.M., showed dietary aide (DA) R prepared residents' lunch plates for service. Further observation showed the DA wore a hairnet, and the hairnet did not cover hair around the DA's face, which measured two inches. Observation on 8/8/23 at 11:17 A.M., showed cook Q prepared the residents' lunch meal. Further observation showed the cook had a full beard and mustache which measured two to three inches, and the cook did not wear a beard guard. Observation on 8/8/23 at 11:20 A.M., showed dietary supervisor (DS) Y worked in the walk-in refrigerator. Further observation showed the DS wore a hairnet, and the hair net did not cover all of the DS's hair, which measured one to two inches around face and neck. Observation on 8/8/23 at 11:22 A.M., showed cook P prepared the residents' dinner meal. Further observation showed the cook had a full beard and mustache which measured half inch to three-quarter inch, and the cook did not wear a beard guard. Observation on 8/8/23 at 11:45 A.M., showed DA S prepared residents' lunch plates for service. Further observation showed the DA had a goatee which measured one inch, and the DA did not wear a beard guard. Observation on 8/9/23 at 10:00 A.M., showed cook Q prepared the residents' lunch meal. Further observation showed the cook had a full beard and mustache which measured two to three inches, and the cook did not wear a beard guard. Observation on 8/9/23 at 10:02 A.M., showed DA R prepped food items for the residents' lunch meal. Further observation showed the DA wore a hair net, and the hair net did not cover hair around the DA's face, which measured two inches. During an interview on 8/9/23 at 12:31 P.M., the dietary manager said the dietary manager and the dietary supervisor were responsible to ensure staff wore hairnets and beard guards according to policy. He/She said the facility had a policy regarding hair nets and beard guards, and staff were trained on the policy. The dietary manager said staff should wear beard guards anytime they have facial hair, and the hair nets should cover all of the hair. He/She was aware staff were not wearing beard guards, and there was no reason for the failure. He/She said he/she noticed staff wore hairnets in a manner that did not cover all their hair, and he/she verbally reminded them to cover all the hair when he/she saw it. During an interview on 8/9/23 at 1:00 P.M., the administrator said the dietary manager was responsible to ensure staff wore hair nets and beard guards according to facility policy. He said the facility had a policy on hair nets and beard guards, and staff were trained on the policy. The administrator said staff should wear hair nets at all times, beard guards if they have facial hair of any length, and the hair nets and beard guards should cover all of the hair. 2. Review of the facility's Ice Machines and Ice Storage Chests policy, dated January 2012, showed the policy did not address drainage through an air gap. Observation on 8/8/23 at 11:50 A.M., showed CNA H scooped ice from the ice machine, located in the kitchen, into a cooler. Further observation showed the ice machine did not drain through an air gap, and the bottom of the drain pipe contained a black and brown substance. During an interview on 8/8/23 at 11:51 P.M., CNA H said the ice in the cooler was used for resident drinks. Observation on 8/8/23 at 10:05 A.M., showed the ice machine, located in the kitchen, did not drain through an air gap, and the bottom of the drain pipe contained a black and brown substance. During an interview on 8/9/23 at 12:31 P.M., the dietary manager said the dietary manager and the maintenance director were responsible to inspect and maintain the ice machine. He/She said the facility had a policy regarding the ice machine, and he/she was trained on the policy. The dietary manager said an outside company cleaned the ice machine every six months, and he/she checked the ice machine every month. The dietary manager said she inspected the ice machine for dirt and mold, but he/she was not aware the ice machine should drain through an air gap. During an interview on 8/9/23 at 1:00 P.M., the administrator said the dietary manager and the maintenance director were responsible to inspect and maintain the ice machine. He said the facility had a policy on the ice machine, and staff were trained on the policy. The administrator said the maintenance director contracted with an outside company to clean the ice machine, and the dietary manager visually inspected the machine between cleanings. The administrator said he was not aware the ice machine did not drain through an air gap, but it was expected the ice machine would be maintained according to regulations. 3. Review of the facility's Sanitization policy, dated November 2022, showed: - All kitchens are kept clean, free from garbage and debris; - All utensils, counters, shelves, and equipment are kept clean. Review of the facility's Daily Cleaning Schedule, undated, showed direction for staff to clean the mixer, prep tables and countertops, beverage table, coffee urns, stovetop, grill, and kitchen floor. Review of the facility's Weekly Cleaning Schedule, undated, showed direction for staff to clean the range hood, coffee machine, and shelves. Observation on 8/8/23 at 11:26 A.M., showed the following: - Stand mixer visibly dirty with brown spots; - Wall at coffee maker visibly dirty with brown spots; - Metal service table with toaster visibly dirty with smudges and drips on the drawer front; - Small refrigerator near stove visibly dirty with drips and spots; - Metal work table with plate warmer visibly dirty on two lower shelves with crumbs and spots. Further observation showed pans and and racks stored in the crumbs; - Steam table visibly dirty with drips and brown accumulation around knobs, with crumbs and spots on the bottom shelf. Further observation showed serving pans stored inverted in the crumbs and spots, and cook P used a pan from the shelf for resident dinner preparation; - Floor under and around cooking equipment under the suppression hood visibly dirty with crumbs and grease buildup; - Warmer visibly dirty with white spots, smudges, and crumbs on the door; - Stove visibly dirty with brown spots, drips, crumbs, and splatters on the oven doors and around knobs. Further observation also showed the oven door handles sticky to touch; - Fryer visibly dirty with drips and spots on front and sides; - Grill visibly dirty with with brown and white spots and splatters; - Two drawer refrigerator visibly dirty with crumbs, chunks, drips, and brown buildup on drawers; - Tilt skillet visibly dirty with brown and white buildups and crumbs; - Single door, metal, lower cabinet visibly dirty with yellow spots, chunks, and drips; - Suppression nozzles visibly dirty with dust. Further observation showed an uncovered pot of water sat on the stove under the suppression nozzles. Observation on 8/9/23 at 10:07 A.M., showed: - Stand mixer visibly dirty with brown spots; - Wall at coffee maker visibly dirty with brown spots; - Metal service table with toaster visibly dirty with smudges and drips on the drawer front; - Small refrigerator near stove visibly dirty with drips and spots; - Metal work table with plate warmer visibly dirty on two lower shelves with crumbs and spots. Further observation showed pans and and racks stored in the crumbs; - Steam table visibly dirty with drips and brown accumulation around knobs, with crumbs and spots on the bottom shelf. Further observation showed serving pans stored inverted in the crumbs and spots, and cook P used a pan from the shelf for resident dinner preparation; - Floor under and around cooking equipment under the suppression hood visibly dirty with crumbs and grease buildup; - Warmer visibly dirty with white spots, smudges, and crumbs on the door; - Stove visibly dirty with brown spots, drips, crumbs, and splatters on the oven doors and around knobs. Further observation also showed the oven door handles sticky to touch; - Fryer visibly dirty with drips and spots on front and sides; - Grill visibly dirty with with brown and white spots and splatters; - Two drawer refrigerator visibly dirty with crumbs, chunks, drips, and brown buildup on drawers; - Tilt skillet visibly dirty with brown and white buildups and crumbs; - Single door, metal, lower cabinet visibly dirty with yellow spots, chunks, and drips; - Suppression nozzles visibly dirty with dust. Further observation showed an uncovered pot of water sat on the stove under the suppression nozzles. During an interview on 8/9/23 at 12:31 P.M., the dietary manager said all dietary staff were responsible to maintain the kitchen in a clean and sanitary manner. He/She said the facility had a checklist for cleaning the kitchen, but no one had been completing the checklist. The dietary manager said it was expected staff would clean their work stations after each service and the floors at the end of the day. She said staff should clean any area they saw was visibly dirty when they saw it. During an interview on 8/9/23 at 1:00 P.M., the administrator said the dietary manager was responsible to ensure the kitchen was maintained in a clean and sanitary manner. He said the facility had a cleaning policy and logs for the kitchen, and it was expected staff would follow the policy and complete the logs. The administrator was not aware the dietary staff were not completing the cleaning logs. 4. Review of the facility's Food Receiving and Storage policy, dated November 2022, showed: - All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date); - Foods in the walk-in are stored off the floor; - The policy did not address dry food storage regarding label, date, and protection from air. Observation on 8/8/23 at 12:00 P.M., of the walk-in freezer, showed: - Two bags of white patties unlabeled; - One ziploc contained round brown disks, unlabeled and undated; - Four boxes of bread sat directly on the freezer floor. Observation on 8/8/23 at 12:05 P.M., of food preparation station, showed: - 11 containers of various open spices, five pounds, undated; - Container of open salt undated; - Baking soda with the box open, unprotected and undated; - Kosher salt with the box open, unprotected and undated; - Shaker of white powder unprotected, unlabeled, and undated; - Open container of [NAME] seasoning undated; - Open container of Greek seasoning undated; - Ziploc bag of Hillbilly Joe's seasoning undated; - 25 containers of various seasonings, 18-22 ounces, undated. Observation on 8/8/23 at 2:50 P.M., of the two drawer refrigerator, showed a plate with two slices of bread, unlabeled and undated. Observation on 8/9/23 at 10:10 A.M., of the walk-in freezer showed: - Two bags of white patties unlabeled; - Four boxes of bread sat directly on the freezer floor. Observation on 8/9/23 at 10:12 A.M., of the food preparation station, showed: - 11 containers of various open spices, five pounds, undated; - Container of open salt undated; - Box open baking soda unprotected and undated; - Box open kosher salt unprotected and undated; - Shaker of white powder unprotected, unlabeled, and undated; - Open container of [NAME] seasoning undated; - Open container of Greek seasoning undated; - Ziploc bag of Hillbilly Joe's seasoning undated; - 25 containers of various seasonings, 18-22 ounces, undated. During an interview on 8/9/23 at 12:31 P.M., the dietary manager said the dietary supervisor was responsible to ensure food was stored in a manner that prevented outdated usage and cross contamination. He/She said the facility had a policy regarding food storage, and the staff were trained on the policy. The dietary manager said the dietary supervisor checked food storage every day, and the dietary supervisor put away the food deliveries. The dietary manager said food deliveries should be put away as soon as possible and should not be left sitting on the floor. She said all open food should be labeled, dated, and protected; and staff should label and date any bags of food that were removed from the original boxes. During an interview on 8/9/23 at 1:00 P.M., the administrator said the dietary manager was responsible to ensure food was stored correctly. He said the facility had a policy on food storage, and staff were trained on the policy. The administrator said food deliveries should be put away as soon as possible and not left on the floor. He said it was expected all food in storage was labeled, dated, and protected. 5. Review of the facility's Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy, dated November 2022, showed employees must wash their hands: - After personal body functions (blowing/wiping nose); - Whenever entering or re-entering the kitchen; - After handling soiled equipment or utensils; - During food preparation, as often as necessary, to remove soil and contamination and to prevent contamination when changing tasks; - After engaging in other activities that contaminate the hands; - Gloves are considered single-use items and must be discarded after completing the task for which they are used; - Gloves are removed, hands are washed, and gloves are replaced. Observation on 8/8/23 at 11:52 A.M., showed cook Q knocked over the wet floor sign. Further observation showed the cook used his/her bare hands to pick up the sign from the floor. The cook walked into the walk-in refrigerator, picked up a container of sliced cheese. The cook donned gloves, prepared resident lunch plates, and touched the plates, baked potatoes, and service utensils. The cook did not hand wash after picking up the wet floor sign and before donning gloves. Observation on 8/8/23 at 11:55 A.M. showed cook Q used his/her gloved hands to get a paper towel and wipe his/her face. Further observation showed the cook used the same gloved hands to prepare resident plates and to touch the plates, baked potatoes, and service utensils. The cook did not remove his/her gloves and hand wash after wiping his/her face with the paper towel. Observation on 8/8/23 at 12:20 P.M., showed DA T entered the kitchen from the utility hallway and touched the door handle with his/her bare hands. Further observation showed the DA put away clean dishes, and he/she touched the food surface area of plates and bowls. The DA did not perform handwashing after entering the kitchen and before touching the clean dishes. Observation on 8/8/23 at 3:12 P.M., showed DA R worked in the dishwasher station. Further observation showed the DA did not hand wash after he/she touched dirty dishes and before he/she touched clean dishes. During an interview on 8/9/23 at 12:31 P.M., the dietary manager said the dietary manager and the dietary supervisor were responsible to ensure staff wore gloves and performed hand washing appropriately. He/She said the facility had a policy regarding hand washing and glove use, and the staff were trained on the policy. The dietary manager said it was expected staff would perform hand washing after entering the kitchen, before and after glove use, when they moved from a dirty task to a clean task, and after touching their personal self. During an interview on 8/9/23 at 1:00 P.M., the administrator said the dietary manager was responsible to ensure dietary staff hand washed and used gloves according to facility policy. He said the facility had a policy on handwashing and glove use, and staff were trained on the policy. The administrator said it was expected the dietary staff hand washed and used gloves according to facility policy.

Based on observation, interview and record review, facility staff failed to maintain a professional standard of care when staff did not follow manufacturer's guidelines to administer insulin using an insulin pen for one resident (Resident #22), failed to obtain specific orders for one resident's (Resident #1) tracheostomy (opening in neck to place a tube to allow air into the lungs) and to have a suction machine at the bedside side, failed to obtain an order and plan care for the use of a catheter (a tube to drain the bladder) for two residents (Resident #308 and #323), failed to discontinue an order for catheter use for one resident (Resident #26) who no longer used a catheter, failed to obtain an order and plan care for the use of a Continuous Positive Airway Pressure (CPAP - pressure to used to help keep airway open) machine for one resident (Resident #15), failed to obtain an order for dialysis and provide written communication between the facility and dialysis center for one resident (Resident #18), and failed to assess under the wound dressings on admission for one resident (Resident #308). The facility census was 64. 1. Review of the facility's Insulin Administration policy, dated September 2014, showed it did not contain direction or procedure for insulin pen use. Review of the Humalog Kwikpen Instructions for Use from www.humalog.com, dated April 2020, showed staff are directed to: -Wipe the rubber seal with an alcohol pad/swab; -Push the capped needle straight onto the pen and twist until tight; -Prime the pen (priming means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly). Turn the Dose knob until a 2 is seen in the dose window. If you do not prime before each injection, you may get too little or too much insulin; -Hold the pen with the needle pointing up, tap the cartridge gently to collect air bubbles at the top, push the Dose knob until it stops and a 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. Insulin should be seen at the tip of the needle; -Turn the dose knob to select the number of units you need to inject; -Inject the insulin by cleansing the site with alcohol and let air dry, insert the needle into the skin, press the dose knob in and count to 5 slowly before removing the needle. Review of Resident #22's Physician Order Sheets (POS), dated 8/10/23 showed: -On 8/1/23, Humalog Solution 100 unit/ml, inject 8 units subcutaneously before meals; -On 8/1/23, Humalog Solution 100 unit/ml, inject 1 unit subcutaneously before meals for a blood sugar between 151-200. Observation on 8/10/23 at 10:44 A.M., showed Certified Medication Technician (CMT) F removed a Humalog insulin pen from the medication cart after he/she obtained a blood sugar of 160. He/She removed the cap, applied the needle, dialed the dose to 9, cleansed the resident's skin, inserted the needle into the resident's right abdomen, depressed the dose knob, and removed the needle. CMT F did not wipe the rubber seal, prime the pen or hold the pen against the skin for a slow count of 5 during administration. During an interview on 8/10/23 at 10:49 A.M., CMT F said he/she had not been instructed on administration of insulin by a pen but thought it should have been cleaned before attaching the needle to decrease risk of infections. CMT F did not know why to prime or how to prime the pen. During an interview on 8/11/23 at 9:30 A.M., Licensed Practical Nurse (LPN C) said staff should obtain an insulin pen, check and verify orders, apply a pen needle, prime the pen, and hold against the skin for a count of 5 during administration. He/she said he/she did not think it was necessary to cleanse the rubber seal before applying the pen needle and was not taught to. LPN C said staff should prime the pen and hold the needle in place during administration for a count of 5 to ensure the entire dose has been given. During an interview on 8/11/23 at 10:19 A.M., the Director of Nursing (DON) said staff are expected to gather supplies, cleanse the rubber seal (to decrease infection), prime with 2 units, verify dose, dial to correct dose, inject and hold the needle in place for 5 seconds to insure the correct dose is given. 2. Review of the facility's Tracheostomy Care policy, revised August 2013, showed staff are directed to do the following: -Check the physician's order; -Tracheostomy tubes should be changed as ordered and as needed (at least monthly); -Tracheostomy care should be provided as often as needed; -A replacement tracheostomy tube must be available at bedside at all times; -A suction machine, supply of suction catheters, exam and sterile gloves, and flush solutions, must be at the bedside at all times. Review of the facility's Medication Orders policy, revised November 2014, showed staff are directed to do the following: -A current list of orders must be maintained in the clinic record of each resident; -Medication orders: when recording orders for medications, specify the type, route, dosage, frequency, and strength of medication ordered; -Treatment orders: when recording treatment orders, specify the treatment, frequency, and duration of the treatment. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 7/1/23, showed staff assessed the resident as follows: -Staff did not assess resident's cognition level; -Required supervision or set up assistance of one staff member for personal hygiene; -Resident had a tracheostomy; -Received tracheostomy care. Review of the resident's physician's orders, dated 8/10/23, showed the following: -Trach care two times a day (BID) (Do not throw away the reusable inner cannula); -Did not contain an order for trach inner cannula size, what to clean the trach site with and strength, what to clean the inner cannula with and strength, and suction as needed in an emergency. Observation on 8/8/23 at 10:56 A.M., showed the resident sat in his/her room with a tracheostomy in place. Further observation showed the resident's room did not contain a suction machine, at the bedside. Observation on 8/9/23 at 8:19 A.M., showed the resident in his/her room with a tracheostomy in place. Further observation showed the resident's room did not contain a suction machine at the bedside. Observation on 8/10/23 at 7:40 A.M., showed the resident sat in his/her chair in his/her room with a tracheostomy in place. Further observation showed the resident's room did not contain a suction machine at the bedside. Observation on 8/10/23 at 1:46 P.M., showed the resident was in his/her bed with his/her eyes closed with a tracheostomy in place. Further observation showed the resident's room did not contain a suction machine at the bedside. Observation on 8/11/23 at 8:35 A.M., showed the resident's room did not contain a suction machine at the bedside. During an interview on 8/10/23 at 1:46 P.M., LPN E said staff normally use a trach cleaning kit each time they provide care. He/She said they are pre-filled with what they use to clean with and he/she thinks they are all the same but not certain of that. During an interview on 8/11/23 at 10:06 A.M., LPN C said she would expect to have emergency equipment at bedside such as a suction machine, Ambu bag, and spare cannula for a resident with a tracheostomy. He/She said he/she would expect the tracheostomy orders to contain what to clean it with, how often to clean the tracheostomy and cannula, size of the cannula, how often to change the cannula, etc. He/She said he/she was not sure what size tracheostomy the resident had, but would expect to see it documented. He/She said he/she was not sure where to find that information. During an interview on 08/11/23 at 10:19 A.M., the Director of Nursing (DON) said he/she would treat residents with a tracheostomy accordingly. He/She said that if it was a new tracheostomy he/she would expect to have emergency equipment at bedside, but an old tracheostomy not necessarily. He/She said he/she would expect the orders to contain the size of the inner cannula, what to clean it with, how often to clean it, how often to change the inner cannula, etc. 3. Review of the facility's Catheter Care, Urinary policy, dated August 2022, showed: -To review the resident's care plan to assess for any special needs of the resident; -To review and document the clinical indications for catheter use prior to inserting; -Remove the catheter as soon as it is no longer needed; -Did not contain directions on what to include in the physician orders or when to obtain a physician order. 4. Review of Resident #308's Entry MDS, dated [DATE] showed the resident admitted on [DATE]. Review of the resident's POS, dated 8/10/23 showed it did not contain an order for the use of a catheter. Review of the resident's baseline care plan, dated 8/7/23 showed it did not contain direction for the use of a catheter. Observation on 8/8/23 at 10:56 A.M., showed the resident in bed and a catheter drainage bag hung from the bed frame. Observation on 8/9/23 at 9:01 A.M., showed the resident in bed with a catheter drainage bag hung to gravity. Observation on 8/9/23 at 10:26 A.M., showed the resident up in a wheelchair with a catheter drainage bag that hung from the bottom of the wheelchair. During an interview on 8/8/23 at 11:02 A.M., the resident's family said a catheter was placed in the hospital because the resident had a rash to the groin. He/She said the resident has a history of urinary tract infections. During an interview on 8/11/23 at 9:30 A.M., LPN C said residents with catheters should have orders for catheters. He/She said the orders should include replacement orders, catheter care, size of catheter, reason for catheter, size of balloon, and placement checking. LPN C did not know why the resident had a catheter but thought it was for urinary retention. During an interview on 8/11/23 at 10:19 A.M., the DON said the use of catheters should have orders in place that include size, balloon size, indication for use, and if any, indications for replacement. He/She was not sure why the resident had a catheter. 5. Review of Resident #323's Discharge, Return Anticipated MDS, dated [DATE], showed facility staff assessed the resident had an indwelling catheter. Review of the resident's POS, dated August 2023 showed an order dated 8/07/23 for Indwelling urinary catheter in privacy bag and catheter leg strap on at all times. Further review showed the POS did not contain a catheter order with the catheter size, balloon size or diagnosis. During an interview on 8/11/23 at 10:19 A.M., the DON said a resident with a catheter should have an order that included catheter size, balloon size, change as needed and diagnosis. 6. Review of Resident #26's Prospective Payment System (PPS) MDS dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Used a catheter; -Had diagnosis of tibia fracture (shin bone). Review of the resident's POS dated 8/10/23, showed: -On 7/21/23, Change catheter #16 french 10 cc bulb attached to gravity drainage bag every month on the 15th and as needed for leaking, plugged or dislodged; -On 7/21/23, May irrigate catheter with sterile water as needed if clogged as ordered by the physician; -On 7/21/23, Monitor catheter for proper placement, no kinking or compression that could obstruct urine flow to gravity bag during catheter care every shift. Observation on 8/8/23 at 3:12 P.M., showed the resident in his/her room in a wheelchair. Further observation showed he/she did not have a catheter. During an interview on 8/8/23 at 3:12 P.M., the resident said the catheter was removed at the facility but could not remember the date. He/she said staff helped him/her to the bathroom. During an interview on 8/11/23 at 9:30 A.M., LPN C said if a catheter was discontinued, there should be a physician order. He/She was not aware there was no order to discontinue the catheter for the resident and knew the resident did not have a catheter. During an interview on 8/11/23 at 10:19 A.M., the DON said when catheters were discontinued, there should be an order to do so. He/She was not aware the catheter was discontinued without an order for the resident. 7. Review of the facility's CPAP/BiPAP Support policy, revised March 2015, showed staff are instructed to review the physician's order to determine the oxygen concentration, flow and CPAP settings for the machine. Staff are also instructed to notify the physician if the resident refused the procedure. Review of Resident #15's Admission MDS, dated [DATE], showed facility staff assessed the resident was not using BiPAP/CPAP while a resident or while not a resident. Review of the resident's POS, dated August 2023 showed it did not contain an order for CPAP. Review of the resident's care plan, revised 6/28/23, showed Resident was at risk for respiratory complications related to asthma, sleep apnea but did not include guidance on CPAP usage. Observation 8/08/23 at 11:03 A.M., showed a CPAP sat on the bedside table and the tubing and mask sat on the floor between the table and bed. During an interview on 8/11/23 at 10:19 A.M., the DON said if a resident came from home with CPAP there should be a doctor's order to reflect home settings and the CPAP use should be in the care plan. 8. Review of the facility's Care of a Resident with End-Stage Renal Disease (ESRD) policy, revised September 2010 showed: -Agreements between the facility and the contracted ESRD facility included all aspects of how the resident's care would be managed including how information would be exchanged between facilities. Review of the Memorandum of Agreement, dated 12/18/18, between the facility and the dialysis provider showed: -Facility staff will make an assessment of each patient's physical condition and determine whether the patient was stable enough to be dialized on an outpatient basis; -If it was determined that a patient was sufficiently stable, this assessment will be communicated to the facility's nurse manager or designee; -This assessment would and communication would occur prior to each and every transfer of a patient to dialysis facility for dialysis on an outpatient basis regardless of the number of times any particular patient may be transferred and dialized. Review of Resident #18's PPS 5-Day MDS, dated [DATE] showed facility staff assessed the resident as received dialysis while a resident and while not a resident. Review of the resident's POS dated, August 2023 showed the record did not contain a doctor's orders for dialysis. Review of the resident's care plan, revised 6/03/23, showed: - Resident required dialysis services related to renal failure; - Dialysis per order; - Collaborate care with dialysis center. Review of the resident's vital signs record showed the resident's blood pressure was charted as 199 systolic (squeezing) on 8/07/23. Further review showed the medical record did not contain a nurse note or documentation of provider notification. During an interview on 8/11/23 at 8:41 A.M., Registered Nurse (RN) U said a resident's dialysis was set up outside of the facility and he/she was not sure if there should be doctor's orders. RN U said when the resident returned from dialysis the nurse should assess the resident for pain, vital signs and any other issues. RN U said he/she was not aware of any documentation requirement and it was not facility policy to document assessments. RN U said there was no facility policy or paper assessments exchanged with dialysis providers and all communications were via phone. He/She added phone communications would be in nurses notes, dietician notes, etc. and no notes meant things were okay. During an interview on 8/11/23 at 10:19 A.M., the DON said a resident who went to dialysis should be assessed before or after dialysis. The DON said facility staff did not have written communication with the dialysis center. The DON also said the nurse notes should have the resident's assessment after dialysis and should include checking the dialysis site, how well the resident tolerated dialysis and vital signs. The DON also said the notes should include provider notification of abnormal vital signs and a systolic blood pressure of 199 would be abnormal. 9. Review of the facility's Skin Assessment policy, dated September 2022, showed: -Assessment of a resident's skin condition helps define prevention strategies; -Assessments should be completed upon admission, as soon as possible but no later than 8 hours from the time of admission to the facility each time there is a new stay. Review of Resident #308's Entry MDS, dated [DATE] showed the resident admitted to the facility on [DATE]. Review of the resident's Admission assessment dated [DATE] showed staff documented the resident had a skin tear on the right arm from a transfer at the hospital and a skin tear on the right leg from the hospital. Observation on 8/8/23 at 10:56 A.M., showed the resident in bed with a foam dressing on his/her right forearm and right upper leg dated 8/6/23. Observation on 8/9/23 at 9:01 A.M., showed the resident in bed with a foam dressing on his/her right forearm and right upper leg dated 8/6/23. During an interview on 8/9/23 at 9:01 A.M., the resident's family said staff did not remove the dressings or change the dressings since admission. He/She said the dressings should have been changed. During an interview on 8/11/23 at 9:30 A.M., LPN C said on admission licensed nurses should remove all dressings and examine the skin, unless ordered by a physician otherwise. He/She said measurements are taken at that time depending on the type of wound. Additionally LPN C said there is no way to know if a wound is getting better or worse if it is not looked at upon admission or even what is under those bandages. He/She said the facility wound nurse will follow up on all wounds after admission. During an interview on 8/11/23 at 10:19 A.M., the DON said wound dressings should be removed on admission to the facility unless there is orders stating otherwise. He/She said staff should inspect what is underneath the bandage and report it to the DON and wound nurse. He/She was not aware the resident's dressings were not removed during admission. 45564 48982

Based on observation, interview, and record review facility staff failed to assist five out of 16 sampled dependent residents (Resident #5, #12, #21, #33, and #313) with grooming and bathing. The facility census was 64. 1. Review of the facility's Activities of Daily Living (ADLs) policy, dated March 2018, showed staff were directed as follows: - Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs); - Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of the facility's Shaving the Resident policy, dated February 2018 showed staff are directed to review the resident's care plan for any special needs of the resident. Additional review of the policy showed it did not contain direction or guidance on when to offer or shave the residents. 2. Review of Resident #5's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: - Severe cognitive impairment; - Required extensive assistance from one person for transfers; - Personal hygiene extensive assistance one person; - Totally dependent on one person for bathing. Review of the resident's care plan, dated 4/3/23, showed staff were directed to assist the resident with bathing and grooming due to physical function deficit. Review of the resident's shower sheets, dated 6/5/23 through 8/7/23, showed staff documented the resident received a shower on 6/9/23, 6/12/23, 6/19/23, 6/26/23, 6/29/236, 7/10/23, 7/31/23, 8/3/23, and 8/7/23. Observation on 8/9/23 at 9:48 A.M., showed the resident had greasy, disheveled hair and a brown substance underneath his/her long, untrimmed finger nails. Observation on 8/11/23 at 10:00 A.M., showed the resident had unkempt hair and long finger nails with a brown substance under the finger nails. 3. Review of Resident #12's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/29/23, showed facility staff assessed the resident as: - Cognitively intact; - Required extensive assistance from one person for transfers; - Required extensive assistance from one person for personal hygiene; - Required physical help from one person for bathing. Review of the resident's care plan, dated 6/1/23, showed staff were directed to assist the resident with bathing and grooming due to physical function deficit. Observation on 8/8/23 at 2:00 P.M., showed the resident sat in a wheelchair with uncombed greasy appearing hair and unkempt facial hair. The resident's clothing had stains and food debris on them. Observation on 8/10/23 at 3:15 P.M., showed the resident was dressed in disheveled clothing and had greasy appearing hair. During an interview on 8/10/23 at 2:16 P.M., the resident said staff do not get him/her dressed in the morning. If he/she had an appointment, he/she had to use a stick to get dressed and retrieve his/her clothing 4. Review of Resident #21's Admission MDS dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required physical assistance of one staff for personal hygiene and bathing; -Had limited range of motion in one upper extremity; -Had no behaviors or rejection of care; -Had diagnosis of dementia, hemiplegia (paralysis on one side of body) and stroke. Review of the resident's care plan dated 8/8/23, showed: -Resident was to be clean and well-groomed at all times; -Resident needed assistance with ADLs related to decreased endurance, weakness, and pain related to hemiplegia affecting right side; -Did not contain direction or guidance for personal hygiene or grooming including facial hair preferences. Observation on 8/8/23 at 11:13 A.M., showed the resident in his/her bed with long facial hair. Observation on 8/8/23 at 2:32 P.M., showed the resident in his/her room with long facial hair. 5. Review of Resident #33's Admission MDS dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required physical assistance of one staff for personal hygiene and bathing; -Had no behaviors or rejection of care; -Had diagnosis of cancer and stroke. Review of the resident's care plan dated 7/7/23 showed: -Resident was to be clean and well-groomed at all times; -Resident needed assistance with ADLs related to decreased endurance, weakness, and pain related to stroke; -Did not contain direction or guidance for personal hygiene or grooming including facial hair preferences. Observation on 8/9/23 at 8:57 A.M., showed the resident in his/her room with long facial hair. Observation on 8/11/23 at 8:36 A.M., showed the resident up with a walker with long facial hair. 6. Review of Resident #313's Entry MDS dated [DATE], showed the resident admitted to the facility on [DATE]. Review of the Resident's Baseline Care plan dated 8/1/23, showed staff assessed the resident as: -Cognitively intact; -Required physical assistance of one staff for grooming and bathing; -Required assistance with ADL tasks. Observation on 8/8/23 at 11:33 A.M., showed the resident sat in his/her wheelchair with long facial hair. Observation on 8/8/23 at 2:28 P.M., showed the resident sat in his/her wheelchair with long facial hair. Observation on 8/10/23 at 11:29 A.M., showed the resident sat in his/her wheelchair with long facial hair. During an interview on 8/8/23 at 11:42 A.M., the resident said he/she did not like to have long facial hair and usually plucked it but did not have tweezers. He/She said the staff have not offered to help him/her with shaving or tweezing. 7. During an interview on 8/10/23 at 2:24 P.M., Certified Nurse Aid (CNA) G said residents should be showered at least twice a week or more. They had showers in the resident rooms and shower chairs to use if the resident required use of a mechanical lift. There should be no reason why a resident would not receive a shower because they required a mechanical transfer. During an interview on 8/10/23 at 2:39 P.M., CNA L said staff assisted residents that required help to brush their teeth, comb their hair, bathe, cut finger nails, and shave if needed. During an interview on 8/11/23 at 8:17 A.M., Registered Nurse (RN) U said showers should be done according to resident preferences but at least twice a week. Personal grooming of dependent residents should be offered by staff, or completed as needed. During an interview on 8/11/23 at 9:30 A.M., Licensed Practical Nurse (LPN) C said staff assist residents to shave with showers twice weekly. He/She did not notice if any residents needed a shave. During an interview on 8/11/23 at 9:38 A.M., CNA K said residents are shaved on shower days which was scheduled twice weekly. He/She said showers and refusals of care should be charted on shower sheets and signed by the resident as refused. CNA K said showers and shaves are getting done. During an interview on 8/11/23 at 10:19 A.M., the Director of Nursing (DON) said staff should offer to shave residents daily or per the resident's preference. He/She said he/she does not think shaving preferences should be in the care plan, instead staff should ask daily if the resident would like shaved. During an interview on 8/11/23 at 10:20 A.M., the administrator and DON said shaving is offered daily or whatever preference the resident has. Showers are at least two times a week. ADLs are care planned and the level of assistance is included in the care plan. 43327

Based on observation, interview and record review, facility staff failed to secure and store medications in a manner to prevent access to residents, visitors and staff. Additionally, facility staff failed to provide safe mechanical lift transfers for two residents (Residents #5 and #7) in a manner to prevent accidents. The facility census was 64. 1. Review of the facility's Storage of Medications policy, dated November 2020, showed: -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications; -Compartments (including, but not limited to, drawers, cabinets, rooms refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Observation on 8/8/23 at 3:06 P.M., showed a medication cart sat near the nurse station unlocked and unattended with three residents present in the area. Additionally, the top drawer contained two medication cups stacked on top of one another. The top medication cup contained an oval yellow tablet and a white oval tablet. The bottom medication cup contained six white round tablets. Further observation of the cart showed the top drawer contained seven insulin pens, finger stick devices, insulin pen needles, resident eye drops and inhalers. The second and third drawers contained bubble packed medications for the residents that reside on the 100 hallway, including a narcotic box that was not behind double lock and various over the counter medications. Observation on 8/9/23 at 8:42 A.M., showed Certified Medication Technician (CMT) F stepped away from the medication cart, entered a resident room down the hall, left the cart unlocked and unattended. Additional observation showed a family member stood by the cart. Observation on 8/10/23 at 10:41 A.M., showed CMT F stepped away from the medication cart and left the cart unlocked on Providence hall. Observation on 8/11/23 at 9:18 A.M., showed the Providence medication cart was unlocked and unattended. During an interview on 8/10/23 at 10:44 A.M., CMT F said sometimes he/she forgets to lock the cart and is just a human error. He/She said failing to lock a medication cart could result in someone getting inside and taking things causing harm. During an interview on 8/11/23 at 9:30 A.M., Licensed Practical Nurse (LPN) C said staff were instructed to lock the medication carts when stepping away from them so others could not get into them and get hurt or take medications that were not prescribed. During an interview on 8/11/23 at 10:19 A.M., the Director of Nursing (DON) said staff were expected to lock the medication carts when out of sight. Failure to lock the medication carts could result in someone coming by and taking things from the cart and getting hurt. 2. Review of the facility's Central Venous Catheter Flushing and Locking policy, revised March 2022, showed staff are instructed to use preservative free 0.9% sodium chloride (normal saline) for flushing a central venous access device (CVAD) and lock CVADs with either preservative free normal saline or heparin according to the manufacturer's directions. 3. Review of Resident #308's Entry Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/07/23, showed facility staff assessed the resident as did not receive intravenous (IV) medications while a resident or while not a resident. Review of the resident's Physician Order Sheet (POS), dated August 2023 showed an order dated 8/07/23 to flush Percutaneously (through the skin) Inserted Central Catheter (PICC) line with 10 milliliter (mls) of normal saline, discard, draw labs, then flush with 5 mls of 10 units/mL heparin. Observation on 8/10/23 at 3:29 P.M., showed LPN C entered the resident's room to respond to an intravenous pump alarm. Further observation showed LPN C opened a drawer in the resident's bathroom and removed a normal saline flush syringe. Further observation showed the bathroom drawer also contained one heparin flush syringe. Observation on 8/10/23 at 3:38 P.M., showed one normal saline flush syringe and one heparin flush syringe on the resident's bedside table and a box of normal saline and heparin flush syringes on the window sill. 4. Review of Resident #324's Admission MDS, dated [DATE], showed facility staff assessed the resident received IV medications while a resident and while not a resident. Review of the resident's POS, dated August 2023 showed the record did not contain an order for heparin flushes. Observation on 8/08/23 at 12:03 P.M., showed one normal saline flush syringe and heparin flush syringe on the dresser at the foot of the resident's bed. Observation on 8/08/23 at 3:06 P.M., showed one normal saline flush syringe and heparin flush syringe on the dresser at the foot of the resident's bed. Observation on 8/09/23 at 10:20 A.M., showed a box of saline flush syringes with four heparin flush syringes on the window sill in the resident's room. Observation on 8/09/23 1:54 P.M., showed a box of saline flush syringes with four heparin flush syringes on the window sill in the resident's room. Observation on 8/10/23 at 8:20 A.M., showed a box with 13 normal saline flush syringes and four heparin flush syringes on the window sill in the resident's room. During an interview on 8/10/23 at 3:22 P.M., LPN C said normal saline and heparin flush syringes should not be on the bedside table or the window sill. The LPN also said heparin is a medication but he/she did not know the facility policy on keeping heparin in resident rooms. During an interview on 8/11/23 at 8:23 A.M., LPN E said heparin flushes should not be left in the resident's room since it was a medication. LPN E said there had to be a doctor's order for heparin flushes and if there was not an order there was no reason for heparin to be in the resident's room. LPN E said whoever flushed the resident's central venous access was responsible for verifying flush orders. During an interview on 8/11/23 at 10:19 A.M., the DON said heparin flush syringes should not be in a resident's room because it was a medication. There should be an order for it and shouldn't be in room without a doctor's order. 5. Review of Resident #319's Entry tracking MDS, dated [DATE], showed it did not contain information related to the resident's cognitive status or medication usage. Review of the resident's medical record showed it did not contain documentation of a medication self-administration assessment. Review of the resident's POS, dated August 2023 showed the record did not contain a physician order for the resident to self administer medications. Review of the resident's care plan showed staff were instructed to administer medications as ordered by the physician. Review of the resident's Medication Administration Record (MAR), dated August 2023 showed facility staff documented they administered medications on 8/09/23. Observation on 8/09/23 at 8:46 A.M., showed the resident sat in a wheelchair at the bedside eating breakfast. Further observation showed a small cup of pills on the tray next to the breakfast plate. Observation on 8/10/23 at 8:48 A.M., showed the resident was not in the room and a breakfast tray set on the bedside table and had a small cup that contained eight pills. Further observation showed approximately one minute later the resident was wheeled into the room by Occupational Therapist (OT) M. During an interview on 8/09/23 at 8:47 A.M., the resident said he/she has to eat before taking pills and staff never watched him/her take morning medications. During an interview at 8:50 A.M., OT M said the resident was at the bathroom sink when the pills were dropped off and the resident went to therapy about 8:20 A.M. During an interview on 8/10/23 at 3:22 P.M., LPN C said staff should watch every resident take medications and should never leave medications on the bedside table. During an interview on 8/11/23 at 10:19 A.M., the DON said a resident would have to be assessed and determined to be capable to self administer medications. The DON also said staff should observe the resident take medications and medications should not be on breakfast tray. 6. Review of the facility's Lifting Machine, Using a Mechanical policy, dated July 2017, showed the policy did not contain direction regarding the legs of the mechanical lift device. 7. Review of Resident #5's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: - Severe cognitive impairment; - Required extensive assistance from one person for transfers; - Required extensive assistance from one person for personal hygiene; - Totally dependent on one person for bathing. Observation on 8/9/23 at 10:19 A.M., showed Certified Nurse Aid (CNA) W and CNA X lifted the resident from a wheelchair to the resident's bed. CNA W pushed the mechanical lift to the wheelchair and spread the legs of the lift device to get it above the resident and around the wheelchair. CNA X and CNA W attached the sling to the lift. CNA W raised the resident while CNA X supported the resident. When CNA W moved the lift away from the chair he/she closed the legs of the lift device, turned the lift around and pushed the lift over to the resident's bed and did not have the legs open. 8. Review of Resident #7's Quarterly MDS dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required physical assistance of two staff for bed mobility and toileting; -Dependent on two staff for transfers; -Had no functional limitation in range of motion. Observation on 8/9/23 at 10:49 A.M., showed CNA K lifted the resident from the bed using a mechanical lift. He/She moved the resident from the bed to the wheelchair and did not support the resident while he/she suspended in the air. When the resident was positioned over the wheelchair, LPN D guided the resident into the wheelchair as the lift was lowered. During an interview on 8/9/23 at 11:02 A.M., CNA K said staff should use two staff for mechanical lift transfers so one could handle the lift and the other could handle the resident so the resident does not fall from the lift. During an interview on 8/9/23 at 11:07 A.M., LPN D said staff should have hands on residents during a mechanical lift transfer but because the room was so small and the wheelchair was in the way so he/she could not get to the resident to help guide the resident to the chair. During an interview on 8/10/23 at 2:41 P.M., CNA G said two staff perform a mechanical lift transfer. One staff operates the lift and the other staff supports the resident. The legs of the lift device should be open to the widest position for stability. During an interview on 8/10/23 at 2:41 P.M., CNA L said the legs of the lift device should be spread when you go around the wheelchair then closed to be able to move. During an interview on 8/11/23 at 8:21 A.M., Registered Nurse (RN) U said two staff perform a mechanical lift transfer. One to operate the lift and the other to steady the resident. The legs of the mechanical lift device should be open for safety. During an interview on 8/11/23 at 10:29 A.M., the administrator and the DON said two staff conduct a mechanical lift transfer. One to operate the lift and the other to steady the resident. The legs should be opened for stability when the resident is attached to the mechanical lift device. 43327 45564 48982

48982 Based on observation, interview and record review, facility staff failed to conduct or complete entrapment assessments and measurements to identify areas of possible entrapment on admission and quarterly for five of eight sampled residents (Resident #1, #26, #36, #37, and #308) who used bed rails. The facility census was 64. 1. Review of the facility's policy titled, Bed Safety and Bed Rails, date revised August 2022, showed staff are directed to do the following: -Bed rails (also referred to as side rails, safety rails, grab assist bars in this policy) are adjustable metal or rigid plastic bars that attach to the bed; -Bed rails are available in a variety of types, shapes, and sizes ranging from one-half, one-quarter, or one-eighth lengths; -The resident's sleeping environment is evaluated by the interdisciplinary team; -Bed frames, mattresses, and bed rails are checked for compatibility and size prior to use; -Bed dimensions are appropriate for the resident's size; -Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail, and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA; -Maintenance staff routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks; -The maintenance department provides a copy of inspections to the administrator and reports results to the QAPI committee for appropriate action. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee; -The use of bed rails or side rails is prohibited unless the criteria for bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent; -Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtained informed consent. Overview of FDA potential zones of entrapment with FDA dimension recommendations: -Zone 1: Within the rail, any open space between the perimeter of the rail can present a risk of head entrapment, the FDA recommends a space less than 4 3/4 inches; -Zone 2: Under the rail, the gap under the rail between the mattress, may allow for dangerous head entrapment, the FDA recommends a space less than 4 3/4 inches; -Zone 3: Between the rail and the mattress, this area is the space between the inside surface of the bed rail and the mattress and if too big it can cause a risk of head entrapment, the FDA recommends a space less than 4 3/4 inches; -Zone 4: Under the rail and the end of the rail, gap between the mattress and the lowermost portion of the rail poses a risk of neck entrapment, the FDA recommends a space less than 2 3/8 inches; -The FDA has not provided dimension recommendations for Zones 5-7 (Zone 5: between split bed rails; Zone 6: between the end of the bed rail and the side edge of the head or foot board; Zone 7: between the head or foot board and the end of the mattress). These zones should be assessed for entrapment risk. The facility should refer to manufacturer guidelines for the bed rails, mattresses, and beds. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/01/23, showed staff assessed the resident as follows: -Staff did not assess resident's cognition level; -Independent for bed mobility; -Independent for transfers. Review of the resident's medical record showed the record did not contain a quarterly bed rail assessment, entrapment zones and measurements or a consent for the use of the bed rails after 4/2022. Observation on 08/09/23 at 8:19 A.M., showed the resident sat on the side of the bed with both bed rails in the upright position while he/she put his/her shoes on. Observation on 08/10/23 at 01:46 P.M., showed the resident in bed with his/her eyes closed and both bed rails in the upright position. Observation on 08/10/23 at 03:10 P.M., showed the resident in bed awake with both bed rails in the upright position. 3. Review of Resident #26's 5-day Prospective Payment System (PPS) MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required two staff physical assistance for bed mobility and transfers; -Did not use restraints. Review of the resident's Bed Rail Assessment, dated 7/21/23, showed the resident used a left and right upper bed rail for transfers and bed mobility. Additionally, the assessment did not contain possible entrapment zones or measurements. Observation on 8/8/23 at 3:17 P.M., showed the resident in bed with both bed rails in the upright position. During an interview on 8/8/23 at 3:22 P.M., the resident said the rails are used for moving him/herself in bed. 4. Review of Resident #36's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Resident required supervision of one staff member for bed mobility; -Resident required limited assistance of one staff member for transfers. Review of the resident's Bed Rail Assessment, dated 2/3/23 and 5/2/23, showed the assessment did not contain entrapment zones and measurements or a consent for the use of the bed rails. Observation on 08/09/23 at 09:07 A.M., showed the resident in bed with his/her eyes closed with both bed rails in the upright position. Observation on 08/09/23 at 03:44 P.M., showed the resident awake in bed with both bed rails in the upright position. Observation on 08/10/23 at 10:46 A.M., showed the resident in bed with both side rails in the upright position. Observation on 08/10/23 at 03:08 P.M., showed the resident in bed with both side rails in the upright position. Observation on 08/11/23 at 08:29 A.M., showed the resident in bed with both side rails in the upright position 5. Review of Resident #37's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Independent with bed mobility; -Independent with transfers. Review of the resident's Bed Rail Assessment, dated, 10/20/22, 1/24/23, 4/24/23, and 7/24/23, showed the assessment did not contain entrapment zones and measurements or a consent for the use of the bed rails. Observation on 08/09/23 at 08:19 A.M., showed the resident in bed with both bed rails in the upright position. Observation 08/10/23 at 07:40 A.M., showed the resident in bed asleep with both bed rails in the upright position. Observation on 08/11/23 at 08:25 A.M., showed the resident in bed with both bed rails in the upright position. 6. Review of Resident #308's Annual MDS dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required two staff physical assistance for bed mobility and transfers; -Did not use restraints. Review of the resident's Bed Rail assessment dated [DATE], showed the resident used a left and right upper bed rail for bed mobility. Additionally, the assessment did not contain possible entrapment zones or measurements. Observation on 8/8/23 at 10:56 A.M., showed the resident in bed with both side rails in the upright position. Observation on 8/9/23 at 9:01 A.M., showed the resident in bed on a low air loss mattress with both side rails in the upright position. During an interview on 8/8/23 at 11:02 A.M., the family said the resident used the bed rails to help turn and reposition in bed. During an interview on 8/9/23 at 9:15 A.M., the family said the resident was issued a new bed with a new mattress because the resident was restless, trying to climb out of bed. During an interview on 08/09/23 at 01:34 P.M., the Administrator and Director of Nursing (DON) both said that bed rail assessments are to be completed upon admission and quarterly. The DON said that staff are expected to get the consent signed as well on admission and quarterly with each bed rail assessment. He/She said that the staff print bed rail assessment out, have it signed by the resident or responsible party, and then scan it back into the resident's chart under documents once it is signed. The Administrator and DON both said that the entrapment assessment is part of the bed rail assessment they use but no measurements are recorded on it. The DON said that they have standing orders on admission for bed rails. During an interview on 8/11/23 at 9:30 A.M., Licensed Practical Nurse (LPN) C said bed rails are assessed on admission for gaps in the mattress and the bed rail, but does not think they are measured. He/She said gaps between the mattress and the bed rail could result in the resident slipping between and getting hurt. During an interview on 08/11/23 at 10:19 A.M., the DON said that entrapment measurements should be done to ensure safety. He/She said that measurements should be done where a gap exist such as between the mattress and footboard, or between the mattress and enabling bar. He/She said that the measurements should be done quarterly with each bed rail assessment. The administrator said that the maintenance director is responsible for ensuring these are completed.

Based on interview and record review, facility staff failed to notify the resident and/or resident representative in writing of a facility initiated transfer to a hospital, including the reasons for the transfer, the bed hold policy, or required agency contact information for three sampled residents (Resident #12, #32, and #53). The facility census was 63. 1. Review of the facility's Transfer or Discharge Notice policy, revised March 2021, showed the following: -Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge; -Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: - The safety of individuals in the facility would be endangered; - The health of individual in the facility would be endangered; - The resident's health improves sufficiently to allow a more immediate transfer or discharge; - An immediate transfer or discharge is required by the resident's urgent medical needs; and/or - The resident has not resided in the facility for thirty (30) days; -The resident and representatives are notified in writing of the following information: - The specific reason for the transfer or discharge; - The effective date of the transfer or discharge; - The location to which the resident is being transferred or discharged ; - An explanation of the resident's right to appeal the transfer or discharge to the state, including: - The name, address, and telephone number of the Office of the State Long-Term Care Ombudsman; - The name, address, email and telephone number for the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies); - How to get assistance completing the appeal process; - The facility bed-hold policy; - The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; - The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies); - The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities (as applies); and - The name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices. 2. Review of Resident #12's medical record showed the resident was discharged and transferred to the hospital from the facility on 1/18/22. Further review showed the record did not contain documentation the resident or resident representative were notified with the required information in writing. During an interview on 04/26/22 at 1:37 P.M., the resident said when transferring to the hospital, he/she and their representative were not notified regarding a bed hold policy. 3. Review of Resident #32's medical record showed the resident was transferred to the hospital from the facility on 4/26/22. Further review showed the record did not contain documentation the resident or resident representative were notified with the required information in writing. 4, Review of Resident #53's medical record showed the resident was discharged and transferred to the hospital from the facility on 4/19/22. Further review showed the record did not contain documentation the resident or resident representative were notified with the required information in writing. 5. During an interview on 4/28/22 at 9:40 A.M., the Director of Nursing said nursing contacted the families by phone regarding resident transfers to the hospital, and that the Social Services Director was responsible for the paperwork. During an interview on 4/28/22 at 9:48 A.M., the Social Services Director said residents and/or representatives were notified of resident transfers verbally in person or by phone, and no written notifications were issued.

Based on record review and interview, facility staff failed to conduct and document a thorough facility-wide assessment to determine what resources are necessary to care for residents during both day-to-day operations and emergencies. The facility census was 63. 1. Review of the Facility Assessment policy, updated October, 2018, showed the following: The team responsible for conducting, reviewing, and updating the facility assessment annually includes: -The Administrator; -A representative of the governing body; -The medical director; -The Director of Nursing (DON); -The infection preventionist; -The director from environmental services, physical operations, dietary services, social services, activity services, and rehabilitative services. The facility assessment should include a detailed review of the resident population annually including: -Resident census data from the last 12 months; -Resident capacity of the facility and its occupancy rate for the last 12 months; -Factors that affect the overall acuity of the residents such as the number of residents with the need for assistance with activities of daily living, mobility impairments, incontinence, cognitive/behavioral impairments, conditions that require specialized care, or religious/cultural factors that affect the delivery of care. The facility assessment should include a detailed review of resources available annually to meet the needs of the resident population including: -The physical characteristics of the facility; -Equipment and supplies; -The contracts/agreements with third parties to provide services, equipment, or supplies to the facility; -Services currently provided; -All personnel; -A Breakdown of training, licensure, equipment, and skill level of all personnel; -The current status of health information technology; -The ability to meet the requirements of our residents during emergency situations; -The ability to meet the requirements of our residents during the emergence of infectious disease events/outbreaks. Review of the facility assessment, last updated 5/15/21, showed staff did not document the following requirements: -Acuity levels of the facility residents to determine the intensity of care and services needed; -Staff competencies necessary to provide care for the residents; -Resident census data from the last 12 months; -Resident capacity of the facility and its occupancy rate for the last 12 months; -Factors that affect the overall acuity of the residents such as the number of residents with the need for assistance with activities of daily living, mobility impairments, incontinence, cognitive/behavioral impairments, conditions that require specialized care, or religious/cultural factors that affect the delivery of care. -The physical characteristics of the facility; -Equipment and supplies; -The contracts/agreements with third parties to provide services, equipment, or supplies to the facility; -Services currently provided; -All personnel; -A Breakdown of training, licensure, equipment, and skill level of all personnel; -The current status of health information technology; -The ability to meet the requirements of our residents during emergency situations; -The ability to meet the requirements of our residents during the emergence of infectious disease events/outbreaks. 2. During an interview on 04/27/22 at 01:30 P.M., the Administrator said they staff based on acuity, it changes daily because it is a rehab facility, and they do not have a paper saying how they do so. The facility assessment does not include a determination of the level and competency of staff needed to meet each resident's needs each day and during emergencies. During an interview on 04/27/22 at 01:35 P.M., the (DON) said they staff based on acuity, it changes every day, so they do not have a paper or grid saying how tehy choose acuity and do not keep track. The DON said they talk about it during daily meetings but it is not recorded anywhere. They decide acuity based on what they have in the facility such as a bariatric resident, they do not have a measurement. The residents' acuity, needs, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessment should include basically everything and it should have what disasters they are at risk for.

Based on interview and record review, facility staff failed to initiate CPR (cardio-pulmonary resuscitation) for one full code resident (Resident #1) when the resident was without a pulse or respirations. The facility also failed to ensure a staff member with healthcare level CPR certification was on duty at all times, and failed to ensure all residents had a physician's orders [REDACTED].#201, #202, #203, #204, and #205). The facility census was 41. The administrator was notified on [DATE] at 10:00 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's policy Emergency Procedure Cardiopulmonary Resuscitation, dated (MONTH) (YEAR), showed: -Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS) for victims of sudden [MEDICAL CONDITION]. -Sudden [MEDICAL CONDITION] (SCA) is a loss of heart function due to abnormal heart rhythms. [MEDICAL CONDITION] occurs soon after symptoms appear, and is the leading cause of death among adults; -Victims of [MEDICAL CONDITION] may initially have gasping respirations or may appear to be having a [MEDICAL CONDITION]. Training in BLS includes recognizing presentations of SCA; -If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR, unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exist for that individual or there are obvious signs of irreversible death (e.g. rigor mortis); -Obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel; -Maintain equipment and supplies necessary for CPR/BLS in the facility at all times; -Provide information on CPR/BLS policies and advance directive to each resident/representative upon admission; -If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Verify or instruct a staff member to verify the DNR or code status of the individual. c. Initiate the basic life support (BLS) sequence of events. -The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing); -All rescuers, trained or not, should provide chest compressions to victims of [MEDICAL CONDITION]. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. -Continue with CPR/BLS until emergency medical personnel arrive. Review of the facility's Code Status Report, dated [DATE], showed the facility had 24 residents with a full code status, one resident with a DNR (do not resuscitate) do CPR only, and 12 residents with a DNR status. Review of the facility's Agency Checklist (for orientation of agency nurses), undated, showed: -Tour of the unit; -Verification of login; -Introduction to electronic health record; -Introduction to the medication cart; -Introduction to the charts; -Report of the patients. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment, dated [DATE], showed the staff assessed the resident as: -Cognitively intact; -Primary [DIAGNOSES REDACTED]. -[DIAGNOSES REDACTED]. -The resident received [MEDICAL TREATMENT], physical therapy, and occupational therapy; -The resident had an active plan to discharge from the facility to the community. Review of the resident's History and Physical, dated [DATE], showed the physician documented the resident as follows: -Full code; -Alert and oriented; -Had a complex stay at the hospital for septic arthritis of the knee and shoulder, and experienced full [MEDICAL CONDITION] in the hospital with CPR that lasted for at least 25 minutes, and resulted in rib and sternal fractures; -[DIAGNOSES REDACTED]. Review of the resident's care plan, last updated [DATE], showed staff documented the resident is at high risk for cardiac issues related to [MEDICAL CONDITION], and [MEDICAL CONDITION]. Monitor for cardiac symptoms and report any findings to the physician. Review of the resident's medical record showed the resident's status as full code. Review of the resident's nurses notes, dated [DATE], showed staff documented on [DATE] at approximately 11:10 P.M., certified nurse assistant (CNA) C alerted registered nurse (RN) A (an agency nurse) of the resident's declining condition. The RN documented he/she was not sure if the resident had a pulse and left the resident's room to get his/her stethoscope. During an interview on [DATE] at 3:06 P.M., CNA C said around 11:00 P.M., on [DATE], he/she found the resident with his/her legs off the bed, and the resident said I don't feel good, will you help me. The CNA said the resident was sweaty and the resident was usually cold. The CNA said he/she went to get the nurse. He/She said the resident started making a weird face, his/her eyes rolled back, his/her arms went stiff and out, he/she grunted, then went into a stare, and quit responding. The CNA said RN A said the resident was a full code and called 911 from the bedside. CNA C said he/she went to the front door of the facility to let in the emergency staff. He/She led the emergency medical staff (EMS) to the resident's room. The CNA said when he/she and EMS arrived on the unit where the resident resided, RN A stood at the desk and told the EMS staff the resident was already gone. EMS said something to the RN, and the RN said the resident passed away. He/She said when EMS entered the room, facility staff was not in the resident's room, but were in the hall by the desk. CNA C said EMS staff started CPR on the resident. During an interview on [DATE] 4:50 P.M., RN A said he/she knew the resident's status was full code. He/She said he/she obtained a blood glucose level and found it was 34, left the resident's room to find medication, and when he/she came back to the room, the resident had further declined. He/She said he/she is not sure if the resident was breathing at that time, and left the room again to find a stethoscope. He/She said he/she did not know if any other staff were with the resident. He/She said he/she met the EMS staff in the hall, and when he/she returned to the room with EMS staff, no other staff members were in the room. The RN said he/she did not initiate CPR. He/She said ideally when a resident is emergently declining, the nurse would stay with the resident and call for help. He/She said he/she did not know if the CNAs were CPR certified, and he/she could not find the medication and equipment he/she left the resident's room to look for it. During an interview on [DATE] at 5:59 P.M., licensed practical nurse (LPN) D said after 11:00 P.M. on [DATE], RN A called for assistance, and he/she sent a staff member to assist. He/She said when EMS arrived, he/she walked with them to the unit and RN A was in the hall. He/She said he/she did not know the resident was in [MEDICAL CONDITION] until after EMS staff went to the room. He/She said if a resident is rapidly declining, he/she would stay with the resident and call for help to acquire the crash cart and medication or equipment needed. During an interview on [DATE] at 8:35 A.M., national registered paramedic (NRP) E said he/she responded to the sick resident call. He/She said when he/she arrived to the resident's room, the resident was in full [MEDICAL CONDITION]. He/She said the first responders initiated CPR, and facility staff were not in the room. He/She said they were unable to revive the resident. During an interview on [DATE] at 2:05 P.M., emergency medical personal (EMS) B said on [DATE] at 11:16 P.M., 911 received a call about a resident with breathing unknown and a possible [MEDICAL CONDITION], and the caller hung up. EMS B said upon arrival to the facility, he/she and his/her coworkers were met at the door by a facility staff member. He/She said when he/she arrived on the unit, a staff member was standing in the hallway and said,he/she is gone. He/she said he/she asked the staff member what that meant and he/she said the resident passed away. The RN told him/her the resident was a full code and he/she asked if CPR was initiated and the RN said no and did not respond why. He/She said when he/she entered the room, the resident was in full [MEDICAL CONDITION] and facility staff were not in the room. He/She said when he/she asked about the last time the resident was breathing, RN A said not real sure. He/she said the ambulance staff arrived at the room right after CPR was initiated. He/She said EMS staff were unable to revive the resident. Review of the Ambulance Patient Report, date of service [DATE], showed the ambulance staff documented the following: -Date and time of the 911 call- [DATE], at 11:16 P.M.; -Arrived at facility at 11:23 P.M.; -CPR initiated by first responders at 11:24 P.M.; -Ambulance staff arrived at bedside at 11:25 P.M.; -First monitored rhythm asystole (no rhythm detected). During an interview on [DATE] at 9:02 A.M., certified medication technician (CMT) F said around 11:15 P.M., charge nurse LPN D sent him/her to assist RN A. He/She went to the resident's room, and RN A was in the resident's room. He/She said the resident was not breathing or responding that I could tell. He/She said the nurse was not doing chest compressions or breaths. The CMT said RN A sent him/her to answer call lights and check on the other residents. He/She said it was about ,[DATE] minutes between the time he/she was sent to the other unit to assist and when EMS arrived. Observation on [DATE] at 9:15 A.M., showed the crash cart in the assisted bathroom directly across from the resident's room. During an interview on [DATE] at 9:40 P.M., RN J said it is standard practice if a resident is in a medical emergency, that the nurse stays with the resident and yells for help. He/she said the nurse should direct staff to get the supplies and equipment needed and stay with the resident. He/She said he/she does not know who is CPR certified in the building. He/She said there is not a system to call for help in a medical emergency or code situation, the nurse would have to direct it. He/She said when an agency nurse works for the facility for the first time, he/she thinks they come in before the shift and get acquainted with the facility. He/She is not sure what information is reviewed with agency staff. During an interview on [DATE] at 3:32 P.M., the resident's physician said if a resident has an acute change in condition, he/she expects the staff to call him/her unless it is an emergency and then they should call 911. He/She said if the resident stops breathing and is a full code, he/she expects staff to initiate CPR immediately. During an interview on [DATE] at 3:56 P.M., the director of nursing (DON) said the orientation of agency nurses to the facility varies based on the agency nurse's comfort level. He/She said there is not a list of CPR/BLS certified staff posted in the building, or indicated on the staff listing. He/She said when a resident has a emergency medical decline, he/she expects them to call 911. He/She said staff are expected to start CPR when a resident is unresponsive and not breathing, and if the resident stops breathing, he/she would not expect staff to leave the resident alone; standard of care would be for someone to start CPR and stay with the resident until EMS arrived and took over. During an interview on [DATE] at 5:18 P.M., LPN G said he/she oriented agency RN A to the building on [DATE]. He/She said the RN came in around 6:00 or 6:30 P.M., and he/she showed him/her around the building, the charting, and the code status' of the residents. He/She said he/she did not show the RN where the crash cart was, go over any policies on CPR, emergency medical response, or any other policies. During an interview on [DATE] at 2:48 P.M., RN A said [DATE] was his/her first shift at the facility. He/She said he/she came in about an hour before the shift and the nurse showed him/her the location of the medication cart on the unit and it's contents, a general tour, and how to contact other staff in the building. He/she gave report on the residents including the code status'. He/She said the facility staff did not go over any emergency policies, which staff were CPR certified, location of the crash cart or [MEDICATION NAME] (glucose given in the muscle for low blood sugar). RN A said during report, the nurse reported the resident was nauseated that day and received medication for his/her nausea. The nurse said the resident was breathing when he/she left to find the [MEDICATION NAME] and when he/she returned, he/she did not think the resident was breathing and he/she left the resident's room to find his/her stethoscope. RN A said he/she is not sure why he/she left to find the stethoscope and did not start CPR. He/She said he/she told EMS staff the resident was gone, because he/she did not find the [MEDICATION NAME] and the resident was not breathing, and he/she said, my fear was he/she was going to be gone when they went in the room. 2. Review of the facility's list of CPR certified staff showed 9 nursing staff members and one transportation staff person with current CPR/BLS certification. During an interview on [DATE] at 2:42 P.M., the assistant director of nursing (ADON) said when he/she started in (MONTH) they collected CPR cards from staff members. He/She said he/she is not sure when or if the schedule had a CPR certified staff on every shift but there is for May. He/She said there is not a list posted for staff or a way for staff to know who is CPR/BLS certified. 3. Review of the facility's policy Admission Assessment and Follow Up: Role of the Nurse, dated (MONTH) 2012, directed staff to: -Determine if the resident has existing advance directives. If so, initiate the process of obtaining a copy for the medical record. If not, provide the resident with information on his/her rights to have advance directives and initiate the process of establishing them. Review of the facility's policy Advance Directives, dated (MONTH) (YEAR), directed staff to: -Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. -Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 4. Review of Resident 201's medical record showed an admitted [DATE]. Additional review showed staff did not document a code status for the resident. Review of the resident's face sheet, dated [DATE], showed staff did not document emergency contact information for the resident. 5. Review of Resident 202's medical record showed an admitted [DATE]. Additional review showed staff did not document a code status for the resident. Review of the resident's face sheet, dated [DATE], showed staff did not document emergency contact information for the resident. 6. Review of Resident 203's medical record showed an admitted [DATE]. Additional review showed staff did not document a code status for the resident. Review of the resident's face sheet, dated [DATE], showed staff did not document emergency contact information for the resident. 7. Review of Resident 204's medical record showed an admitted [DATE]. Additional review showed staff did not document a code status for the resident. Review of the resident's face sheet, dated [DATE], showed staff did not document emergency contact information for the resident. 8. Review of Resident 205's medical record showed an admitted [DATE]. Additional review showed staff did not document a code status for the resident. Review of the Resident's face sheet, dated [DATE], showed staff did not document emergency contact information for the resident. 9. Review of Resident 206's medical record showed an admitted [DATE]. Additional review showed staff did not document a code status for the resident. Review of the resident's face sheet, dated [DATE], showed staff did not document emergency contact information for the resident. During an interview on [DATE], at 6:35 P.M., RN Q said all outpatient surgery residents are assumed to have full code status and it is not documented in the resident records. During an interview on [DATE], at 7:45 P.M., the administrator said all outpatient surgery residents do not have a code status in their medical records and it is assumed they have full code status. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 817 MO 048

Based on interview and record review, facility failed to orient an agency nurse to the emergency supplies, including the location of the crash cart, [MEDICATION NAME], and glucose gel. The facility also failed to orient the agency nurse on policies and procedures related to cardiopulmonary resuscitation (CPR) and emergency medical response. Additionally, the agency nurse failed to address an acute medical change in condition for one resident (Resident #1), when the resident had a low blood sugar and [MEDICAL CONDITION]. The facility census was 41. The administrator was notified on [DATE] at 10:00 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's policy Emergency Procedure Cardiopulmonary Resuscitation, dated (MONTH) (YEAR), showed: -Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS) for victims of sudden [MEDICAL CONDITION]. -Sudden [MEDICAL CONDITION] (SCA) is a loss of heart function due to abnormal heart rhythms. [MEDICAL CONDITION] occurs soon after symptoms appear, and is the leading cause of death among adults; -Victims of [MEDICAL CONDITION] may initially have gasping respirations or may appear to be having a [MEDICAL CONDITION]. Training in BLS includes recognizing presentations of SCA; -If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless, it is know that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exist for that individual or there are obvious signs of irreversible death (e.g. rigor mortis); -Obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel; -Maintain equipment and supplies necessary for CPR/BLS in the facility at all times; -Provide information on CPR/BLS policies and advance directive to each resident/representative upon admission; -If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Verify or instruct a staff member to verify the DNR or code status of the individual. c. Initiate the basic life support (BLS) sequence of events. -The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing); -All rescuers, trained or not, should provide chest compressions to victims of [MEDICAL CONDITION]. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. -Continue with CPR/BLS until emergency medical personnel arrive. Review of the facility's policy Nursing Care of the Resident with Diabetes Mellitus, dated (MONTH) (YEAR), showed: -Diabetes is a disorder were glucose (sugar) cannot be taken up by the cells; -[DIAGNOSES REDACTED] (blood sugar below reference ranges) signs and symptoms usually have a sudden onset and may include the following: a. Weakness, dizziness, or faintness; b. Restlessness and/or muscle twitching; c. [MEDICAL CONDITION](increased heart rate); d. Pale, cool, moist skin; e. Excessive perspiration; f. Irritability or bizarre changes in behavior; g. Blurred or impaired vision; h. Headaches; i. Numbness of the tongue and lips/thick speech; j. (More severe) stupor, unconsciousness and/or convulsions and; k. (More severe) coma; -Severity of [DIAGNOSES REDACTED] is determined by a combination of blood sugar results and clinical symptoms; -Management of [DIAGNOSES REDACTED]: 1. Asymptomatic and responsive residents with [DIAGNOSES REDACTED] (less than 70 milligrams/deciliter (mg/dL) or less than the physician ordered parameter: a. Give an oral form of rapidly absorbed glucose (juice or soda); b. Recheck blood glucose in 15 minutes; 2. For symptomatic but responsive (conscious): a. If the resident is able to swallow (1) Give an oral form of rapidly absorbed glucose (juice or soda); (2) Recheck blood glucose in 15 minutes; (3) Repeat juice if indicated and recheck blood glucose in 15 minutes; b. If the resident is unable to swallow (1) Immediately administer oral glucose paste to the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or IV (intravenous) 50% [MEDICATION NAME] (sugar) per facility protocol; (2) Recheck blood glucose in 15 minutes; and (3) Repeat protocol if indicated and recheck blood glucose in 15 minutes. 3. Remain with the resident, monitor vital signs, hold all diabetic medication and notify the physician for further orders; 4 For symptomatic and unresponsive residents with [DIAGNOSES REDACTED]: a. Immediately administer oral glucose paste to the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or IV (intravenous) 50% [MEDICATION NAME] (sugar) per facility protocol; b. If resident remains unresponsive call 911 in accordance with resident's advance directives; c. Remain with the resident; d. Monitor the resident's vital signs; e. Hold all diabetic medications. Review of the facility's Agency Checklist (for orientation of agency nurses), undated, showed: -Tour of the unit; -Verification of login; -Introduction to electronic health record; -Introduction to the medication cart; -Introduction to the charts; -Report of the patient's. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment, dated [DATE], showed the staff assessed the resident as: -Cognitively intact; -Primary [DIAGNOSES REDACTED]. -[DIAGNOSES REDACTED]. -The resident received [MEDICAL TREATMENT], physical therapy, and occupational therapy; -The resident had an active plan to discharge from the facility to the community. Review of the resident's History and Physical, dated [DATE], showed the physician documented the resident as follows: -Full code; -Alert and oriented; -Had a complex stay at the hospital for septic arthritis of the knee and shoulder, and experienced full [MEDICAL CONDITION] in the hospital with CPR that lasted for at least 25 minutes, and resulted in rib and sternal fractures; -[DIAGNOSES REDACTED]. Review of the resident's care plan, last updated [DATE], showed staff documented the resident is at high risk for cardiac issues related to [MEDICAL CONDITION], and [MEDICAL CONDITION]; monitor for cardiac symptoms and report any findings to the physician. Review of the resident's medical record showed the resident's status is a full code. Review of the resident's nurses notes, dated [DATE], showed staff documented on [DATE], at approximately 11:10 P.M., CNA C alerted registered nurse (RN) A (an agency nurse) of the resident's declining condition. The resident was sweaty and clammy, and the RN obtained a blood sugar result of 34. Additional review showed the RN left the resident to obtain [MEDICATION NAME] (glucose given in the muscle for low blood sugar), and could not find it. The RN documented he/she was not sure if the resident had a pulse and left to get his/her stethoscope. During an interview on [DATE] at 3:06 P.M., CNA C said around 11:00 P.M., on [DATE], he/she found the resident with his/her legs off the bed, and the resident said I don't feel good, will you help me. The CNA said the resident was sweaty and the resident was usually cold. The CNA said he/she went to get the nurse. He/She said the resident started making a weird face, his/her eyes rolled back, his/her arms went stiff and out, he/she grunted, then went into a stare, and quit responding. The CNA said RN A said the resident was a full code and called 911 from the bedside. CNA C said he/she went to the front door of the facility to let in the emergency staff. He/She led the emergency medical staff (EMS) to the resident's room. The CNA said when he/she and EMS arrived on the unit where the resident resides, RN A stood at the desk and told EMS staff the resident was already gone. EMS said something to the RN, and the RN said the resident passed away. He/She said when EMS entered the room, facility staff was not in the resident's room, but were in the hall by the desk. CNA C said EMS staff started CPR on the resident. During an interview on [DATE] at 4:50 P.M., RN A said CNA C alerted him/her to the resident's change in condition. He/She said when he/she went into the room the resident appeared clammy and not alert. He/She said he/she left the room and got a glucometer and called licensed practical nurse (LPN) D for assistance. He/She said when he/she got back the resident looked worse, and he/she knew the resident's status was full code. The nurse said he/she called 911 while he/she took the resident's blood glucose (sugar) and the result was 34. The RN said he/she left the resident's room to obtain [MEDICATION NAME] ([MEDICATION NAME] given in the muscle for low blood sugar), but could not find [MEDICATION NAME] on the unit. He/She said when he/she returned to the resident's room the resident looked worse, and he/she left the room to get his/her stethoscope. The RN said he/she did not initiate CPR. He/She said he/she left the room after he/she called 911 and did not know if another staff member was in the room with the resident. He/She said ideally when a resident is emergently declining the nurse would stay with the resident and call for help, he/she said he/she did not know if the CNA's were CPR certified, and he/she could not find the medication and equipment he/she left to look for it. During an interview on [DATE] at 5:15 P.M., licensed practical nurse (LPN) L said glucose gel (an oral gel for low blood sugar) is located on the medication cart. He/She said [MEDICATION NAME] is only kept in the ADU (automatic dispensing unit) on the Providence unit, which is on the opposite end of the facility. (The resident was on Stadium unit). During an interview on [DATE] at 5:59 P.M., LPN D said after 11:00 P.M. on [DATE] RN A called for assistance, and he/she sent a certified medication technician (CMT) to assist. He/She said when EMS arrived he/she walked with them to the unit and RN A was in the hall. He/She said he/she did not know the resident was in [MEDICAL CONDITION] until after EMS staff went to the room. He/She said if a resident is rapidly declining, he/she would stay with the resident and call for help to acquire the crash cart and medication or equipment needed. He/She said no other staff members asked him/her for [MEDICATION NAME], glucose, or the crash cart. During an interview on [DATE] at 8:35 A.M., the national registered paramedic (NRP) E said he/she responded to a sick resident call. He/She said when he/she arrived to the room, the resident was in full [MEDICAL CONDITION]. He/She said the first responders initiated CPR, and facility staff were not in the room. He/She said the facility staff did not inform that the resident's blood glucose was 34. He/She said glucose would have been started immediately if he/she had known. He/She said he/she checked the resident's blood glucose half way through the call and the result was 11. NRP E said he/she rechecked it, because they did not have information to show the resident was diabetic and he/she wanted to ensure the equipment was working properly. He/She said if he/she had known about the result of 34 upon arrival, he/she would have checked the blood glucose immediately and would have been able to administer [MEDICATION NAME] sooner. He/She said they were unable to revive the resident. Review of the Ambulance Patient Report, date of service [DATE], showed the ambulance staff documented the following: -Date and time of the 911 call- [DATE], at 11:16 P.M.; -Arrived at facility at 11:23 P.M.; -CPR initiated by first responders at 11:24 P.M.; -Ambulance staff arrived at bedside at 11:25 P.M.; -First monitored rhythm asystole (no rhythm detected); -Report of actions taken to include CPR, intubation, attempts at IV access; -Blood glucose 11 with no report of low blood sugar or history of diabetes; -[MEDICATION NAME] administered in the resident's left hip and then transferred and secured to the cot for transport; -Transport on [DATE], at 12:02 A.M. Observation on [DATE] at 9:15 A.M., showed the crash cart on the Stadium unit in the assisted bathroom directly across from the resident's room. Observation on [DATE] 9:37 A.M., showed the history on the glucometer (device that reads blood sugar) had a result of 34 on [DATE] at 11:16 P.M. During an interview on [DATE] at 9:40 A.M., RN J said it is standard practice if a resident is in a medical emergency, the nurse stays with the resident and yells for help. He/she said the nurse should direct staff to get the supplies and equipment needed and stay with the resident. He/She said there is not a system to call for help in a medical emergency or code situation, the nurse would have to direct it. He/She said when an agency nurse works for the facility for the first time, he/she thinks they come in before the shift and get acquainted with the facility. He/She is not sure what information is reviewed with them. He/She said if a resident is unresponsive and unable to swallow with a low blood glucose, the nurse should administer [MEDICATION NAME]. He/She said he/she does not know the contents of the crash cart but thinks nurse management checks it. During an interview on [DATE] at 10:05 A.M., CNA K said he/she does not know what is on the crash carts, but the crash cart on the Stadium unit has always been in the assisted bathroom, across the hall from the resident's room. During an interview on [DATE] at 10:18 A.M., the administrator (ADM) said on the night of [DATE], the only [MEDICATION NAME] in the building was on the Providence unit in the ADU, and the agency nurse did not have access to it. He/She said the unit where the resident resided did not have [MEDICATION NAME] available. During an interview on [DATE] at 2:05 P.M., emergency medical services (EMS) B said the facility staff did not report the resident's blood sugar was 34. He/She said if the blood glucose would have been reported, they would have started the [MEDICATION NAME] immediately. He/She said EMS staff were unable to revive the resident. During an interview on [DATE] 3:32 P.M., the resident's physician said he/she expects staff to notify him/her if a resident's blood glucose is 34, if there is new [MEDICAL CONDITION] activity or if the resident had an acute change in condition. He/She said if the resident's blood glucose is 34 and the resident goes unresponsive, he/she expects the nurse to stay with the resident and send other staff for medications and the supplies needed. He/She said staff should contact 911 first if an emergency, and if the blood sugar is 34, administration of glucose could change the outcome of the resuscitation efforts. During an interview on [DATE] at 3:56 P.M., the director of nursing (DON) said the orientation of agency nurses to the facility varies based on the agency nurse's comfort level. He/She said when a resident has an emergency medical decline he/she expects them to call 911. He/She said staff are expected to start CPR when a resident is unresponsive and not breathing, and if the resident stopped breathing he/she would not expect staff to leave the resident alone; standard of care would be for someone to start CPR and stay with the resident until EMS arrived and took over. During an interview on [DATE], at 5:18 P.M., LPN G said he/she oriented agency RN A to the building on [DATE]. He/She said the RN came in around 6:00 or 6:30 P.M., and he/she showed RN A around the building, the charting, and where to find code status' of the residents. He/She said he/she did not show the RN where the crash cart was, go over any policies on CPR, emergency medical response, location of [MEDICATION NAME], glucose gel, or any other policies. During an interview on [DATE], at 2:48 P.M., RN A said [DATE] was his/her first shift at the facility. He/She said he/she came in about an hour before the shift and the nurse showed me the location of the medication cart on the unit and contents, a general tour, and how to contact other staff in the building. He/she gave report on the resident's including the code status. He/She said the facility staff did not go over any emergency policies, which staff were CPR certified, or location of the crash cart or [MEDICATION NAME]. He/she said during report, the nurse reported the resident was nauseated that day and received medication for his/her nausea. RN A said when he/she left to find the [MEDICATION NAME], the resident was breathing. He/She said when he/she returned, he/she did not think the resident was breathing and he/she left to get his/her stethoscope. He/she said he/she is not sure why he/she left to find his/her stethoscope and did not start CPR. He/She said he/she told EMS staff the resident was gone, because he/she did not find the [MEDICATION NAME] and the resident was not breathing, and he/she said, my fear was he/she was going to be gone when they went in the room. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 817 MO 048

Based on interview and record review, facility staff failed to provide education, test, and return demonstrations as identified by the facility on the facility assessment to ensure competent staff. The facility also failed to provide 12 hours of training annually to certified nurse assistants (CNA)s, and dementia training for CNAs as required. The facility census was 41. 1. Review of the Facility Assessment showed the facility identified the following competency needs: For all staff: -Abuse, Neglect, Exploitation and Reporting-at orientation, annually, lecture, pre/post test and review for competency gaps; -Resident Rights-at orientation, annually, lecture, pre/post test and review for competency gaps; -Person Centered Care-at orientation, annually, lecture; -Cultural Competency-at orientation, annually, lecture; -Disaster Planning and Procedures-at orientation, annually, lecture, return demonstration, and review for competency gaps; -Infection Control/Handwashing-at orientation, annually, lecture, return demonstration, pre/post test and review for competency gaps; -Basic Dementia care and communication/behavioral approaches (except dietary)-at orientation, annually, lecture, and review for competency gaps; For licensed staff and nursing assistants: -Pressure Ulcer/Wound prevention-at orientation, annually, lecture, return demonstration, pre/post test and review for competency gaps; -Skin Care-at orientation, annually, lecture, return demonstration, pre/post test and review for competency gaps; -Effective Communication-at orientation, annually, lecture, pre/post test and review for competency gaps; -Dementia Care and Abuse Prevention-at orientation, annually, lecture, pre/post test and review for competency gaps; -Care for Persons with Cognitive Impairment-at orientation, annually, lecture, pre/post test and review for competency gaps; -Pain management Nurse role/CNA role-at orientation, annually, lecture, return demonstration, pre/post test and review for competency gaps; -Resident Assessments and exams-at orientation, annually, lecture, return demonstration, pre/post test and review for competency gaps; -Measurements-at orientation, annually, lecture, return demonstration, pre/post test and review for competency gaps; -Infection Control-at orientation, annually, lecture, return demonstration, pre/post test and review for competency gaps; -Identifying changes in condition-at orientation, annually, lecture, return demonstration, pre/post test and review for competency gaps; -Activities of daily living-at orientation, annually, lecture, return demonstration, pre/post test and review for competency gaps; -Specialized Care (catheter care, tube feedings, oxygen administration, etc.)-at orientation, annually, lecture, return demonstration, pre/post test and review for competency gaps; -Licensed Nurse Skills Checklist-at orientation, annually, lecture, return demonstration, pre/post test and review for competency gaps; -Nursing Assistant Skills Checklist-at orientation, annually, lecture, return demonstration, pre/post test and review for competency gaps; -Basic training in ROM and restorative care-at orientation, annually, lecture, return demonstration, pre/post test and review for competency gaps; For licensed staff: -Medication Administration-at orientation, annually, lecture, return demonstration, pre/post test and review for competency gaps; -Admission/Discharge medication reconciliation/Education orientation, annually, lecture, return demonstration, pre/post test and review for competency gaps. Review of the New Employee Orientation, undated, showed all traditionally hired staff (not agency) complete the following: -Resident Abuse and Neglect; -Resident Rights; -Infection Control; -Admission/Readmission policy; -Other topics not included on the Facility Assessment list. Review of the facility's employee education records, for a sample of employees, showed facility staff documented the following education completed in the last year: -Certified nurse assistant (CNA) M-hire date [DATE]- did not include any documented education; -CNA C-hire date [DATE]-Abuse and Neglect, and infection control/hand washing post test; -CNA N-hire date [DATE]-did not include any documented education; -CMT F-hire date [DATE]-Infection control/hand washing post test; -Licensed practical nurse (LPN) G-hire date [DATE]-Abuse and Neglect, and infection control/hand washing post test; -LPN O-hire date [DATE]-Abuse and Neglect, and infection control/hand washing post test; -Registered nurse (RN) P-hire date [DATE]-Jobs description and list of responsibilities; abuse and neglect, and infection control post test; -RN J-hire date [DATE]-Jobs description and list of responsibilities; and abuse and neglect post test; The documented CNA training did not contain 12 hours of annual documentation, dementia training, or training identified in the facility assessment. 2. Review of the facility's Code Status Report, dated [DATE], showed the facility has 24 residents with a full code status, one resident with a DNR (do not resuscitate) do CPR only, and 12 residents with a DNR status. Review of the facility's list of CPR certified staff, showed 9 nursing staff and one transportation staff member with current CPR/BLS certification, Review of the facility's Agency Checklist (for orientation of agency nurses), undated, showed; -Tour of the unit; -Verification of login; -Introduction to electronic health record; -Introduction to the medication cart; -Introduction to the charts; -Report of the patient's. During an interview on [DATE], at 3:06 P.M., CNA C said he/she received education when he/she was hired and with staff meetings, and with things that come up. He/She said he/she does not remember if he/she had dementia training at this facility and does not know if he/she has his/her 12 hours of training. During an interview on [DATE], at 5:18 P.M., LPN G said he/she oriented agency RN A to the building on [DATE]. He/She said the RN came in around 6:00 or 6:30 P.M., and he/she showed the RN around the building, the charting, and code status' of the residents. He/She said he/she did not show the RN where the crash cart was, go over any policies on CPR, emergency medical response, location of [MEDICATION NAME], glucose gel, or any other policies. During an interview on [DATE] at 2:48 P.M., RN A said [DATE] was his/her first shift at the facility. He/She said he/she came in about an hour before the shift and the nurse showed him/her the location and contents of the medication cart on the unit, a general tour, and how to contact other staff in the building. He/She gave report on the residents including the code status. He/She said the facility staff did not go over any emergency policies, which staff were CPR certified, location of the crash cart or where to locate [MEDICATION NAME]. During an interview on [DATE], at 9:40 A.M., RN J said he/she said he/she does not know which staff are CPR certified in the building. He/She said there is not a system to call for help in a medical emergency or code situation, the nurse would have to direct it. He/She said when an agency nurse works in the facility for the first time, he/she thinks they come in before the shift and get acquainted with the facility. He/She is not sure what information is reviewed with them. During an interview on [DATE], at 3:56 P.M., the director of nursing (DON) said the orientation of agency nurses to the facility varies on the agency nurses' comfort level. He/She said there is not a list of CPR/BLS certified staff posted in the building, or indicated on the staff listing. He/she said the ADON is responsible for developing the employee education and competencies, but the files by the previous employee were not well maintained and he/she does not know what education has been completed. He/She requested the employee training for the agency staff, but the agency did not provide the education and competencies for their staff. He/She said he/she would provide the documentation if he/she receives it. During an interview on [DATE], at 2:42 P.M., the assistant director of nursing (ADON) said he/she does the nursing schedule with the help of the DON. He/She said when he/she started in February, they collected CPR cards from staff members. He/She said the DON started in (MONTH) and gave him/her a list of certified staff. He/She said he/she is not sure when or if the schedule had a CPR certified staff on every shift but, but have been mindful of it lately. He/She said there is not a list posted for staff or a way for staff to know who is CPR/BLS certified. During an interview on [DATE], at 5:48 P.M., the ADON said he/she is charge of staff education. He/She said he/she has not seen the list in the facility assessment of identified competencies and training needs. He/She said he/she cannot find the competencies from before he/she started the position in February. He/She said he/she has not organized education and training documentation, so if it was done he/she cannot find it. He/She said he/she has been working on a skills fair, but did not have the list so some of it is on the to do list, but not all of it. He/She said it is important to do the return demonstration, if there is documentation of return demonstrations then he/she does not know where it is.

Based on observation, interview and record review, facility staff failed to allow sanitized dishes to air dry prior to stacking in storage to prevent the growth of food-borne pathogens. The facility census was 41. 1. Review of the facility's Dishwashing Machine Use policy dated (MONTH) 2010, showed staff are instructed to allow dishes to air dry after they are ran through the dishwashing machine. Observations on 05/05/19 during the initial kitchen tour beginning at 2:23 P.M., showed the following: -eight metal food preparation pans stacked together wet inside the cabinet underneath the cook's preparation station; -six insulated dome plate covers and nine insulated plate holders stacked together wet on the service shelf in the cook's station; -three glass dessert bowls and 3 glass soup bowls stacked together wet on the shelf beneath the aides preparation station. Further observation showed Dietary Aide A removed sanitized dishes from the mechanical dishwasher and stacked the dishes together while wet on a service cart. During an interview 05/07/19 at 12:00 P.M., the Dietary Manager said all dishes should be air dried before they are put away and all staff are trained on this requirement. During an interview on 05/07/19, the administrator said all dishes should be air dried before they are put away and and all staff are trained on this requirement.

Based on interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The facility staff failed to complete the [MEDICAL CONDITION] screening for three residents (Resident # 25, #8, and #10) out of five sampled residents, on admission to prevent the spread of infection. Facility staff also failed to sanitize a multiple resident use glucometer between three residents (Resident #21, #187, and #8) to prevent the spread of infection. Additionally, facility staff failed to don gloves to perform a PICC line medication administration for one resident (Resident #26). The facility census was 41. 1. Review of the facility's building maintenance, inspection and testing records, showed the records did not contain documentation of a complete water management program to monitor the facility's water systems for the growth of waterborne pathogens and prevent LD. Review showed documentation of a Legionella Water Management policy guideline, dated (MONTH) (YEAR), which instructed the facility staff to include a detailed description and diagram of the facility water system; identify areas in the water system that could encourage the growth and spread of Legionella and other waterborne bacteria; identify situations that can lead to Legionella growth; and develop specific measures to control the introduction and/or spread of Legionella in accordance with the Centers for Disease Control and Prevention guidelines and the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) recommendations. Review showed the records did not contain documentation of a risk assessment, a detailed description of the facility water systems or developed procedures to monitor and inhibit the growth of Legionella and other waterborne pathogens. During an interview on 05/07/19 at 1:00 P.M., the Maintenance Director said the facility only provided him/her with the policy guidelines and he/she has the plumbing plans for the building, but he/she did not have any additional information for the water management program. During an interview on 05/07/19 at 2:30 P.M., the administrator said he/she did not have documentation of a facility risk assessment, a detailed description of the facility water systems or developed procedures for the inspection, testing and maintenance of the facility water systems. The administrator said he/she did not know the information provided about the water management program did not contain all the required elements. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as [MEDICAL CONDITION] or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of [DIAGNOSES REDACTED] was published in (YEAR) by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In (YEAR), the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard(https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: --Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; --Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; --Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. 2. Review of the facility's policy titled [MEDICAL CONDITION], Screening Residents For, revised (MONTH) 2013, showed: -The facility will screen referrals for admission and readmission for information regarding exposure to, or symptoms of, [MEDICAL CONDITION] infection and disease (TB) and will check results of recent (within 12 months) [MEDICAL CONDITION] skin tests (TST), blood assay for [DIAGNOSES REDACTED] (BAMT) or chest Y-rays (CXR). -Any resident without documented negative TST, BAMT, or CXR within the previous 12 months will receive a baseline (two-step) TST or (one step) BAMT upon admission. If the first TST is negative, a follow-up TST will be administered 1 to 3 weeks after the initial test is read. The BAMT is a one step test. Review of Resident #25's Minimum Data Set (MDS), a federally mandated assessment, dated 4/15/19, showed staff documented the following: - admitted [DATE]. Review of the resident's medical record showed it did not contain documentation of a completed two step TST or a completed one step BMAT. 3. Review of Resident #8's MDS, dated [DATE], showed staff documented the following: - admitted [DATE]. Review of the resident's medical record showed it did not contain documentation of a completed two step TST or a completed one step BMAT. 4. Review of Resident #10's MDS, dated [DATE], showed staff documented the following: - admitted [DATE]. Review of the resident's medical record showed it did not contain documentation of a completed two step TST or a one step BMAT. During an interview on 5/9/19 at 7:30 P.M., the ADM and DON said staff did not document the administration of, or the reading of results of the TB skin tests for residents #25, #8, and #10. 5. Review of the glucometer care instructions, undated showed the following: -To disinfect meter, clean the meter surface with one of the approved disinfecting wipes. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Review of the disinfecting wipe directions showed: -Thoroughly wet pre-cleaned, hard, non-porous surface with a wipe, keep wet for 2 minutes (5 minutes if fungus is suspected), and allow to dry. Use as many wipes as needed for the treated surface to remain wet for the entire contact time. Observation on 5/7/19 at 11:28 A.M., showed licensed practical nurse (LPN) R perform glucose fingerstick checks for three residents (Resident #187, #8, and #21). Additional observation showed staff did not disinfect the glucometer as directed between residents. During an interview on 5/7/19 at 11:55 A.M., LPN R said staff should wipe the glucometer off between resident use with micro-kill wipes. He/She did not know how long the glucometer should remain wet for disinfection. During an interview on 5/9/19 at 7:30 P.M., the ADM and DON said staff should follow the glucometer disinfecting instructions. They said the facility did not have a policy for disinfecting glucometers. 6. Review of the facility's policy titled Central Venous and Midline Catheter (a catheter placed in a large vein to administer fluids and medication) Flushing, revised (YEAR), showed facility licensed nurses are instructed prior to flushing catheter: - Perform hand antisepsis (handwashing). Don (apply) non-sterile gloves. Observation on 5/7/19 at 11:14 A.M., showed LPN L did not put on gloves before he/she flushed the peripherally inserted central line (PICC) line for Resident #26. During an interview on 5/8/19 at 12:15 P.M., LPN Q said staff should wash hands and apply gloves before flushing a PICC line. During an interview on 5/8/19 at 7:30 P.M., the ADON and DON said staff are expected to follow the facility policy for use of PICC lines.

Based on observation, interview, and record review, facility staff failed to complete an admission baseline nursing assessment for six residents (Resident #201, #202, #203, #204, #205, and #206) out of six residents sampled. The facility staff also failed to follow physician orders [REDACTED].#25) and failed to check a peripherally inserted central catheter (PICC) line for placement and patency by checking for a blood return for one resident (Resident #26). The facility census was 41. Review of the facility's policy Admission Assessment and Follow Up: Role of the Nurse, dated (MONTH) 2012, directed staff to: -Conduct an admission assessment (history and physical), including: a. A summary of the individual's recent medical history, including hospitalization , acute illnesses, and overall status prior to admission. b. Relevant medical, social, and family history. c. A list of active medical [DIAGNOSES REDACTED]. d. Current medications and treatments. -Conduct a physical assessment, including the following systems: a. Eyes, Ears, Nose, Throat; b. Head and Neck; c. Teeth and Gums d. Cardiovascular; e. Respiratory; f. Neurological; g. Musculoskeletal h. Gastrointestinal; i. Genito-Urinary; and j. Skin -Conduct supplemental assessments (following facility forms and protocol) including; a. Activity level; b. Pain assessment; c. Fall risk assessment; d. Neurological assessment; e. Skin assessment; f. Functional assessment - ability to perform ADLs; and g. Behavioral assessment. -The following information should be recorded in the resident's medical record: 1. The date and time the assessment was performed 2. The name and title of the individual(s) who performed the procedure. 3. All relevant assessment data obtained during the procedure. 4. How the resident tolerated the assessment. 5. Orders obtained from the physician. 6. The signature and title of the person recording the data. 1. Review of Resident #201's medical record showed an admitted [DATE]. Additional review showed facility staff did not document an admission assessment for the resident. 2. Review of Resident #202's medical record showed an admitted [DATE]. Additional review showed facility staff did not document an admission assessment for the resident. 3. Review of Resident #203's medical record showed an admitted [DATE]. Additional review showed facility staff did not document an admission assessment for the resident. 4. Review of Resident #204's medical record showed an admitted [DATE]. Additional review showed facility staff did not document an admission assessment for the resident. 5. Review of Resident #205's medical record showed an admitted [DATE]. Additional review showed facility staff did not document an admission assessment for the resident. 6. Review of Resident #206's medical record showed an admitted [DATE]. Additional review showed facility staff did not document an admission assessment for the resident. During an interview on 05/09/19 at 6:45 P.M., the care coordinator registered nurse (RN) Q said he/she was unsure if the outpatient surgery residents receive an admission assessment. During an interview on 05/09/19 at 7:45 P.M., the administrator (ADM) said he/she expects staff to complete an admission nursing assessment on the outpatient surgery residents. 7. Review of Resident #25's admission minimum data set (MDS), a federally mandated assessment tool, dated 4/15/19, showed staff assessed the resident as follows: - Severe cognitive impairment; - [DIAGNOSES REDACTED]. Review of the resident's physician order [REDACTED]. Review of the resident's care plan, dated 4/28/19, showed staff are directed to obtain blood glucose levels as ordered, document and notify the resident's physician as needed. Review of the resident's Medication Administration Record [REDACTED] -04/09/19 at 11:40 AM, FSBS 425; -04/11/19 at 08:18 AM, FSBS 323; -04/12/19 at 12:17 PM, FSBS 303; -04/12/19 at 17:35 PM, FSBS 362; -04/13/19 at 10:49 AM, FSBS 379; -04/13/19 at 12:50 PM, FSBS 371; -04/13/19 at 17:30 PM, FSBS 365; -04/19/19 at 20:01 PM, FSBS 427; -04/20/19 at 17:18 PM, FSBS 367; -04/20/19 at 20:13 PM, FSBS 354 -04/21/19 at 17:56 PM, FSBS 306; -05/06/19 at 20:01 PM, FSBS 319; -05/07/19 at 12:07 PM, FSBS 347; -05/07/19 at 20:26 PM, FSBS 350; -05/08/19 at 20:37 PM, FSBS 320; -05/09/19 at 11:43 AM, FSBS 368. Review of the resident's medical record dated from 4/9/19 through 5/9/19, showed staff did not notify the resident's physician of the FSBS results greater than 300 on the above listed dates and times. During an interview on 5/8/19, at 9:40 A.M., RN J said if a resident's blood glucose is outside of the physician's parameters, staff are expected to notify the physician as the order directs. During an interview on 5/9/19, at 7:45 P.M., the ADM and director of nursing (DON) said staff did not document physician notification of the resident's FSBS results greater than 300 on the dates and times listed above. 8. Review of the facility's policy titled Central Venous and Midline Catheter (a catheter placed in a large vein to administer fluids and medication) Flushing, revised (MONTH) (YEAR), showed facility staff are instructed to aspirate the catheter for blood return to confirm patency prior to administration of medications and solutions. Review of Resident #26's baseline care plan dated 5/1/19, showed staff documented the resident has a peripherally inserted central catheter (PICC line) for antibiotic infusion. Review of the resident's POS dated 5/8/19, showed staff are directed to flush the PICC line with 5 milliliters (ml) of normal saline before medication administration. Observation on 5/7/19 at 11:14 A.M., showed LPN L flush the resident's PICC line with 10 cubic centimeter (cc) of normal saline. The LPN did not check for placement and patency by pulling back on the syringe for a blood return. During an interview on 5/8/19 at 12:15 P.M., LPN Q said staff should check a PICC line for patency by gently pulling back on the syringe for a blood return before flushing anything through it. During an interview on 5/8/19 at 7:30 P.M., the ADON and DON said they expect staff to follow the facility policy for PICC lines.