Every finding on record at Crestview Manor Healthcare

Based on observation and interviews, the facility failed to ensure meals were served at a palatable temperature at time of delivery. This failed practice had the potential to affect more than a minimal number of residents residing in the long term care facility. Census: 69 Findings included:a) ObservationOn 02/10/26, a request was made of the Nursing Aides (NAs) on [NAME] wing to allow the State Agency (SA) to test the temperature of the last regular tray on the cart. The NA alerted the dietary manager (DM) to bring a new tray for the resident and a thermometer. The DM #84 and corporate dietary #104 tested the temperatures at 12:40 PM with the following results:-Hamburger = 114.4 degrees Fahrenheit (F)-Potatoes = 107.8 degrees F-Corn = 92.7 degrees F-Fruit = 54.7 degrees Fb) InterviewDuring an interview on 02/10/26 at 12:40 PM, the corporate dietary #104 stated temperatures at time of service should be greater than 120 degrees F for hot foods and less than 41 degrees F for cold food. Another interview with the Administrator, completed on 02/10/26 at 12:41 PM, confirmed the palatable temperature range.

Based on record review, resident interview, and staff interviews, the facility failed to review Resident #40's care plan related to activities. This failed practice was found to be true for one (1) of 16 resident care plans reviewed during the long-term care survey process. Resident identifier: #40. Facility census: 69.Findings included:a) Record reviewRecord review, completed on 02/10/26, of the care plan for Resident #40 reads as follows: Resident receives three (3) one-to-one's (1:1's) weekly. Date Initiated: 12/12/25. Further record review of the 1:1 list provided by the Activity Director revealed Resident #40 was not on the list.b) InterviewsDuring an interview on 02/09/2026 at 2:01 PM, Resident #40 stated he does not go to Bingo or other activities but does enjoy playing dominoes. Resident stated he does not have anyone come to his room to offer in room activities.In an interview on 02/10/26 with the Activities Director (AD) at 2:39 PM, it was confirmed that the resident had no documented 1:1 visits.In an interview on 02/10/26 with the Administrator at 2:46 PM, it was confirmed 1:1 visits were not documented as being completed by the activity staff.

Based on resident interview, staff interviews, and record review, the facility failed to ensure activity programming was based on Resident #40's person centered care plan and personal interests. The facility had no documentation to reflect Resident #40 received activities of interests. This failed practice was found true for one (1) of two (2) residents reviewed for the care area of activities during the long-term care survey process. Resident identifier: #40 Facility census: 69.Findings included:a) InterviewsDuring an interview on 02/09/2026 at 2:01 PM, Resident #40 stated he does not go to Bingo or other activities but does enjoy playing dominoes. Resident stated he does not have anyone come to his room to offer in room activities.In an interview on 02/10/26 with the Activities Director (AD) at 2:39 PM, it was confirmed that the resident had no documented 1:1 visits.In an interview on 02/10/26 with the Administrator at 2:46 PM, it was confirmed 1:1 visits were not documented as being completed by the activity staff.b) Record reviewRecord review, completed on 02/10/26, of the care plan for Resident #40 reads as follows: Resident receives three (3) one-to-one's (1:1's) weekly. Date Initiated: 12/12/25. Further record review of the 1:1 list provided by the Activity Director revealed Resident #40 was not on the list.

Based on observation and staff interviews, the facility failed to ensure foods and equipment were stored under sanitary conditions. This failed practice had the potential to contaminate food-contact surfaces and cause foodborne illness. It also had the potential to affect more than a minimal number of residents who receive nutrition through the kitchen. These were random opportunities of discovery during the follow up kitchen tour. Census: 69.a) ObservationDuring a kitchen tour on 02/10/26, there was buildup noted in the bottom of the walk-in refrigerator. This was verified by corporate dietary #104 at 9:03 AM.There was a storage bin full of lids that had a brown sticky substance along the bottom of the bin. This was verified by corporate dietary #104 at 9:00 AM.Wet nesting (the practice of stacking wet dishware that does not allow air drying and can create an environment that supports bacterial growth) was identified in metal bowls and in insulated serving bowls. There were also three (3) melted/damaged insulated bowls identified and discarded by Dietician #105. b) InterviewAn interview was conducted with corporate dietary #104, at 9:03 AM on 02/10/26, in which the buildup in the walk-in refrigerator and the brown sticky substance along the bottom of the bin were verified.At 9:10 AM on 02/10/26, DM #84 verified the wet nesting and the damaged bowls.

49467 Based on record review, and resident, family, and staff interviews, the facility failed to provide the necessary supervision required to keep the environment for Resident #273 as free from accidents as possible, causing Resident #273 to have multiple falls in which she sustained multiple injuries. This was true for one (1) of three (3) residents reviewed for falls during the survey process. Resident Identifier: #273. Facility census: 69. Additionally, based on observation and resident and staff interview, the facility failed to keep the resident environment, over which it had control, was as free of accident hazards as possible, by leaving a potentially toxic substance on Resident #66's bedside table, making it accessible to other residents in the facility. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Resident identifier:66. Facility census: 69. Findings included: a) Resident #273 Resident #273 was admitted to the facility on [DATE] with a diagnosis of a nondisplaced fracture of base of neck of right femur. The resident did not have surgery performed on the fracture, instead, had a brace on the right leg and was non weight bearing. Brief Interview of Mental Status (BIMS) conducted on the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/24 was seven (7). The score indicates severe cognitive impairment. Diagnoses included Dementia, Diabetes, Renal Failure, cataracts, depression, Arthritis and Congestive Heart Failure (CHF). At approximately 12:00 PM on 06/25/24, a review of Resident #273's electronic health record was conducted, related to falls the resident suffered while she was at the facility. During the review, it was discovered Resident #273 suffered two falls with major injury while at the facility. On 04/10/24, Resident #273 suffered an unwitnessed fall that resulted in a fracture of her right elbow. On 05/22/24, Resident #273 suffered an unwitnessed fall that resulted in a laceration on her forehead of approximately two (2) inches, a laceration between her eyes, laceration of her left elbow, and a fractured neck. A review of Resident #273's care plan revealed the facility stated the resident should be 1:1 when resident tries to get up unassisted as she is non weight bearing at this time. This was listed as a fall intervention due to resident is at risk for falls r/t (related to) recent fall with fx (fracture)./rx (prescription) antidepressant. At approximately 1:00 PM on 06/25/24, an interview was conducted over the phone with a family member of Resident #273. The family member stated the facility was very aware the resident was unable to bear weight on their right leg due to the recent fracture, and the brace, and was continuously attempting to stand and walk on her own. The family member states the facility was not providing one (1) on one (1) care for Resident #273 despite stating she needed it. As a result, the family member states the family requested alarms for when Resident #273 would attempt to stand and walk on her own, but the facility told them alarms were not allowed by the State Agency (SA). The family member states that on 04/10/22, Resident #273 suffered a fall and hurt her right arm, at which time the facility ordered mobile x-rays for the resident. The family member states the facility told the resident's family the results of the mobile x-rays revealed no fracture, however, the resident continued to complain of pain in her arm, until she attended an orthopedic appointment on 04/15/22, at which time an x-ray was completed in their office. This x-ray revealed a fracture of the right elbow. Family member states the orthopedic doctor placed a brace on the resident's right arm and she returned to the facility. The next day, the family member states that while visiting the resident, the brace on her arm was gone and could not be located. The facility notes reveal the brace was found in a trash can and alleges the resident removed it. This resulted in the resident returning to the orthopedic doctor and having a cast placed on her arm. Family member states that the resident's family received a call on the night of 05/22/2024 informing them the resident suffered a fall and was being transferred to the hospital. Family member states emergency services were preparing to life flight Resident #273 due to her being lethargic and almost unresponsive after the fall. Family member states the fall was unwitnessed. At approximately 2:05 PM on 06/25/24 an interview was conducted with the Interim Director of Nursing (IDON) concerning the care plan and one (1) on one (1) interventions for Resident #273. However, the IDON stated You will need to speak with (First Name) the MDS Coordinator because she is the one that put that in and she is getting ready to take over the Director of Nursing (DON) position. I wasn ' t here at that time and she was, so she would know more than me. At approximately 2:14 PM on 06/25/24, an interview was conducted with the MDS Coordinator concerning the one (1) on one (1) intervention in the care plan for Resident #273. During the interview, the MDS Coordinator stated she entered the one (1) on one (1) intervention due to a physician's order stemming from Resident #273 continuously attempting to stand up out of her wheelchair and walk unassisted, while being non-weight bearing. The MDS coordinator stated Resident #273 was not under constant one (1) on one (1) supervision and acknowledged it would be difficult for staff at the facility to know when the resident attempted to stand up unassisted without her being under constant supervision, making it difficult for the staff to implement the intervention of 1:1 when resident tries to get up unassisted as she is non weight bearing at this time. The MDS Coordinator acknowledged there were multiple instances of Resident #273 attempting to stand and walk unassisted prior to both falls at the facility. The MDS Coordinator stated she believes the intervention for one (1) on one (1) supervision should have been removed from the care plan but acknowledged it was never removed, and still in place at the time of both falls, meaning the care plan was not being followed at the time of the falls. The MDS Coordinator states, however, they do not know if or when the intervention should have been removed, that the old DON would know, but they were no longer with the company. At approximately 2:50 PM on 06/25/24, an interview was conducted with a second family member of Resident #273. During this interview, the family member stated When we brought her into the facility, we were told she would need one (1) on one (1) supervision because she kept trying to stand up when she wasn't supposed to. She would try to get out of her chair, out of bed, all the time by herself and she wasn't supposed to because her leg was broken and she had the brace on it, and she was at risk of falling. The family member states the family was told both falls at the facility were unwitnessed and there was no supervision to prevent Resident #273 from getting up on her own. At approximately 3:15 PM on 06/25/24, an interview was conducted with Resident #7, a roommate of Resident #273 at the time of her falls. Concerning the fall on 05/22/24, Resident #7 states that Resident #273 was in her wheelchair, falling asleep, moving her head side to side. Resident #7 stated It looked like she was trying to get comfortable enough to sleep. I was watching TV and looked away for a minute. When I looked back, she was leaning forward in her chair, almost in the floor. I looked back at the TV again and that's when I heard the other lady in our room yell that (Resident's first name) Resident #273 had fallen. Resident #7 stated she saw Resident #273 lying in the floor, at which time facility staff came into the room to attend to her. Resident #7 confirmed there was no one (1) on one (1) supervision taking place at the time of the fall. Review of both facility reported incidents from 04/10/2024 and 05/22/2024 confirm both falls were unwitnessed and no supervision was taking place, per the care plan for Resident #273.

Based on resident interview, staff interview and observation, the facility failed to ensure hot food were served at a temperature of at least 120 degrees Fahrenheit (F). This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #21, #50, #66, and #51. Facility Census 69. Findings included: a) Resident #21 During the initial interview on 06/24/24 at 1:30 PM, Resident #21 stated, Hell no my food isn't hot. During an observation on 06/25/24 at 12:25 PM, the temperature of the lunch food at point of service was as follows: Ground chicken thigh: 115.5 degrees F. Spinach: 117 degrees F. Further observation showed that Resident #21 had refused the lunch tray and the lunch tray was tempt immediately after the last tray was delivered. The Corporate dietary manager confirmed that temperature at point of service should be at 120 degrees F. b) Resident #50 During the initial interview on 06/24/24 at 2:00 PM, Resident #50 states, The Food is cold, to get a hot cup of coffee around here would be a miracle. During an observation on 06/25/24 at 12:25 PM, the temperature of the lunch food at point of service was as follows: Ground chicken thigh: 115.5 degrees F. Spinach: 117 degrees F. The Corporate dietary manager confirmed that temperature at point of service should be at 120 degrees F. c) Resident #66 During the initial interview on 06/25/24 at 2:17 PM, Resident #66 states with a giggle Are you kidding me the food is always cold. During an observation on 06/25/24 at 12:25 PM, the temperature of the lunch food at point of service was as follows: Ground chicken thigh: 115.5 degrees F. Spinach: 117 degrees F. The Corporate dietary manager confirmed that temperature at point of service should be at 120 degrees F. d) Resident #51 At approximately 2:10 PM on 06/24/24, an interview was conducted with Resident #51. During the interview, Resident #51 stated I'm really happy with this place except for when my food is cold. It is cold a good bit of the time. That's the only thing I don't really like about it here. Temperatures were taken at the point of service for the lunch meal at approximately 12:25 PM, at which point the temperature of the chicken served was 115.5 degrees F and the spinach was 117 degrees F. 49467

Based on record review, resident interview and staff interview, the facility failed to adequately resolve a grievance. This was true for one (1) of two (2) residents reviewed for personal property. Resident identifier: #27. Facility census 59. Findings included: On 6/24/24 at 12:45 PM, Resident #27 reported that she had some clothing come up missing a couple of months ago and the facility told her family to replace the clothing and they would refund resident's family the money. She reported that the money had not yet been refunded, she can't remember if she had filed a grievance or complaint. On 06/24/24 at 3:44 PM, review of resident's grievance from 04/22/24 stated that resident had missing clothing. 8 (eight) items- green sweater, solid green shirt, denim pants, pjs, socks white, gray bra, solid red shirt, pink shirt. This grievance completed by Social Worker (SW) stated Have family replace missing items and reimburse family for money spent to replace items. On 06/25/24 at 2:25 PM, an interview with the Social Worker (SW) who reported that resident's family was reimbursed for the clothing that was missing in April and would look for a receipt. He also reported that the resident has a history of missing items that the facility had replaced. On 06/25/24 at 3:40 PM, an interview with the SW who reported that the resident's family was not reimbursed because the facility replaced the items in question. The resident's daughter also replaced the same items and requested to be reimbursed. The SW acknowledged that the grievance stated Have family replace missing items and reimburse family for money spent to replace items. The SW stated that they would make arrangements to refund the resident's family.

Based on record review and staff interview, the facility failed to update the Preadmission Screening and Resident Review (PASSAR) for Resident #3, after being diagnosed with major depressive disorder. Resident #51's PASSAR was not updated after being diagnosed with Post Traumatic Stress Disorder (PTSD) and Unspecified Psychosis. This was true for two (2) of two (2) residents reviewed for PASSAR's during the survey process. Resident identifiers: #3, #51. Facility census: 69. Findings included: a) Resident #3 At approximately 12:30 PM on 06/25/2024, a review of the electronic health record of Resident #3 was conducted. During this review, it was revealed Resident #3 was diagnosed with major depressive disorder on 09/28/2022. However, the most recent PASSAR completed for Resident #3 was on 06/10/2022, and makes no mention of the diagnosis of major depressive disorder. At approximately 1:53 PM on 06/26/2024, an interview was conducted with the Minimum Data Set (MDS) Coordinator concerning the PASSAR for Resident #3. The MDS Coordinator acknowledged the diagnosis of major depressive disorder on 09/28/2022 and the most recent PASSAR being completed on 06/10/2022. The MDS Coordinator acknowledged a new PASSAR should have been completed after Resident #3 was diagnosed with major depressive disorder. b) Resident #51 At approximately 2:30 PM on 06/24/2024, a review of the electronic health record of Resident #51 was conducted. During this review, it was revealed Resident #51 was diagnosed with PTSD and a psychosis disorder on 11/25/2022. However, the most recent PASSAR completed for Resident #51 was on 11/14/2022, and makes no mention of the diagnoses of PTSD or the psychosis disorder. At approximately 1:53 PM on 06/26/2024, an interview was conducted with the MDS Coordinator concerning the PASSAR for Resident #51. The MDS Coordinator acknowledged the diagnoses of PTSD and psychosis on 11/25/2022 and the most recent PASSAR being completed on 11/14/2022. The MDS Coordinator acknowledged a new PASSAR should have been completed after Resident #51 was diagnosed with PTSD and the psychosis disorder.

Based on record review and staff interview, the facility failed to accurately develop care plans related to capacity and one on one supervision. This failed practice was found true for (2) two of 17 residents reviewed for care plans during the Long-Term Care Survey Process. Resident identifiers: #50 and #273. Facility census: 69. Findings Included: a) Resident #50 A record review on 06/25/24 at 11:06 AM, of Resident #50's care plan revealed the following: Intervention revised on 03/06/24: The resident has a communication problem r/t vision deficit/lacks capacity to make medical decisions. Further record review revealed a capacity form completed on 01/05/24 that is marked as Resident #50 demonstrates capacity to make decisions. During an interview on 06/26/24 at 12:15 PM, The Director of Social Services (DSS) confirmed that Resident #50 does have capacity and the care plan was wrong. b) Resident #273 Resident #273 was admitted to the facility on [DATE] with a diagnosis of a nondisplaced fracture of base of neck of right femur. The resident did not have surgery performed on the fracture, instead, she had a brace on her right leg and was non weight bearing. At approximately 12:00 PM on 06/25/24, a review of Resident #273's electronic health record was conducted related to falls the resident suffered while at the facility. During the review, it was discovered Resident #273 suffered two (2) falls with major injury while at the facility. On 04/10/24, Resident #273 suffered an unwitnessed fall that resulted in a fracture of the right elbow. On 05/22/24, Resident #273 suffered an unwitnessed fall that resulted in a laceration on her forehead of approximately two (2) inches, a laceration between the eyes, laceration of the left elbow, and a fractured neck. A review of Resident #273's care plan revealed the facility stated the resident should be 1:1 when resident tries to get up unassisted as she is non weight bearing at this time. This was listed as a fall intervention due to resident is at risk for falls r/t (related to) recent fall with fx (fracture)./rx (prescription) antidepressant. At approximately 1:00 PM on 06/25/24, a telephone interview was conducted with a family member of Resident #273. The family member stated the facility was very aware the resident was unable to bear weight on the right leg due to the recent fracture, and the brace, and was continuously attempting to stand and walk on her own. The family member states the facility was not providing one (1) on one (1) care for Resident #273 despite stating she needed it. As a result, the family member states the family requested alarms for when Resident #273 would attempt to stand and walk on her own, but the facility told them alarms were not allowed by the State Agency (SA). The family member states that on 04/10/22, Resident #273 suffered a fall and hurt her right arm, at which time the facility ordered mobile x-rays for the resident. The family member states the facility told the resident's family the results of the mobile x-rays revealed no fracture, however, the resident continued to complain of pain in her arm, until she attended an orthopedic appointment on 04/15/22, at which time an x-ray was completed in their office. This x-ray revealed a fracture of the right elbow. Family member states the orthopedic doctor placed a brace on the resident's right arm and she returned to the facility. The next day, the family member states that while visiting the resident, the brace on her arm was gone and could not be located. The facility notes reveal the brace was found in a trash can and alleges the resident removed it. This resulted in the resident returning to the orthopedic doctor and having a cast placed on her arm. Family member states that the resident's family received a call on the night of 05/22/24 informing them the resident suffered a fall and was being transferred to the hospital. Family member states emergency services were preparing to life flight Resident #273 due to her being lethargic and almost unresponsive after the fall. Family member states the fall was unwitnessed. At approximately 2:05 PM on 06/25/24 an interview was conducted with the Interim Director of Nursing (IDON) concerning the care plan and one (1) on one (1) interventions for Resident #273. However, the IDON stated You will need to speak with (First Name) the MDS Coordinator because she is the one that put that in and she is getting ready to take over the Director of Nursing (DON) position. I wasn't here at that time and she was, so she would know more than me. At approximately 2:14 PM on 06/25/24, an interview was conducted with the MDS Coordinator concerning the one (1) on one (1) intervention in the care plan for Resident #273. During the interview, the MDS Coordinator stated she entered the one (1) on one (1) intervention due to a physician's order stemming from Resident #273 continuously attempting to stand up out of her wheelchair and walk unassisted, while being non-weight bearing. The MDS coordinator stated Resident #273 was not under constant one (1) on one (1) supervision and acknowledged it would be difficult for staff at the facility to know when the resident attempted to stand up unassisted without her being under constant supervision, making it difficult for the staff to implement the intervention of 1:1 when resident tries to get up unassisted as she is non weight bearing at this time. The MDS Coordinator acknowledged there were multiple instances of Resident #273 attempting to stand and walk unassisted prior to both falls at the facility. The MDS Coordinator stated she believes the intervention for one (1) on one (1) supervision should have been removed from the care plan but acknowledged it was never removed, and still in place at the time of both falls, meaning the care plan was not being followed at the time of the falls. The MDS Coordinator states, however, they do not know if or when the intervention should have been removed, that the old DON would know, but they were no longer with the company. At approximately 2:50 PM on 06/25/24, an interview was conducted with a second family member of Resident #273. During this interview, the family member stated When we brought her into the facility, we were told she would need one (1) on one (1) supervision because she kept trying to stand up when she wasn't supposed to. She would try to get out of her chair, out of bed, all the time by herself and she wasn't supposed to because her leg was broken and she had the brace on it, and she was at risk of falling. The family member states the family were told both falls at the facility were unwitnessed and there was no supervision to prevent Resident #273 from getting up on her own. At approximately 3:15 PM on 06/25/24, an interview was conducted with Resident #7, a roommate of Resident #273 at the time of her falls. Concerning the fall on 05/22/2024, Resident #7 stated that Resident #273 was in her wheelchair, falling asleep, moving her head side to side. Resident #7 stated It looked like she was trying to get comfortable enough to sleep. I was watching TV and looked away for a minute. When I looked back, she was leaning forward in her chair, almost in the floor. I looked back at the TV again and that's when I heard the other lady in our room yell that (Resident's first name) Resident #273 had fallen. Resident #7 stated she saw Resident #273 lying in the floor, at which time facility staff came into the room to attend to her. Resident #7 confirmed there was no one (1) on one (1) supervision taking place at the time of the fall. Review of both facility reported incidents from 04/10/24 and 05/22/24 confirm both falls were unwitnessed and no supervision was taking place, per the care plan for Resident #273. 49467

Based on record review and staff interview the facility failed to complete a discharge summary of Resident #72. This failed practice was found true for (1) one of (1) residents reviewed for unplanned discharge during the Long-Term Care Survey Process. Resident identifier #72. Facility census 69. Findings Include a) Resident #72 A record review on 06/26/24 at 12:54 PM, revealed that Resident #72 had an unplanned discharge from the facility. Further record review revealed that a discharge summary was not completed in its entirety. During an interview on 06/26/24 at 12:57 PM, the Director of Nursing (DON) stated, Her discharge was so confusing. It was planned in the fact that she was going home, but unplanned because we did not know when her son was coming to get her. The DON further stated, We do have a problem with our discharge process and we are working on it,

Based on observation, record review, and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. A multidose medication vial was not dated when opened. This was a random opportunity for discovery made during the medication storage task. Facility census: 69. Findings included: a) Medication Storage During investigation of the [NAME] and [NAME] hallways medication preparation room on 06/25/24 at 9:35 AM, a multidose vial of Tubersol tuberculin purified protein derivative was found to not have been dated when opened. Tuberculin purified protein derivative is given by injection to aid in the diagnosis of tuberculosis. According to the Tubersol package insert accompanying the vial and available on the Food and Drug Administration website, A vial of Tubersol which has been entered and in use for 30 days should be discarded. Because the vial had not been dated when opened, it could not be determined when the vial should be discarded. Licensed Practical Nurse (LPN) #59 verified the Tubersol vial was not dated when opened. No further information was provided through the completion of the survey.

Based on record review and staff interview the facility failed to ensure the Infection Prevention and Control Program (IPCP) policy and procedures were reviewed annually in accordance with the federal guidance and the facility assessment. This had a potential to affect all residents residing in the facility. Facility Census: 63 Findings included: a) IPCP policy and procedures During an record review on [DATE] at 9:00 AM the facility policies and procedures were not reviewed annually were as follows: -A facility policy and procedure titled Infection Prevention Program with a reviewed date of [DATE] -A facility policy and procedure titled CPR(Cardiopulmonary resuscitation) Guidance during the COVID-19 Pandemic with a reviewed date of [DATE]. During a review on [DATE] at 9:13 AM the facility assessment read as follows. .Part 3: Facility resources needed to provide competent support and care for our resident population every day and during emergencies. .Policies and Procedures for provision of care 3.5 .Policies and procedures are reviewed annually and revised as needed. During an interview on [DATE] at 9:24 AM the Executive Director (ED) stated the facility was bought out in May. She stated, I assumed we would have a year to review everything. The ED acknowledged the facility assessment stated the policy and procedure would be revised as needed, which would include the take over date.

Based on observation, facility policy, record review and staff interview, the facility failed to ensure foods were stored and prepared in a safe, clean, and sanitary environment. During the observation of the kitchen, unsanitary and unclean areas were discovered. This had the potential to affect all residents receiving nourishment from the kitchen. Facility Census: 63. Findings included: A review of the facility policy titled Equipment with a revision date of 09/2017 read as follows. Procedures: 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directors and training materials. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be clean and sanitized after every use. 4. All non food contact equipment will be clean and free of debris A review of the facility policy titled Environment with a revision date of 09/2017 reads as follows. Procedures: 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting and ventilation. 2. The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces. 3. All food contact surfaces will be cleaned and sanitized after each use. 4. The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces. a) Facility Kitchen An initial tour of the kitchen with the Culinary Director (CD) beginning on 09/06/23 at 8:49 AM revealed the follow: -On the floor behind the Stove were food particles, an empty butter container, an empty dirty storage bag and a flat adhesive bait pad which had several bugs attached including a few dead and 2 alive roaches. -The stove drip pan had a large amount of food particles, several grease spills and a large amount of build up. During an immediate interview the CD stated It looks like it has not been cleaned in several days. During an immediate interview Cook #18 stated I cleaned the burners yesterday but did not do the drip pan or the oven. -The stove temperature knobs had grease build up on and around them. The CD pulled off the stove temperature knob and under it was full of dust with grease build up. During an immediate interview Cook #18 stated I did not know the knobs came off to clean under them. -The oven had food particles build up and grease spillage. During an immediate interview the CD acknowledged the oven had not been clean. The CD was asked for a kitchen/equipment cleaning list. A dining services opening checklist was provided by the CD on 09/06/23 at 9:27 AM. The week on 17-22, no month was provided. The job duties included: all equipment clean inside and out was void documentation on the following dates: -08/17/23 -08/20/23 Floors swept and mopped from last night was void any documentation for the week provided During an immediate interview the CD stated This is all the documentation I could find on the cleaning, we have not been keeping up with it. The maintenance completes a cleaning monthly, pulls out everything and cleans the vents. During an interview on 09/06/23 at 9:13 Am The Director of Plant Maintenance stated the other Maintenance man (Maintenance Technician #23's name) comes in monthly after the kitchen is closed and does a detailed cleaning. The Director of Plant Maintenance was asked for the monthly kitchen cleaning log. The Dietary Maintenance Log was presented to this surveyor on 09/06/23 at 9:35 AM it was void cleaning for the month of 08/23. The Director of Plant Maintenance acknowledged it was void of cleaning in August.

Based on observation and staff interview the facility failed to maintain sanitary condition of the outside garbage receptacle to prevent the harborage and feeding of pests. This deficient practice has the potential to affect all the residents that reside in the facility. Facility Census:63 Findings included: a) Garbage Receptacle During several observations of the outside garbage receptacle lids not closed on the follow date and times: -09/06/23 at 8:30 AM -09/06/23 at 8:48 AM -09/06/23 at 9:11 AM -09/06/23 at 9:42 AM -09/06/23 at 10:30 AM -09/06/23 at 11:03 AM -09/06/23 at 12:08 AM During a tour of outside of the facility on 09/06/23 at 12:15 PM Laundry Staff #83 was pushing a cart labeled Trash I observed her with the trash removal into the garbage receptacle. Laundry Staff #83 was trying to close the lid to the garbage receptacle but was unsuccessful. Laundry Staff #83 stated it was too bent and too heavy for me to close, and left the garbage receptacle lid open. During an interview, on 09/06/23 at 12:38 PM, the Executive Director and the Director of Plant Maintenance, acknowledged the garbage receptacle lids were open, and needed to be closed at all times.

Based on observation,record review and staff interview the facility failed to ensure an environment for residents that was free of rodents. The practice had the potential to affect more than a limited number of residents receiving nourishment from the facility kitchen. Facility Census: 63 Findings Included: a) Kitchen During an initial tour of the kitchen with the Culinary Director (CD) beginning on 09/06/23 at 8:49 AM revealed the following pest control traps. On the floor under the steam table/serving table were the following pest control traps A round ant bait trap A white carbon bait box with large of amount of bugs inside, including roaches A white flat adhesive bait pad with large amount of bugs attached including 4 roaches During an immediate interview the Culinary Director (CD) and Cook #18 acknowledged the bugs inside and on the bait. On the floor behind the stove an observation revealed a flat adhesive bait pad which had a large amount of bugs attached including a few dead and 2 alive roaches During an immediate interview the Culinary Director (CD) and Cook #18 acknowledged the bugs on the bait. On the floor under the Juice and Coffee Station an observation revealed two (2) black bug trapper boxes both of the box containing bugs including roaches. During an immediate interview the Culinary Director (CD) and Cook #18 acknowledged the bugs inside the bait. On the floor under the three compartment (3) sink observationr revealed a black bug trapper boxes with several bugs containing bugs including roaches. Observation also revealed a flat adhesive bait pad with several bugs attached. During an immediate interview the Culinary Director (CD) and Cook #18 acknowledged the bugs inside and on the bait. On the floor under another serving table with the toaster on it A black bug trapper boxes with several bugs containing bugs including roaches A flat adhesive bait pad with several bugs attached During an immediate interview the Culinary Director (CD) and Director of Plant maintenance acknowledged the bugs inside and on the bait. Inside the Thermal plate warmer caddy contained a large amount of food particles and seven dead roaches. During an immediate interview the Culinary Director (CD) and Director of Plant maintenance acknowledged the bugs inside of the plate warmer. The CD stated, We are unable to clean it, we don't know how to take it apart to clean it. The Director of Plant Maintenance pulled the inside of the Thermal plate warmer plate holder out and stated you just lift it out, you can clean it. The Dry storage room revealed a loose white plastic lid sitting on a shelf with two (2) sealed packages of cake mixes. A large amount of small black ants were crawling on the lid around the cake mixes. During an immediate interview the CD stated we have an ant problem, but the roaches come on the boxes from the food truck, that's how we get those. b) Interviews During an interview on 09/06/23 at 9:13 AM the Director of Plant Maintenance stated that we have always had an ant problem, I have worked here almost [AGE] years. We have roaches also. The pest control comes out monthly and we also spray in the kitchen when needed. During an interview on 09/06/23 at 11:10 AM Maintenance Technician #23 stated, I do the dietary monthly cleaning on the last Thursday of the month. I pull out the stove and all the serving tables to mop and buff under everything. The roaches and ants are everywhere. I have worked here over a year and there has always been a problem with both. The white adhesive traps were put out by myself and the (The director of plant maintenance's name) about a week and half ago. And stated I am sure they were full when you looked at them. The dietary is always calling us to come and change the adhesive traps. c) Pest Control During a review of a (a name of local) pest control invoice revealed the following comments(typed as written). 08/21/23: Replaced monitors in kitchen. There were five (5) on trap I replaced. 07/17/23: Ants in Activities office around air conditioning unit. 05/15/23: Kitchen had a few roaches in one trap. 03/17/23: Complaining of roaches around plate warmer machine in kitchen.

Based on observations during the kitchen tour and staff interview the facility failed to store food in a safe and sanitary manner in accordance with professional standards for food service safety. It was discovered during the kitchen tour that food items were not stored properly after opening and the walk-in cooler was very dirty. This had the potential to affect any residents receiving nourishment from the kitchen. Facility census: 63. Findings included: a) Kitchen tour During the kitchen tour on 09/12/22 at 10:55 AM, it was discovered a five (5) pound bag of potato squares had been damaged and the contents were spilling onto the floor. A package of pancakes were not dated after opening. In addition, the walk-in cooler had a buildup of a black tarry substance on the floor. The platforms used to keep food off the floor had debris under them. An interview with the Dietary Manager on 09/12/22 at 11:00 AM, verified the package of potato squares was damaged and the pancakes were not dated after opening. Also the floor of the walk-in cooler was dirty and needed to be cleaned.

Based on medical record review and staff interview the facility failed to develop a comprehensive care plan in the area of dialysis services. This was discovered for one (1) of one (1) residents reviewed for dialysis services. Resident #11's care plan interventions did not include the specified days hemodialysis services were being provided. Resident identifier: #11 Facility census: 63 Findings included: a) Resident #11 A medical record review for Resident #11 on 09/13/22, revealed the care plan interventions for dialysis services were incomplete. It did not specify on what days hemodialysis services were being provided for Resident #11. An interview with the Director of Nursing (DON) on 09/14/22 at 10:30 AM, verified the care plan interventions for dialysis services did not include the days of the week Resident #11 received hemodialysis.

Based on record review and staff interview, the facility failed to revise a care plan for the care area of risk for falls. This is true for one (1) of two (2) residents reviewed for the care area of accidents during the long-term survey. Resident #7. Facility Census: 63. Findings Included: a) Resident #7 On 09/13/22 at 2:00 PM, the care plan with the focus area of risk for falls was reviewed. An intervention of hourly rounds at night was found. A review of the record found no evidence of the hourly rounds at night being completed. An interview on 09/13/22 at 2:38 PM with Assistant Director of Nursing (ADON) #32 was held. The ADON #32 stated, the intervention of hourly rounds at night was discontinued in June. The ADON #32 confirmed the care plan had not been revised to discontinue the intervention. No further information was provided during the survey process.

Based on medical record review and staff interview, the facility failed to notify the residents physician when a change of condition occurred. This was a random opportunity for discovery. Resident identifier: 163. Facility census: 63. Findings include: a) Resident #163 Review of Resident #163's original discharge summary from the hospital dated 02/25/22, revealed the resident had a pacemaker with an ICD implanted due to manage his atrial fibrillation with rapid ventricular rhythm. A implantable cardioverter-defibrillator (ICD) is a device that detects any life-threatening, rapid heartbeat. This abnormal heartbeat is called an arrhythmia. If it occurs, the ICD quickly sends an electrical shock to the heart. The shock changes the rhythm back to normal. This is called defibrillation. Review of Resident #163's nurses note, written by Employee #12, a Licensed Practical Nurse (LPN), dated 05/20/22 at 11:49 am, found a note which read: Daughter called the facility and spoke to the Minimum Data Set (MDS) nurse. Daughter stated that the resident's cardiology office had called her and stated that the pacemaker readings were showing runs of ventricular tachycardia (fast heart rate) and the cardiologist wanted him to be sent to the emergency room . Additionally, a nurses note written by LPN #70, dated 05/20/22 at 12:20 PM, which read, Earlier this am around 8:00 am, the resident kept ringing his call light and saying that his pacemaker was shocking him. Resident did this approximately 4 times . Further review found no nurses notes concerning the notification of the physician when the pacemaker with ICD was shocking the resident until the daughter called several hours later and requested the resident be sent out to emergency room as recommended by the cardiologist. On 09/14/22 at 9:15 AM, the Director of Nursing (DON) confirmed the nurse failed to notify the attending physician of the resident receiving a shock from his pacemaker with an ICD at least four (4) times.

Based on medical record review and staff interviews, the facility failed to provide care and services to promote healing of a known pressure ulcer and to prevent further pressure ulcers from developing. The facility failed to accurately assess and/or correctly document the location of the coccyx/buttocks wound care site (incorrect measurements and staging were conducted on 04/28/22, 05/10/22 and 05/17/22. Resident identifier: #163. Facility census: 63. Findings include: a) Resident #163 Resident #163 was originally admitted to the facility on [DATE]. Admitting diagnosis included: atrial fibrillation, acute and chronic respiratory distress with hypoxia, and rheumatoid arthritis. Review of the admission assessment dated [DATE] at 2:39 PM, revealed the resident required extensive assistant with bed mobility, dressing, toilet use and personal hygiene; total dependence on staff for transfers; and independent with feeding after initial setup. No skin issues were noted on initial assessment. The Resident was alert to person, place, time, and situation. Review of the baseline care plan completed on 02/27/22 at 1:20 PM, noted the resident should be turned and reposition every two (2) hours, have a pressure reducing mattress and a cushion in chair. Review of Resident #163's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 03/03/22, reveals the resident was at risk of developing pressure ulcers/injuries and is coded to indicate he has a pressure reducing device for the bed. The Resident was hospitalized from 03/13/22 through 03/18/22 for the treatment of right lower lobe pneumonia, atrial fibrillation, congestive heart failure and hyperkalemia. Re-admission nursing assessment dated [DATE] at 5:32 PM, reveals the resident has the following pressure ulcer/injuries by Employee #3, Licensed Practical Nurse (LPN) and verified by RN #9 on 03/19/22 at 1:06 PM: --Suspected deep tissue injury- coccyx measuring 3.3 centimeters (cm) in length and 0.5 cm in width. -- Suspected deep tissue injury- right heel measuring 3.0 (cm) in length and 6.0 cm in width. -- Suspected deep tissue injury- left heel measuring 4.0 (cm) in length and 5.0 cm in width. Deep tissue injury (DTI): intact or non-intact skin with localized area of persistent non-blanchable, deep red, maroon, purple discoloration, or separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. --Stage II pressure ulcer on right buttocks measuring 0.5 cm in length and 0.2 cm in width and less than 0.1 cm in depth. --Stage II pressure ulcer on left buttocks measuring 0.3 cm in length and 0.2 cm in width and less than 0.1 cm in depth. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Treatment orders written on 03/18/22 were as follows: Cleanse areas on coccyx and buttocks with normal saline and apply skin prep to discoloration on coccyx and zinc to the open areas on buttocks daily. Skin prep to be applied to bilateral heels daily. No orders were found for pressure-relieving mattress or a pressure relieving device for the chair. Weekly pressure ulcer assessment dated [DATE] at 10:10 am by RN #46, reveals the resident has the following pressure ulcer/injuries by RN #46: --Suspected deep tissue injury- coccyx measuring 3.2 centimeters (cm) in length and 0.5 cm in width. -- Suspected deep tissue injury- right heel measuring 3.0 (cm) in length and 6.0 cm in width. -- Suspected deep tissue injury- left heel measuring 3.0 (cm) in length and 5.0 cm in width. --Stage II pressure ulcer on right buttocks measuring 0.5 cm in length and 0.2 cm in width and less than 0.1 cm in depth. --Stage II pressure ulcer on left buttocks measuring 0.3 cm in length and 0.2 cm in width and less than 0.1 cm in depth. Weekly pressure ulcer assessment dated [DATE] at 4:06 PM by RN #46, reveals the resident has the following pressure ulcer/injuries: --Unstageable- coccyx measuring 3.0 centimeters (cm) in length and 1.5 cm in width with no depth. Unstageable: full thickness skin and tissue loss in which the extent of tissue damage within the ulcer, cannot be confirmed because it is obscured by slough or eschar. --Stage II pressure ulcer on right buttocks measuring 0.3 cm in length and 0.2 cm in width and less than 0.1 cm in depth. --Stage II pressure ulcer on left buttocks measuring 0.2 cm in length and 0.2 cm in width and less than 0.1 cm in depth. Pressure ulcers on left and right heels resolved. Weekly pressure ulcer assessment dated [DATE] at 3:56 PM by RN #46, reveals the resident has the following pressure ulcer/injuries: --Unstageable- coccyx measuring 3.5 centimeters (cm) in length and 1.5 cm in width with no depth. Comments/summary: Area on coccyx declining measures 3.5 cm in length and 1.5 cm in width, wound bed is covered with 90% yellow slough. --Stage II pressure ulcer on left buttocks measuring 0.2 cm in length and 0.4 cm in width and less than 0.1 cm in depth. Pressure ulcer on the right buttock healed. The Physician wrote an order for the air mattress on 04/04/22. No orders for chair cushion noted. Weekly pressure ulcer assessment dated [DATE] at 8:02 am by RN #46, reveals the resident has the following pressure ulcer/injuries: --Unstageable- coccyx measuring 3.4 centimeters (cm) in length and 0.5 cm in width with no depth. Pressure ulcer on left buttocks healed. Weekly pressure ulcer assessment dated [DATE] at 3:46 PM by RN #46, reveals the resident has the following pressure ulcer/injuries: --Unstageable- coccyx measuring 3.4 centimeters (cm) in length and 0.5 cm in width with no depth. The Resident was hospitalized from 04/24/22 through 04/28/22 for the treatment of atrial fibrillation with a rapid ventricular rate, hypotension, acute respiratory failure, chronic obstructive pulmonary disease, and decubitus ulcer of buttocks. Re-admission nursing assessment dated [DATE] at 5:20 PM by RN #46, reveals the resident has the following pressure ulcer/injuries: --Unstageable- coccyx measuring 4.0 centimeters (cm) in length and 3.2 cm in width with no depth. Details/comments: Resident had an unstageable wound to coccyx prior to admission, upon re-admission wound is covered 100% yellow slough with surrounding skin purple in color measuring 8 cm in length and 3.0 cm in width. Interview with the Director of Nursing (DON) on 09/13/22 at 11:10 am, found the measurements for the unstageable wound on the coccyx should include the entire area including the purple-colored skin. She verified the measurements should read: 12 cm in length and 6.2 cm in width; this includes the area with slough and the purple-colored skin surrounding the area. The Resident was hospitalized from 04/30/22 through 05/02/22 for the treatment of atrial fibrillation with a rapid ventricular rate, hypotension, acute respiratory failure secondary to Covid-19 pneumonia, chronic obstructive pulmonary disease, and decubitus ulcer of buttocks. Evaluation by Registered Nurse completed on 05/03/22 at 4:42 PM by RN #9, reveal the following pressure ulcers as follows: --Stage IV on coccyx area measuring 3.5 cm in length and 2.0 cm in width and no depth measured. Stage 4: full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are exposed. Weekly pressure ulcer assessment dated [DATE] at 1:30 PM by RN #46, reveals the resident has the following pressure ulcer/injuries: --Unstageable- coccyx measuring 3.3 centimeters (cm) in length and 2.0 cm in width with no depth. --SDTI- coccyx 0.9 cm in length and 0.5 cm in width. Weekly pressure ulcer assessment dated [DATE] at 3:57 PM by RN #46, reveals the resident has the following pressure ulcer/injuries: --Unstageable- coccyx measuring 5.5 centimeters (cm) in length and 3.2 cm in width with no depth. --Unstageable- right buttock measuring 1.5 centimeters (cm) in length and 1.2 cm in width with no depth. Description for pain management with the wound/treatment: wound to coccyx has increased and now encompasses the sacrum and right buttock, area is 100% covered with yellow slough. Interview with the DON on 09/14/22 at 9:15 am, found the nurses had failed to accurately stage and measure the pressure area on the sacral/coccyx area and extending on to the entire right buttocks. She also confirmed a pressure-relieving cushion for his chair was never ordered.

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The state agency determined these failures placed Resident #17 and other residents receiving fingerstick blood glucose monitoring and insulin coverage in an immediate jeopardy situation due to potential complications from [CONDITION(S)] resulting from failure to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility submitted a plan of correction (POC) at 4:38 PM. The state agency requested changes and an additional POC was submitted at 4:50 PM. At 4:55 PM, the POC was accepted by the state agency. The state agency verified the POC was implemented by conducting staff interviews and the immediate jeopardy was abated at 5:15 PM on 05/19/21. Once the immediate jeopardy was abated, deficient practices remained and the scope and severity was decreased from a J to an D. Additionally, the facility failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to perform neurological checks according to professional standards of practice after unwitnessed falls for two (2) of five (5) residents reviewed for the care area of falls. Resident identifiers: #17, #43, #22, and #3. Facility census: 60. Findings included: a) Resident #17 Review of Resident #17's medical records revealed from 02/27/21 to 05/7/21, the resident had the following order in place: [MEDICATION(S)] R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if [blood glucose level] 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units Call MD, subcutaneously three times a day related to type 2 diabetes mellitus with diabetic [CONDITION(S)]. The glucose level was to be obtained by fingerstick. Fingerstick blood glucose monitoring is a procedure performed by nurses utilizing a blood glucose monitor and a drop of blood obtained by sticking the resident's finger with a small lancet. The blood glucose fingerstick results were documented on the Medication Administration Record (MAR). Sometimes the blood glucose fingerstick results were documented on the Weights and Vitals Summary tab in the Electronic Medical Record (EMR). On 04/5/21 at 4:45 PM, the MAR recorded the resident's blood glucose was 424 and 10 units of insulin were administered as ordered by the sliding scale. There is no indication the physician was notified as ordered for blood glucose level 401-450. The next fingerstick blood glucose was obtained 05/06/21 at 6:45 AM, and the result was 262. On 04/07/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. NA does not correspond to a chart code on the MAR. The Weights and Vitals Summary tab recorded the blood glucose level as 530 on 04/07/21 at 1:37 PM. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 530. A nursing progress note written on 04/07/21 at 1:40 PM stated, Blood sugar 530. Administered 10 units at this time of coverage. Will re-check and re-assess. The insulin administration was not documented on the MAR. There was no indication the physician was notified. The next fingerstick blood glucose was obtained 04/7/21 at 4:45 PM and the result was 254. On 04/08/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. A nursing progress note written on 04/08/21 at 12:41 PM stated, Resident's blood sugar reading hi at this time 10 units administered and to be re-assessed. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level too high for the glucometer to read. The insulin administration was not documented on the MAR. There was no indication the physician was notified at this time. On 04/08/21 at 4:00 PM, a nursing progress note stated, Resident's blood sugar still reading hi. Message left for Dr. William's via cell phone to return call to facility concerning blood sugar. Awaiting call back from MD. A nursing progress note written on 04/08/21 at 6:11 PM stated, Blood sugar 561 at this time. 12 units [MEDICATION(S)] R administered per standing order for coverage. Still awaiting a call back from MD to notify of high blood sugar. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 561. The insulin administration was not documented on the MAR. A nursing progress note written on 04/08/21 at 7:41 PM stated his regularly scheduled insulin was given and blood sugar reading hi. Resident not showing s/s [signs/symptoms] of [CONDITION(S)] at this time. Awaiting return call physician. A nursing progress note written on 04/08/21 at 8:14 PM stated, rechecked residents [sic] sugar and it was 469. Resident #17's fingerstick blood glucose was next checked on 04/09/21 at 6:45 AM and was 252. On 04/10/21 at 6:45 AM, the MAR reported the resident's fingerstick blood glucose level was 430 and 10 units of insulin was administered as specified in the sliding scale order. There was no indication the physician was notified for blood glucose level between 401-450 as specified in the sliding scale order. The next fingerstick blood glucose was obtained 04/08/21 at 11:30 AM and the result was 258. On 04/12/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 471 on 04/12/21 at 1:21 PM. A nursing progress note written on 04/12/21 at 1:19 PM stated, Blood sugar 471. 10 units administered and to be re-checked. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 471. The insulin administration was not documented on the MAR. There was no indication the physician was notified for blood glucose level between 401-450 as specified in the sliding scale order. The next fingerstick blood glucose was obtained 04/12/21 at 4:45 PM and the result was 433. According to the MAR, 10 units of insulin was administered as specified in the sliding scale order. There was no indication the physician was notified as specified in the sliding scale order. On 04/12/21 at 8:24 PM, the Weights and Vitals Summary tab recorded the blood glucose level as 431. There was no indication the physician was notified. The blood glucose level was rechecked on 04/12/21 at 10:46 PM and was recorded as 366 on the Weights and Vitals Summary tab. On 04/17/21 at 4:45 PM, the MAR recorded the resident's blood glucose level as 421 and 10 units of insulin was administered as specified in the sliding scale order. There was no indication the physician was notified as specified in the sliding scale order. The next fingerstick blood glucose was obtained 04/18/21 at 6:45 AM and the result was 102. On 04/20/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 459 on 04/20/21 at 1:00 PM. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 459. A nursing progress note written on 04/12/21 at 12:34 PM stated, Blood sugar 459. 10 units administered. There was no indication the physician was notified. The next fingerstick blood glucose was obtained 04/20/21 at 4:45 PM and the result was 258. On 04/21/21 at 11:30 AM, the MAR recorded the resident's blood glucose level as 421 and 10 units of insulin was administered as specified in the order. There was no indication the physician was notified as specified in the order. The next fingerstick blood glucose was obtained 04/21/21 at 4:45 PM and the result was 359. On 04/22/21 at 11:30 AM, the MAR recorded the resident's blood glucose level as 429 and 10 units of insulin was administered as specified in the order. There was no indication the physician was notified as specified in the order. On 04/22/21 at 4:45 PM, the MAR recorded the resident's blood glucose level as 450 and 10 units of insulin was administered as specified in the order. There was no indication the physician was notified as specified in the order. The next fingerstick blood glucose was obtained on 04/23/21 at 6:45 AM and the result was 214. On 04/27/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 453 on 04/27/21 at 12:49 PM. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 453. A progress note written on 04/27/21 at 12:45 PM stated, Blood sugar 453. 10 units administered at this time. There is no indication the physician was notified. On 04/27/21 at 4:45 PM, the MAR recorded the resident's blood glucose level as 404. 10 units of insulin was administered as specified in the order. There was no indication the physician was notified as specified in the order. On 04/30/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 475 on 04/27/21 at 12:49 PM. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 475. A progress note written on 04/30/21 at 1:01 PM stated, Blood sugar 475 at this time. 10 units administered in upper right arm. There is no indication the physician was notified. On 04/30/21 at 4:45 PM, the MAR recorded the resident's blood glucose level as 408. 10 units of insulin was administered as specified in the order. There was no indication the physician was notified as specified in the order. The next blood glucose level was obtained on 05/01/21 at 6:45 AM and the result was 200. On 05/02/21 at 6:45 AM, Resident #17's Medication Administration Record was blank in the area to record the blood glucose level. No blood glucose level was recorded on the Weights and Vitals Summary tab or in the progress notes. On 05/02/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 475 on 05/02/21 at 12:42 PM. The orders do not address the amount of insulin to be given for a blood glucose level of 475. A nursing progress note written on 05/02/21 at 12:21 PM stated, Resident's blood sugar is 475. 10 units administered in left arm and to be re-checked. The insulin administration was not documented on the MAR. There was no indication the physician was notified. The resident's next fingerstick blood glucose was obtained on 05/02/21 at 4:45 PM and was 378. On 05/05/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 202 on 05/05/21 at 10:52 AM. According to the physician orders, the resident should have received 2 units of insulin for a blood glucose level of 202. There is no indication on the MAR that 2 units of insulin was administered. On 05/05/21 at 4:45 PM, the MAR recorded the resident's blood glucose was 427 and 10 units of insulin was administered. There is no indication the physician was notified as ordered for blood glucose level 401-450. On 05/06/21 at 4:45 PM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 471 on 05/06/21 at 6:21 PM. The orders do not address the amount of insulin to be given for a blood glucose level of 471. A nursing progress note written on 05/06/21 at 6:15 PM stated, Blood sugar 471. 10 units administered and to be re-checked by night shift LN [licensed nurse]. The insulin administration was not documented on the MAR. There is no indication the physician was notified. Resident #17's finger stick blood glucose was next checked 05/07/21 at 6:07 AM and was 217. On 05/07/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 598 on 05/07/21 at 1:35 PM. A nursing progress note written on 05/07/21 at 1:32 PM stated, Resident's blood sugar is 598 at this time. 12 units administered in right arm, per standing order. Will re-check. The insulin administration was not documented on the MAR. Resident #17's finger stick blood glucose was next checked on 05/07/21 at 6:17 PM and was 499. A nursing note written on 05/07/21 at 4:17 PM stated, [Physician's name] in facility and reviewed resident's recent blood sugars with noted increase. New order received and noted to change [MEDICATION(S)] R coverage order at this time and to increase amount of units administered each time coverage is needed. On 05/07/21, the following new order was written: [MEDICATION(S)] R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if 201 - 250 = 7 units ; 251 - 300 = 9 units ; 301 - 350 = 11 units ; 351 - 400 = 13 units; 401 - 450 = 15 units Re-check in 2 hours and if still above 400, contact MD., subcutaneously three times a day related to type 2 diabetes mellitus with diabetic [CONDITION(S)]. On 05/12/21 at 11:30 AM, the MAR recorded the resident's blood glucose finger stick was recorded as 450. The resident received 15 units of insulin. There is no indication the physician was notified as specified in the order. The next fingerstick blood glucose level was obtained 05/12/21 at 4:45 PM and was 417. The resident was administered 15 units of insulin. There is no indication the physician was notified for the blood glucose level remaining over 400. Following this, there was no indication the blood glucose level was re-checked in 2 hours as ordered for a blood glucose level between 401-450. The resident's fingerstick blood glucose level was next checked on 05/13/21 at 6:45 AM and the result was 334. On 05/14/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 489 on 05/14/21 at 1:30 PM. The orders do not address the amount of insulin to be given for a blood glucose level of 489. A progress note written on 05/14/21 at 1:29 PM stated, Blood sugar 489. 15 units administered at this time. To be re-checked. The insulin administration was not documented on the MAR. There was no indication the physician was notified. There is no indication the blood glucose level was rechecked in 2 hours as ordered. The resident's blood glucose was next checked on 05/14/21 at 4:45 PM. The MAR recorded the resident's blood glucose level as 402 and 15 units of insulin were administered. There was no indication the blood glucose level was re-checked in 2 hours as ordered for a blood glucose level between 401-450. The resident's blood glucose level was next checked on 05/15/21 at 6:14 AM, and the result was 204. On 05/15/21 at 11:30 AM, the MAR recorded the resident's fingerstick blood glucose level as 420 and 15 units of insulin was administered. There was no indication the blood glucose level was re-checked in 2 hours as ordered for a blood glucose level between 401-450. The resident's blood glucose level was next checked on 05/15/21 at 4:45 PM, and the result was 185. On 05/17/21 at 11:30 AM the MAR recorded the resident's blood glucose level as 440 and 15 units of insulin was administered. There was no indication the blood glucose level was re-checked in 2 hours as ordered for a blood glucose level between 401-450. The resident's blood glucose level was next checked on 05/15/21 at 4:45 PM, and the result was recorded as 271. On 05/19/21 at 9:03 AM, the Director of Nursing (DON) was notified regarding the facility's failure to follow Resident #17's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed Resident #17's insulin coverage was for blood glucose levels up to 450. She confirmed nurses were to call the physician for blood glucose levels between 401-450. On 05/19/21 at 11:20 AM, Registered Nurse #3 stated the facility had no further information regarding the matter. During an interview on 05/19/21 at 12:50 PM Registered Nurse (RN) #20 was asked what she would do if a resident's fingerstick blood glucose results were higher than addressed by the parameters for insulin coverage. RN # 20 stated, I would not give sliding scale coverage if above parameters. I would call the doctor and get further orders. If I call and get no answer from the doctor, I would call again. If I have an emergency and can't get him, then I would call my nurse manager. During an interview on 05/19/21 at 12:55 PM, RN #16 was asked the same question. RN #16 stated, If the blood sugar is over the parameters, I would not give any insulin; I would call the doctor. If I couldn't get a hold of the doctor and they are really symptomatic like sweating, dizzy, can't see, thirsty, then I would give the 15 units ordered for 400-450. During an interview on 05/19/21 at 1:00 PM, Licensed Practical Nurse #14 (LPN) was asked the same question. LPN #14 stated, I would give the amount of insulin ordered for 400-450. Then I would recheck in 2 hours. Then I would call the doctor if the blood sugar isn't down. If I can't get the doctor, then I would call the RN on call. On 05/19/21 at 2:30 PM, the Director of Nursing (DON) was notified regarding Resident #17's fingerstick blood glucose readings for April 2021 as described above. The DON confirmed the resident's order was to call the doctor for fingerstick blood glucose levels 401-450. Regarding the standing order mentioned in the progress notes on 04/08/21 and 05/07/21, the DON stated the facility has standing orders for insulin coverage for elevated blood glucose levels. However, the facility standing orders are superseded by specific orders written by the physician for a resident. On 05/19/21 at 3:05 PM, the DON stated she believed the nurses were following facility's usual standing order instead of the resident's specific standing order. The DON stated, That still doesn't make it right. The facility provided the following POC to abate the immediate jeopardy situation: 1. Immediate action(s) taken for the resident(s) found to have been affected: All nurses will be educated immediately and at the beginning of their next scheduled shift regarding following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Identification of other residents having the potential to be affected was accomplished by: All residents that have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An audit was performed to identify all residents that had sliding scale insulin physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Actions taken/systems put into place to reduce the risk of future occurrence include: All nursing staff will receive education immediately or at the beginning of their next scheduled shift regarding following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing, or designee, will audit all residents with sliding scale insulin physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Corrective action will be completed immediately upon discovery. 4. How the corrective action(s) will be monitored to ensure practice will not reoccur: The Director of Nursing, or designee, will submit audits to the Administrator weekly for review. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. b) Resident #43 Review of Resident #43's medical records revealed an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . Hemoglobin A1-c measures the average amount of glucose in the blood over a period of time. No hemoglobin A1-c result for 12/17/20 could be located in the resident's electronic medical record. On 05/18/21 at 2:14 PM, Assistant Director of Nursing confirmed Resident #43 had no results for a hemoglobin A1-c performed on 12/17/20. No further information was provided through the completion of the survey process. c) Resident #22 Review of Resident #22's medical records revealed the resident experienced an unwitnessed fall on 04/07/21. According to the progress notes, neurological examinations were initiated and documented on a flow sheet. Neurological examinations include monitoring the resident's level of consciousness, motor response, pupil response, and vital signs. Changes in these areas may indicate the resident received a head injury during the unwitnessed fall. Resident #22's neurological examinations flow sheet dated 04/07/21 documented Resident #22 was sleeping at 10:00 PM. No neurological examinations were performed at that time due to the resident being asleep. During an interview on 05/19/21 at 9:03 AM, Director of Nursing (DON) stated the purpose of neurological checks is to make sure nothing is going on. She stated a resident sleeping might indicate a problem with the resident's consciousness. The DON stated education had already been started with staff to ensure residents are awoken for neurological evaluations. No further information was provided through the completion of the survey process. d) Resident #3 Review of the care plan found the resident had fallen several times since February 2021. Falls occurred on 02/9/21, 03/18/21, 03/21/21, 03/23/21, 04/04/21, 04/15/21, 04/20/2021, and 05/04/21. On 02/09/21, 04/04/21, 04/15/21, and 05/04/21, the resident had unwitnessed falls. The facility started neurological assessment flow sheets with each fall; however, many of the observations were not obtained because the documentation noted the resident was sleeping. (The purpose of a neurological assessment is to detect any possible neurological damage which could have resulted from the resident possibly hitting her head in an unwitnessed fall. Therefore, the resident needs to be awakened to be assessed for signs and symptoms of any head injury.) The neurological assessment requires staff to write the date, time, level of consciousness, pupil response, motor function, pain response, vital signs, any observations (i.e. seizures, headaches, vomiting, paralysis) and the the signature of the nurse completing the observations. For the unwitnessed fall on 02/09/21 the nurses documented the resident was sleeping on the following days and times: 02/09/21 at 10:00 PM, 02/10/21 2:00 AM, 6:00 AM, 10:00 Am, 02/11/21 at 7:00 AM and 7:00 PM For the unwitnessed fall on 04/04/21 staff documented the resident was sleeping on the following days and times: 04/04/21 at 9:30 AM, 1:30 PM, 5:30 PM, and 9:30 PM 04/05/21 at 1:30 AM For the unwitnessed fall on 04/15/21 staff documented the resident was sleeping on the following days and times: 04/15/21 at 11:30 PM 04/16/21 at 3:30 AM, 7:00 PM 04/17/21 at 7:00 AM 04/18/21 at 7:00 PM For the unwitnessed fall on 05/04/21, staff documented the resident was sleeping on the following days and times: 05/04/21 at 3:00 AM 05/05/21 at 12:30 AM, 7:30 AM, 11:30 AM, 3:30 PM, at 7:30 PM and 11:30 PM On 05/19/21 at 9:00 AM, the Director of Nursing and the Assistant Director of Nursing (ADON) #99 said the facility policy for obtaining neurological checks after an unwitnessed fall is: every hour for the first 4 hours every 4 hours for 24 hours every shift for the next 72 hours. The DON confirmed staff should not be writing the resident was sleeping, because sleeping might indicate a problem from the head injury.

Based on observation, staff interview, record review, and review of the Guidance for Industry and FDA (Food Drug Administration) Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued on 03/10/06. The facility failed to ensure Resident #7's environment over which they had control was a free of accident hazards as possible. There was a 6.5 inch gap between Resident #7's mattress and her foot board creating an entrapment risk for Resident #7. The state agency determined this placed Resident #7 at an immediate risk for serious harm and or death related to entrapment. The facility was notified of the Immediate Jeopardy at 11:49 a.m. on 05/18/21. The facility submitted thier first plan of correction at 12:38 p.m. the State Agency requested corrections to the plan of correction. The facility submitted another plan of correction at 2:16 p.m. on 05/18/21. The State Agency again requested changes and the the third and final Plan of Correction was submitted and accepted at 2:58 p.m. The State Agency observed with complaince with the plan of correction and the immidiate jeoparrdy was abated at 6:05 p.m. on 05/18/21. Once the immidiate jeopardy was abated a deficient practice remained for Resident #3 whose bed was not in the lowest position when observed. The scope and severity was decreased from a J to a D. Resident Indentifiers: #7 and #3. Facility Census: 60. Findings included: A) Resident #7 Observations of Resident #7 in her room on 05/17/21 at 2:05 PM found the resident up in her Geri chair. Her legs were hanging off the side of her chair. Resident #7's bed was observed, and an obvious gap was present between the end of the Residents mattress and her foot board. Review of Resident #7's medical record found she had unwitnessed falls from her bed on 06/04/20, 08/02/20, 08/17/20, 12/13/20, 01/03/21, and 01/04/21. This is an indication Resident #7 was able to move about in her bed without help from staff. Review of Resident #7's physician orders found a physician order for a Concave Mattress to the bed. Which was entered into the medical record on 01/05/21. Review of Resident #7's Minimum Data Set (MDS) with the following Assessment Reference Dates (ARDs) 04/01/20, 07/01/20, 09/30/20, 12/30/20, 02/05/21, and 05/05/21 found Section G Functional Status A. Bed Mobility was coded to reflect Resident #7 was an extensive assist with bed mobility. Extensive assist is defined as resident is involved in activity, but staff provided weight bearing support. A review of Resident #7's care plan found an intervention dated 10/11/18 which indicated Resident #7 was an extensive assist with bed mobility. Review of Resident #7's therapy screens dated 03/20/20, 09/16/20, 12/22/20, and 04/23/21 found the resident had no decline in her bed mobility. An interview with Nurse Aide (NA) #41 at 8:45 AM on 05/18/21, confirmed Resident #7 does move some in the bed on her own. She stated, she can wiggle in the bed and likes to curl up in the bed. She stated, I call her my pretzel lady and she laughs. An interview with NA # 43 at 8:50 am on 05/18/21, confirmed Resident #7 does move some in the bed on her own. She stated, I have only been here two (2) weeks, but she does like to curl up in the bed and will move some. An interview with Licensed Practical Nurse (LPN) #82 at 8:55 a.m. on 05/18/21, confirmed Resident #7 does move some in the bed. She stated she can grab the handrail and help with her turning and she can reposition herself in the bed. On 05/18/21 at 9:29 a.m. the Maintenance Director with the Nursing Home Administrator (NHA) present, measured the gap between Resident #7's mattress and foot board. The gap was found to be 7 inches. An interview with the NHA at 9:37 a.m. on 05/18/21 confirmed the gap should not be there she stated we usually get spacers to put in the gap. An additional interview with the Maintenance Director at approximately 9:50 a.m. on 05/18/21 found he measured to the foot board but not to where the frame connected to the foot board. He remeasured and the gap was still found to be 6.5 inches. He stated, I know what the problem is. This is a 76-inch mattress (he pulled the tag on the mattress up and said it says so right here.) These beds take an 80-inch mattress. Review of the Guidance for Industry and FDA (Food Drug Administration) Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued on 03/10/06 found the following, The body part dimensions used to develop FDA's dimensional limit recommendations are summarized in Table 2 below. Table 2 Key Body Part Dimension Head 120 mm (4 ¾ inches) Neck 60 mm (2 3/8 inches) and an angle > 60 degree Chest 318 mm (12 ½ inches) This document also defines seven (7) zones for risk of entrapment. Zone 7 is defined in this document as the area Between the Head or Foot Board and the Mattress End. At 11:00 a.m. on 05/18/21 the NHA provided a policy titled, Bed Maintenance and Inspections which contained the following, Policy: It is the policy of this facility to conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify and avoid areas of Possible entrapment. Definitions: Bed Rails also known as side rails are adjustable metal or rigid plastic bars that attach to the bed. Policy Explanation and Compliance Guidelines: --The Maintenance Director or Designee is responsible for keeping records of bed inspections and maintenance. --A list of bed frames, mattresses, and bed rails will be maintained, including the manufacturer for each. The Maintenance Director shall be notified of any new equipment brought into the facility. --The Maintenance Director shall review each manufacturer's recommendations and requirements for Maintenance and bed inspections, and shall establish a Maintenance and inspections schedule accordingly. --Bed rails shall be securely and properly installed according to manufacturer's requirements. --When bed rails and mattresses are used and purchased separately from the bed frame, the facility will ensure that the bed rails, mattress, and bed frame are compatible. --Bed frame, mattress, and bed rail inspections will be conducted upon each item entering the facility and then placed on a regularly scheduled inspection and Maintenance cycle according to the manufacturer's recommendations, to include manufacturer's time frame recommendations. --If bed equipment is found to be outside of the manufacturer's requirements for any reason, the facility will perform Maintenance to the bed equipment and remove from use. Please note: The Policy did not have an Implementation date or revision date. The NHA provided a form titled, Bed Rail Inspection which is what she stated the Maintenance director uses to monitor for areas of entrapment. This form was completed on 04/14/21 for 14 beds. On 04/14/21 Resident #7's bed was not reviewed for entrapment. The Maintenance director only reviews and measures Zone 1, Zone 2, Zone 3, and Zone 4. He does not measure Zone 7 which is the relevant zone to Resident #7's situation. An additional interview with the NHA and the Maintanance Director in the afternoon of 05/18/21 found they do not monitor Zone 7 becuase there is not a set recommendation from the FDA for Zone 7. They agreed Zone 7 was a risk for entrapment but indicated most entrapments occur in Zones 1-4 and that is why they do not monitor the other Zones. b) Facility's Plan of Correction The facility submitted the following plan of correction: 1. Immediate actions taken for the residents found to have been affected to include: The Maintenance Supervisor immediately put a gap spacer between the matress and the foot board on resident #7's bed. Maintenance Director does have another matress that is 80 inches and will replace. 2. Indentification of other residents having the potential to be affected was accomplished by: All resident had the potential to be affected by the deficit practice. The Maintenance Assistant audited all resident beds to ensure no other gaps that are out of acceptable parameters are found. Any areas found will be corrected immediately. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: All nursing staff will recieve training to identify risk of entrapment immediately and at the beginning of thier next scheduled shift, Maintenance Supervisor, or designee, will inspect all 7 bed entrapment zones weekly for 4 week and monthly thereafter. Form will be updated to include all 7 zones. Maintenance Director, or desginee, will inspect and document all mattresses when ordered and delivered to ensure mattress is of correct size for beds prior to being put in use. 4. How the corrective actions will be monitored to ensure the practice will not reoccur: Maintenance Director will submit audits of bed rail/entrapement and any documentation of new mattress inspections to the administrator weekly for review. The administrator will report summary of the audits to the QA committee monthly for review for 3 months. c) Resident #3 Review of the resident's care plan found the resident had fallen on the following dates in the past year: 05/10/20, 05/12/20, 05/15/20, 05/20/2020, 05/30/2020, 06/19/20, 07/6/20, 07/16/2020, 08/01/20, 08/09/2020, 08/12/2020, 08/14/20, 04/8/21/2020, 08/27/2020, 09/08/20, 09/11/20, 09/12/20, 09/14/20, 09/23/20, 09/24/20, 09/27/20, 09/28/20, 09/30/20, 10/01/2020,10/5/20, 10/7/20, 10/12/2020, 10/15/20, 10/19/2020, 10/26/2020, 10/27/2020, 11/8/20, 11/11/20, 11/17/2020, 11/21/20, 12/2/20, 12/5/20, 12/06/20, 12/15/20, 12/20/20, 12/24/20, 12/25/20,12/28/20, 12/29/20, 01/05/21, 01/08/21, 01/09/21, 01/10/21, 01/19/21, 01/22/21, 02/9/21, 03/18/21, 3/21/21, 03/23/2021, 04/4/21, 04/15/21, 04/20/21, and 05/4/21. On 05/10/21, the physician wrote an order for, Low bed at all times when in bed. On 05/18/21 at 7:25 AM, observation found the resident was asleep in her bed. Nursing assistant (NA) #53 verified the residents bed was not in the lowest position. NA #53 pushed a button on the foot board of the resident's bed and lowered the bed. Review of the resident's care plan, revised on 05/11/21 found a focus/problem: Resident is at risk for ongoing falls due to wandering, confusion, ambulating and transferring independently . The goal associated with the focus: Will attempt to prevent further serious injuries from falls thru review date. Interventions included: low bed while occupied On 05/19/21 at 9:00 AM, the Director of Nursing said she was aware of the observation, NA #53 had already told her. No further information was provided at the close of the survey.

Based on policy review, observation, record review, resident interview and staff interview, the facility failed to ensure a resident was free from neglect when they failed to appropriately respond to the resident's psychiatric emergency. Resident #23 had a [DIAGNOSES REDACTED]. On [DATE] at 6:07 PM, a staff member documented Resident #23 had been heard saying she wanted to die and did not care anymore. On [DATE] at 6:41 PM the same staff member documented that Resident #23 had expressed a desire to die a second time. Multiple staff members documented numerous times in the days following Resident #23's comments on [DATE] that Resident #23 was lethargic, less conversational than normal, resistive to care, verbally and physically aggressive, and had a flat affect. Review of facility records also found that following her comments on [DATE] Resident #23 refused food numerous times. However, no one in the nursing facility acted on the comments made by Resident #23 on [DATE] until surveyor intervention on [DATE]. This deficient practice was found during a random opportunity for discovery and affected one (1) resident with the potential to affect more than an isolated number of residents. Resident identifier: #23. Facility census: 60. The facility's failure to appropriately and timely respond to Resident #23's psychiatric emergency placed Resident #23 at risk for likely serious psychological harm and/or death, resulting in the determination of an Immediate Jeopardy (IJ) situation. This occurrence was the result of a system failure to prevent neglect. The facility's Administrator and Director of Nursing (DoN) were notified of the IJ on [DATE] at 6:25 PM. The facility submitted their Plan of Correction (PoC) via electronic mail (email) on [DATE] at 6:53 PM. The State Agency requested changes to the facility's PoC on [DATE] at 7:12 PM. The requested changes were made to the PoC by the facility and resubmitted via email on [DATE] at 8:23 PM. The PoC was accepted by the State Agency on [DATE] at 8:48 PM. After the survey team observed that the initial components of the facility's PoC had been implemented, the IJ was abated on [DATE] at 9:30 AM. The team were conducting interviews, observations and record reviews throughout the process to abate the immediate jeopardy. The facility's PoC (typed as written) consisted of the following: 1. Staff will provide immediate 1:1 (one to one) services with Resident, (Resident #23's Name), to ensure safety. Physician, (Physician's Name), was notified via telephone on [DATE] of Resident's statements of wanting to die and (Physician's Name) is currently in facility to assess Resident. Staff will remain with Resident until (Physician's Name) assesses and determines further treatment needs and if she is a danger to self and feels safe for her to remain in the facility or recommends transfer to ER (emergency room ) for further evaluation. 2. All residents had the potential to be affected. All residents' nurse's notes will be reviewed immediately from [DATE] to present to ensure no other residents are identified to have made statements of wanting to die or harm themselves. Immediate action of 1:1 staff intervention until assessed will be taken for any other residents that are identified. 3. Management team will continue to read all nurse's notes per facility procedure daily to identify if any other residents are noted to make any statements of wanting to die and also when PHQ9 (a nine-question instrument used to screen residents for the presence and severity of depression) assessments are completed, any resident indicating thoughts of wanting to die will be assessed immediately. 4. All staff working now will be in-serviced immediately and all other staff, prior to providing care to resident, will be in-serviced to report any resident statements of wanting to die or kill themselves to the Charge Nurse as soon as resident expresses these statements. Staff will be instructed to ensure resident safety until Physician can be notified and resident assessed for what further interventions are indicated. 5. Director of Nursing will be responsible for ensuring all resident's are assessed when a resident is identified of making statements of wanting to die or harm themselves and ensure plan of correction is implemented. Director of Nursing will report to QA (quality assurance) Committee monthly for 3 months. Findings included: a) Policy Review A review of the facility's Abuse, Neglect, and Exploitation policy, implemented on [DATE], revealed the following definition for neglect: failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy further stated that the staff assigned to each resident would have knowledge of the individual residents' care needs and behavioral symptoms and be able to identify and intervene in situations in which neglect is likely to occur. A review of the facility's Behavioral Health Services policy, also implemented on [DATE], found that all residents in the facility would receive necessary behavioral health care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning. The policy further stated that facility staff would be trained to meet the behavioral health needs of residents. b) Resident #23 On [DATE] at 10:32 AM an interview was attempted with Resident #23. Resident #23 did not provide meaningful responses to questions and was observed to have a flat affect. Record review found that Resident #23 received [MEDICATION NAME] 20 milligrams for other recurrent [MEDICAL CONDITION]. A progress note written by Licensed Practical Nurse (LPN) #12 on [DATE] at 6:07 PM revealed the following information regarding Resident #23: The resident was overheard saying that she wants to die and that she doesn't care anymore. Another progress note written by LPN #12 on [DATE] at 6:41 PM explained that Resident #23 had refused her vitamin K medication, stating, as written by LPN #12, well then I throw a clot and die. No evidence was found in the medical record to suggest that any staff member had appropriately responded to Resident #23's psychiatric emergency by reporting it to the charge nurse and/or contacting Resident #23's Physician. According to progress notes written on [DATE], Resident #23 was lethargic that day and required the total assistance of two (2) staff members for all care. Resident #23 also required assistance with all meals, was resistive to care, and had a flat affect. Resident #23 refused a scheduled shower, telling the Nurse Aides to leave her alone. She was also observed to have a distressed, agitated look on her face when she was awake, and she refused to get out of bed, becoming agitated when staff offered to help her get up. Also, documentation stated that Resident #23 was confused and did not respond appropriately to staff, staring blankly. According to a progress note written on [DATE] at 6:49 PM, Resident #23 was extremely lethargic and required maximum assistance of two staff members for care. The progress note indicated that Resident #23 continuously stated, Leave me alone! The note also stated that Resident #23 became verbally aggressive with staff and then began crying uncontrollably when staff attempted to redirect her. Resident #23 could not specify what was wrong. She required assistance with all meals on [DATE] and had a flat affect and a blank stare while awake. She also refused to be weighed on [DATE], per a second progress note written that day at 6:52 PM. Per multiple progress notes written on [DATE] Resident #23 refused her morning medications. She had a flat affect and a blank stare and would not verbally respond to staff. When she did respond, she yelled out, Leave me alone. Resident #23 was physically aggressive toward Nurse Aides, swatting them, and she was overheard screaming. She refused all her evening medications. On [DATE] at 11:54 AM Resident #23 was observed refusing to rouse and eat lunch despite staff attempting to rouse and cue her multiple times. Per Resident #23's activities of daily living (ADL) records for (MONTH) 2019, Resident #23 refused six (6) snacks and five (5) meals between the dates of [DATE] and [DATE]. During an interview on [DATE] at 2:03 PM the facility's DoN stated that the facility's Social Worker (SW) should have spoken with Resident #23 regarding her expression of the desire to die to determine if Resident #23 had a suicide plan. The DoN stated that she was unsure if there was documentation of the SW's conversation with Resident #23, but that she would check with the SW. On [DATE] at 3:45 PM an interview with the facility's SW confirmed that neither she (the SW) nor any other staff member had attempted to investigate Resident #23's expression of the desire to die. The SW stated that she wasn't in the building when the comments were made and that she had called a priest to come to the facility and speak with Resident #23 on [DATE]. During a meeting with the facility's Administrator and DoN on [DATE] at 6:25 PM the DoN stated that the method the facility had devised to address Resident #23's comments was to call the priest. When asked what the intention was for calling the priest, the DoN stated that she didn't know. She added that the SW had suggested calling the priest because she (the SW) had looked at Resident #23's medical record and had discovered that Resident #23 was Catholic. However, Resident #23's most recent comprehensive minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] indicated that Resident #23's religion was Not very important to her. The DoN further stated that she had spoken with LPN #12, who had said he didn't believe Resident #23 was being serious when she said she wanted to die. The facility placed Resident #23 under 1:1 supervision immediately following this meeting with the Administrator and DoN. On [DATE] at 6:57 PM an interview was conducted with LPN #12. LPN #12 recalled the night of [DATE] and stated that Resident #23 was screaming at the top of her lungs and refusing her medications. She said she didn't care if she threw a clot and died . Resident #23's roommate reported to LPN #12 that she had overheard Resident #23 saying she wanted to die and did not care anymore. LPN #12 confirmed that he did not tell the Physician, the DoN, or another person in authority what Resident #23 had said. LPN #12 stated that Resident #23 did not make any specific threats. He said, If she had stated she was going to commit suicide I would have talked to the doctor. He added, There was no immediate threat. After Physician intervention on [DATE] at 8:25 PM, Resident #23 was smiling and laughing appropriately during conversation. The Physician stated that Resident #23 reported no suicidal ideation and that she could be removed from 1:1 supervision back to routine nursing supervision. On [DATE] at approximately 3:20 PM Resident #23 responded to surveyor questions appropriately, though she still had a flat affect. The facility's failure to appropriately and timely respond to Resident #23's psychiatric emergency placed Resident #23 at risk for likely serious psychological harm and/or death, resulting in the determination of an Immediate Jeopardy (IJ) situation. This occurrence was the result of a system failure to prevent neglect.

Based on record review, resident interview, and staff interview the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for three (3) of seven (7) residents receiving [MEDICATION NAME]. The facility failed to identify and initiate timely laboratory monitoring for residents on anticoagulants, whose [MEDICATION NAME] (PT)/International Normalized Ratio (INR) results were not stable and/or within the residents' target range. Resident #6 was admitted to the facility after a lengthy hospital stay which included a fluctuation in his PT/INR and blood [MEDICAL CONDITION] for hemorrhage. Twenty-two (22) days later he was transferred back to an acute care center and found to have a critically high PT/INR of 12.53. Resident #2 was admitted with multiple bruises and a high INR level of 4.7. Her daily [MEDICATION NAME] dose was continued and standing orders were initiated for monthly PT/INR checks. Resident #2's PT/INR levels were drawn thirty-eight (38) after her admission and remained above her target range. In addiction, Resident #1 presented to the facility with a low INR level. Her [MEDICATION NAME] dose was increased without an increase in the frequency of laboratory checks. Her INR level remained below her therapeutic range and she was transferred to acute care where she was diagnosed with [REDACTED]. On 11/18/14 at 3:30 p.m., the findings were relayed to the OHFLAC office for review and the decision was made to identify this as an Immediate Jeopardy (IJ). After reviewing the medical records, conducting staff interviews, and a resident interview, it was determined an immediate jeopardy (IJ) existed for Residents #6 #2, and #1. On 11/18/14 at 5:00 p.m., the Administrator and the Assistant Director of Nursing (ADON) were notified of the immediate jeopardy. The IJ was removed on 11/18/14 at 6:14 p.m., when the Administrator presented a written plan of correction which stated the facility composed a list of current residents receiving anti-coagulant therapy and contacted the physician for orders for PT/INR labs on all residents receiving anticoagulant therapy and had not had a PT/INR in the past seven (7) days. Blood samples were obtained on 11/18/14, and the results were reported to the attending physician. The current medication policy was revised and included a plan to draw PT/INR labs on any new admission receiving anticoagulant therapy. Abnormal lab values were to be reported and monitored weekly until a therapeutic level had been achieved or at the physician's discretion. A copy of the revised medication policy was received on 11/19/14. Section #5 stated, "For medications that require management through therapeutic level monitoring, appropriate labs will be drawn upon admit. This includes most specifically the anticoagulant class of medications, which, if outside therapeutic limits, will be monitored weekly with appropriate physician notification, until lab values indicate a therapeutic level has been achieved or until monitoring is transitioned to a lesser frequency at the physician's discretion." Resident identifiers: #6, #2, and #1. Facility census: 61. Findings include: a) Resident #6 The resident's medical record was reviewed on 11/18/14 at 11:00 a.m. Resident #6, was admitted to the facility on [DATE] after a twenty-two (22) day stay at an acute care center for repair of a [MEDICAL CONDITION]. His discharge records from the acute care center indicate the resident was on [MEDICATION NAME] for [MEDICAL CONDITION] and his PT/INR lab values fluctuated during his stay. On 09/19/14, the PT was found to be increased to a level of 31.2 (the normal value is 8.7-13.1) and the INR was elevated to 2.32 (the normal INR range is 0.8-1.2). On 09/23/14, the PT had decreased to 19.3 and the INR was down to 1.76. The last value found in the discharge records was dated 09/24/14. At that time, the PT was elevated to 25.5 and the INR had increased to 1.76. The records indicated the resident had been transfused after an undetermined cause of blood loss and his [MEDICATION NAME] dose was adjusted as needed. The resident was admitted to the facility on [DATE]. His admitting orders, dated 10/03/14, included [MEDICATION NAME] 5 milligrams (mg) daily. The PT/INR labs were ordered to be done monthly per the facility's "Standing Orders" form; which stated under the section titled "Laboratory" "#3" "Monthly...If on [MEDICATION NAME] Levels." On the morning 10/25/14, a large bruise was found on Resident #6's left flank, and he was transferred to an acute care center for evaluation. A nurse's note written by licensed practical nurse (LPN) #18, on 10/25/14 at 2:11 p.m., indicated the nurse had called the acute care center and was informed the resident was being admitted , with [MEDICAL CONDITION] and his "PT/INR" value was "critically high at 12.53." The attending physician was interviewed on 11/18/14 at 12:10 p.m., he reported his routine was to check the resident's PT/INR level monthly unless the level had been unstable. He did not remember Resident #6 and could not answer any questions about him. An interview was conducted with LPN #40 on 11/18/14 at 12:15 p.m. She reported the facility only checked the residents' PT/INR levels monthly. Resident #6 had not been there thirty (30) days, so his level had not been drawn. . . b) Resident #2 On 11/17/14 at 3:00 p.m., in an interview with Resident #2, she commented she was admitted to the facility in July of this year and had been on [MEDICATION NAME] since 2008 when she had a pacemaker inserted for her heart problems. She said she was at the facility for about a month before they did her laboratory testing for [MEDICATION NAME]. Resident #2 stated her caregiver, (who had been caring for her for twenty-six (26) years) kept asking the nurses about monitoring her [MEDICATION NAME] levels and she was told, "They are only done here monthly." She stated, "I broke my left ankle when I fell and then had to have an operation, I was worried about having some bleeding or a blood clot." Review of the resident's medical record, on 11/18/14 at 10:00 a.m., found she was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission nurse's progress note, dated 07/21/14, revealed the resident had "multiple bruising to bilat arms and hands, bruising to left side and under left breast, bruising to left hip and lateral thigh from fall, left ankle half cast and wrapped with ace." A review of the discharge summary from the community hospital, dated 07/21/14, revealed the resident was on [MEDICATION NAME] 5 mg by mouth daily. An INR, completed on the morning of 07/21/14, revealed an INR of 4.7 (high and not in target range) and she was given a decreased dose of [MEDICATION NAME] 2.5 mg by mouth at the hospital prior to the facility admission. She was documented to have a target range for her INR results of 2.0-3.0. The facility's standing orders for this resident, dated 07/21/14, included, "3. Monthly...If on [MEDICATION NAME] Levels." A physician's order, dated 07/21/14, was for "[MEDICATION NAME] Sodium Tablet 5 mg Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION] FIBRILLATION. Hold for 2 days then start new order." Resident #2's first laboratory test for a PT/INR at the facility was 08/28/14. The test showed an INR of 3.60 (laboratory reference range of 0.80-1.20) which was high. On 08/29/14, the physician changed the order to "[MEDICATION NAME] tablet 5 mg ([MEDICATION NAME] Sodium) Give 1 tablet by mouth one time a day every Sun, Mon, Wed, Fri related to [MEDICAL CONDITION] FIBRILLATION. [MEDICATION NAME] tablet 2.5 mg ([MEDICATION NAME] Sodium) give 1 tablet by mouth one time a day every Tue, Thu, Sat related to [MEDICAL CONDITION] FIBRILLATION." No physician orders were found for changes in the laboratory monitoring after the dosage change of [MEDICATION NAME]. A laboratory result, dated 09/25/14, revealed an INR of 2.76, which was within the target range. A laboratory test, dated 10/23/14, had an INR of 5.88, which was high for the target range of 2.0-3.0. At that time, new physician orders were written for a decrease in the [MEDICATION NAME] dosage. A confidential interview was conducted, on 11/18/14 at 11:00 a.m., with Employee A. The employee stated he/she was, "Unaware of any residents in the facility being on the medication [MEDICATION NAME] and had never been told what to watch for or precautions because of the medicine." On 11/18/14 at 11:45 p.m. a continued review of the medical record revealed the care plan dated 10/22/14 did not contain a focus, goal or intervention related to the resident being on the medication [MEDICATION NAME]. A confidential interview was conducted with Employee B, on 11/18/14 at 2:40 p.m. The employee stated, "The resident should have had an INR done before the monthly order, because she was bruised everywhere on admission and her INR was critical by being high. Whoever admitted her should have looked at those things and notified the physician immediately. We are just lucky she didn't have a bleed." A monthly Medication Regimen Review dated 07/31/13, revealed the box was checked beside "Irregularities, not significant" with a notation to give [MEDICATION NAME] with dairy foods. On 08/28/14 the box was checked beside "No Irregularities and a notation "aug (August) labs not in chart yet." The Medication Regimen Review dated 09/23/14 and 10/18/14 were checked "No Irregularities." The monthly Medication Regimen Reviews by the pharmacist did not acknowledge the higher than target range INRs or the [MEDICATION NAME] dosage changes and the need for more frequent laboratory testing of PT/INR to prevent adverse consequences related to anticoagulation therapy. On 11/20/14 at 8:40 a.m., in an interview with Employee #79, the facility pharmacist, she commented she tried to review the discharge summary from the previous hospital upon admission and check to see if a PT/INR was ordered. During the interview she stated, "I questioned the facility about just having scheduled monthly PT/INRs for the residents on [MEDICATION NAME] and they told me that is the way it has always been done. So I did not question it anymore." After reviewing the discharge summary for Resident #2 and her PT/INR results, she stated, "I did not see that, I missed it." She further stated, "Yes her high INR results and her dosage changes should have been monitored more closely." c) Resident #1 On 11//17/14 at 2:45 p.m., in an interview with Resident #1, she commented she had been on the mediation [MEDICATION NAME] for her "heart problems for years." Review of the medical record, on 11/17/14 at 3:25 p.m., revealed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. She was admitted on the medication [MEDICATION NAME] with a documented target range for her INR results of 2.0-3.0. The facility's standing orders for this resident, dated 05/16/14 included, "3. Monthly...If on [MEDICATION NAME] Levels." Resident #1 was transferred to the community hospital on [DATE], then transferred to a trauma hospital for possible stroke or [MEDICAL CONDITION] (TIA) and was re-admitted to the facility on [DATE] with a new [DIAGNOSES REDACTED]. A physician's order dated 06/10/14 stated, "PT/INR every night related to [MEDICAL CONDITION] until 06/12/14." A PT/INR dated 06/12/14, revealed results of an INR of 2.0, with the INR results being within the target range. An order was written 06/20/14 to increase her [MEDICATION NAME] dosage to 4 mg by mouth daily. No order was located to monitor PT/INR more frequently than the original standing orders of monthly PT/INR. A medication review, dated 06/24/14, was conducted by the Pharmacist with the box checked beside "irregularities, not significant, and a notation of check lipids & LFT?" No recommendation or notation to monitor the PT/INR that was not within the target range. Laboratory results revealed on 09/25/14 an INR result of 1.50 and on 10/23/14 an INR result of 1.40, which is not within the target range of INR results for this resident. A pharmacy review was conducted on 09/23/14 with the box checked beside "irregularities, not significant and a notation of Sept PT/INR?" A pharmacy review on 10/28/14 revealed the box checked beside "no irregularities." The Pharmacist failed to identify the INR results for this resident were not within the target range and to initiate recommendations for a dosage change and/or more frequent laboratory monitoring. On 11/17/14 at 3:45 p.m., a continued review of the medical record revealed the care plan dated 11/13/14 did not contain a focus, goal or intervention related to the resident being on the medication [MEDICATION NAME]. At 10:20 a.m. on 11/18/14, in an interview with Cooks #13 and #27. They both stated, no residents in the facility were on any dietary restrictions for the medication [MEDICATION NAME]. In a confidential interview with Employee B, on 11/18/14 at 2:40 p.m., she stated, "The resident should have had an INR done before the monthly order, because she was at risk for a clot with her INRs being low. None of the staff, including myself, notified the physician, but he should have noticed it too. Even after we thought she had a stroke, but it turned out to be a TIA, she was not monitored properly with more frequent INR to get her within her target range and keep her there." On 11/20/14 at 8:40 a.m., in an interview with Consulting Pharmacist #79, she commented she tried to review the discharge summary from previous hospital upon admission and check to see if a PT/INR was ordered. During the interview she stated, "I questioned the facility about just having scheduled monthly PT/INRs for the residents on [MEDICATION NAME] and they told me that is the way it has always been done. So I did not question it anymore." She agreed Resident #1 "Should have been monitored more closely with more frequent PT/INRs since she had a TIA episode, a medication dosage change and her INRs were below her target range." d) At 10:20 a.m. on 11/18/14 an interview was conducted with two (2) cooks, Employees #13 and #27. They both stated no residents in the facility were on any dietary restrictions for the medication [MEDICATION NAME]. An interview was conducted on 11/20/14 at 11:00 a.m. with the Dietary Manager. She commented that no dietary restrictions are placed on residents without a physician order and no residents within the facility are on dietary restrictions. During the interview she stated, no physician orders have been received restricting any residents from green leafy vegetables that are on [MEDICATION NAME]. "We only serve them maybe once a week so that would be okay. I am not sure about the residents that are unstable with their laboratory values." .

Based on record review and staff interview, the facility failed to ensure the medication regimen for three (3) of seven (7) residents reviewed for adverse effects of anticoagulation medications, were monitored for adverse effects of anti-coagulation medications. The facility failed to identify newly admitted residents receiving the medication [MEDICATION NAME]. Abnormal [MEDICATION NAME] (PT)/International Normalized Ratio (INR) results from referring facilities were not acknowledged or identified, and plans of care were not developed to meet individual resident needs to prevent a decline and/or harm for residents receiving anticoagulation therapy. This practice had the potential to affect all residents receiving the medication [MEDICATION NAME]. Resident #6 was admitted to the facility after a lengthy hospital stay which included a fluctuation in his PT/INR and blood [MEDICAL CONDITION] for hemorrhage. Twenty-two (22) days later he was transferred back to an acute care center and was found to have a critically high PT/INR of 12.53. Resident #2 was admitted with multiple bruises and a high INR level of 4.7. Her daily [MEDICATION NAME] dose was held for two (2) days and then restarted. Standing orders were initiated for monthly PT/INR checks. Resident #2's PT/INR levels were drawn thirty-eight (38) after her admission and remained above her target range. Resident #1 presented to the facility with a low INR level. Her [MEDICATION NAME] dose was increased without an increase in the frequency of laboratory checks. Her INR level remained below her therapeutic range and she was transferred to acute care on 06/08/14, where she was diagnosed with [REDACTED]. On 11/18/14 at 3:30 p.m., the findings were relayed to the OHFLAC office for review and the decision was made to identify this as an Immediate Jeopardy (IJ). After reviewing the medical records, conducting staff interviews, and a resident interview, it was determined an immediate jeopardy (IJ) existed for Residents #6 #2 and #1. On 11/18/14 at 5:00 p.m., the Administrator and the Assistant Director of Nursing (ADON) were notified of the immediate jeopardy. The IJ was removed on 11/18/14 at 6:14 p.m., when the Administrator presented a written plan of correction which stated the facility composed a list of current residents receiving anti-coagulant therapy and contacted the physician for orders for PT/INR labs on all residents receiving anticoagulant therapy and had not had a PT/INR in the past seven (7) days. Blood samples were obtained on 11/18/14, and the results were reported to the attending physician. The current medication policy was revised and included a plan to draw PT/INR labs on any new admission receiving anticoagulant therapy. Abnormal lab values were to be reported and monitored weekly until a therapeutic level had been achieved or at the physician's discretion. A copy of the revised medication policy was received on 11/19/14. Section #5 stated, "For medications that require management through therapeutic level monitoring, appropriate labs will be drawn upon admit. This includes most specifically the anticoagulant class of medications, which, if outside therapeutic limits, will be monitored weekly with appropriate physician notification, until lab values indicate a therapeutic level has been achieved or until monitoring is transitioned to a lesser frequency at the physician's discretion." Resident identifiers: #6, #2, and #1. Facility census: 61. Findings include: a) Resident #6 Review of the resident's medical record on 11/18/14 at 11:00 a.m., found he was admitted to the facility on [DATE] after a twenty-two (22) day stay at an acute care center for repair of a [MEDICAL CONDITION]. His discharge records from the acute care center indicated the resident was on [MEDICATION NAME] for [MEDICAL CONDITION] and his PT/INR lab values fluctuated during his stay. On 09/19/14, the PT was found to be increased to a level of 31.2 (the normal value is 8.7-13.1) and the INR was elevated to 2.32 (the normal INR range is 0.8-1.2). On 09/23/14, the PT had decreased to 19.3 and the INR was down to 1.76. The last value found in the discharge records was dated 09/24/14, the PT was elevated to 25.5 and the INR had increased to 1.76. The records indicated the resident had been transfused after an undetermined cause of blood loss and his [MEDICATION NAME] dose was adjusted as needed. The resident was admitted to the facility on [DATE]. His admitting orders dated 10/03/14, included [MEDICATION NAME] 5 milligrams (mg) orally everyday. The PT/INR labs were ordered to be done monthly per the facility "Standing Orders" form which stated under the section titled "Laboratory" "#3" "Monthly...If on [MEDICATION NAME] Levels." On the morning of 10/25/14, a large bruise was found on Resident #6's left flank. He was transferred to an acute care center for evaluation. A nurse's note written by Licensed Practical Nurse (LPN) #18, on 10/25/14 at 2:11 p.m., indicated the nurse had called the acute care center and was informed the resident was being admitted , with [MEDICAL CONDITION] and his "PT/INR" value was "critically high at 12.53." In an interview on 11/18/14 at 12:10 p.m., the attending physician reported his routine was to check the resident's PT/INR level monthly unless the level had been unstable. He did not remember Resident #6 and could not answer any questions about him. An interview was conducted with licensed practical nurse (LPN) #40 on 11/18/14 at 12:15 p.m. She reported the facility only checked residents' PT/INR levels monthly. Resident #6 had not been there thirty (30) days so his level had not been drawn. At the time of admission, the facility failed to identify the resident had fluctuating PT/INRs, had recently experienced bleeding of unknown origin, and had required [MEDICAL CONDITION]. On 11/20/14 at 8:40 a.m., an interview was conducted with Employee #79, the consulting Pharmacist. She said she tried to review the discharge summary from the previous hospital upon admission and check to see if a PT/INR was ordered. During the interview she stated, "I questioned the facility about just having scheduled monthly PT/INRs for the residents on [MEDICATION NAME] and they told me that is the way it has always been done. So I did not question it anymore." . b) Resident #1 On 11//17/14 at 2:45 p.m., an interview was conducted with Resident #1. She commented she has been on the mediation [MEDICATION NAME] for her "heart problems for years." Review of the medical record, on 11/17/14 at 3:25 p.m., revealed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. She was admitted on the medication [MEDICATION NAME] with a documented target range for her INR results of 2.0-3.0. Facility standing orders for this resident dated 05/16/14 reveal, "3. Monthly...If on [MEDICATION NAME] Levels." Resident #1 was transferred to the community hospital on [DATE], then transferred to a trauma hospital for possible stroke or [MEDICAL CONDITION] (TIA) and was re-admitted to the facility on [DATE] with a new [DIAGNOSES REDACTED]. A physician order dated 06/10/14 stated, "PT/INR every night related to [MEDICAL CONDITION] until 06/12/14." The PT/INR dated 06/12/14 revealed results of INR -2.0, with the INR results being within the target range. An order dated 06/20/14 to increase her [MEDICATION NAME] dosage to 4 mg by mouth daily, no order was located to monitor PT/INR more frequently than the original standing orders of monthly PT/INR. A medication review dated 06/24/14 was conducted by the Pharmacist with the box checked beside "irregularities, not significant, and a notation of check lipids & LFT (liver function test)?" There was no recommendation or notation to monitor the PT/INR that was not within the target range. Laboratory results revealed on 09/25/14 an INR result of 1.50 and on 10/23/14 an INR result of 1.40, which was not within the target range of INR results for this resident. A pharmacy review was conducted on 09/23/14 with the box checked beside "irregularities, not significant and a notation of Sept (September) PT/INR?" A pharmacy review on 10/28/14 revealed the box checked beside "No irregularities." The Pharmacist failed to identify the INR results for this resident were not within the target range and to initiate recommendations for a dosage change and/or more frequent laboratory monitoring. On 11/20/14 at 8:40 a.m., an interview was conducted with Employee #79, the consulting Pharmacist. She commented she tried to review the discharge summary from the previous hospital upon admission and checked to see if a PT/INR was ordered. During the interview she stated, "I questioned the facility about just having scheduled monthly PT/INRs for the residents on [MEDICATION NAME] and they told me that is the way it has always been done. So I did not question it anymore." She agreed Resident #1 "should have been monitored more closely with more frequent PT/INRs since she had a TIA episode, a medication dosage change and her INRs were below her target range." c) Resident #2 On 11/17/14 at 3:00 p.m., an interview was conducted with Resident #2. She commented she had been on [MEDICATION NAME] since 2008 when she had a pacemaker inserted for her heart problems. She said she was at the facility for about a month before they did her laboratory testing for [MEDICATION NAME]. Resident #2 stated her caregiver (who has been caring for her for twenty-six (26) years) kept asking the nurses about monitoring her [MEDICATION NAME] levels and she was told "they are only done here monthly." She stated, "I broke my left ankle when I fell and then had to have an operation, I was worried about having some bleeding or a blood clot." A medical record review was conducted on 11/18/14 at 10:00 a.m. She was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission nurses progress note, dated 07/21/14, revealed the resident had "multiple bruising to bilat arms and hands, bruising to left side and under left breast, bruising to left hip and lateral thigh from fall, left ankle half cast and wrapped with ace." A review of the discharge summary from the community hospital dated 07/21/14 revealed the resident is on [MEDICATION NAME] 5 mg by mouth daily. An INR completed on the morning of 07/21/14, revealed an INR of 4.7 (high and not in target range) and she was given a decreased dose of [MEDICATION NAME] 2.5 mg by mouth at the hospital prior to the nursing facility admission. She was documented to have a target range for her INR results of 2.0-3.0. Facility standing orders for this resident dated 07/21/14 reveal, "3. Monthly...If on [MEDICATION NAME] Levels." A Physician order, dated 07/21/14. revealed, "[MEDICATION NAME] Sodium Tablet 5 mg Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION] FIBRILLATION. Hold for 2 days then start new order." Resident #2's first laboratory test for a PT/INR at the facility was 08/28/14 with INR of 3.60 (laboratory reference range of 0.80-1.20, and high for target range). A physician order for [REDACTED]." There were no Physician orders for changes in the laboratory monitoring after the dosage change of [MEDICATION NAME]. A laboratory result, dated 09/25/14, revealed INR 2.76 and this was within the target range. A laboratory test dated 10/23/14 of INR 5.88 which is high for the target range of 2.0-3.0. At that time, new physician orders were written for a decrease in the [MEDICATION NAME] dosage. A monthly Medication Regimen Review dated 07/31/13, reveled the box was checked beside Irregularities, not significant with a notation to give [MEDICATION NAME] with dairy foods. On 08/28/14 the box was checked beside No Irregularities and a notation "aug labs not in chart yet." The Medication Regimen Review dated 09/23/14 and 10/18/14 were checked "No Irregularities." The monthly Medication Regimen Reviews by the pharmacist did not acknowledge the higher than target range INRs or the [MEDICATION NAME] dosage changes and the need for more frequent laboratory testing of PT/INR to prevent adverse consequences related to anticoagulation therapy. On 11/18/14 at 11:45 p.m., review of the medical record revealed the care plan, dated 10/22/14, did not contain a focus, goal or intervention related to the resident being on the medication [MEDICATION NAME]. A confidential interview was conducted with Employee B, on 11/18/14 at 2:40 p.m. She stated, "The resident should have had an INR done before the monthly order, because she was bruised everywhere on admission and her INR was critically high. Whoever admitted her should have looked at those things and notified the Physician immediately. We are just lucky, she didn't have a bleed." On 11/20/14 at 8:40 a.m., an interview was conducted with Employee #79, the facility Pharmacist. She commented she tries to review the discharge summary from previous hospital upon admission and checks to see if a PT/INR is ordered. During the interview she stated, "I questioned the facility about just having scheduled monthly PT/INRs for the residents on [MEDICATION NAME] and they told me that is the way it has always been done. So I did not question it anymore." After reviewing the discharge summary for Resident #2 and her PT/INR results, she stated, "I did not see that, I missed it." She further stated, "Yes, her high INR results and her dosage changes should have been monitored more closely." .

Based on observation, record review, resident interview, and staff interview, the facility failed to provide care and services to prevent the development of an avoidable pressure ulcer (PU) for one (1) of thirteen (13) sample residents. The resident developed an avoidable Stage III PU in the facility thirty-three (33) days after the removal of a cast and the placement of a controlled ankle movement (CAM) boot. The facility did not monitor the ankle or provide interventions for the prevention of skin breakdown, which resulted from the use of the CAM boot. The resident had an initial raw area which developed into an unstageable pressure area, and subsequently became a Stage III pressure ulcer. Resident identifier: #2. Facility census: 61 Findings include: a) Resident #2 Medical record review revealed the resident had surgery of the left ankle and a cast was applied. On 08/23/14, the orthopedic physician changed the cast to a controlled ankle movement (CAM) boot. Recommendations for surgical wound care, non-weight bearing (NWB) status, and CAM boot removal for range of motion (ROM) and personal hygiene were documented at that time. On 08/27/14 the orthopedic physician identified a raw area on the resident's left ankle. The facility failed to acknowledge these notations and failed to put procedures in place to prevent further tissue breakdown and the subsequent development of an avoidable Stage III pressure ulcer (PU). There was no evidence the facility was aware of any skin breakdown on the resident's ankle until 09/15/14, when an unstageable PU was identified. According to documentation, as of 09/22/14 the PU was a Stage III PU. On 11/17/14 at 3:00 p.m., an interview was conducted with Resident #2. She commented she was admitted to the facility in July of this year because she had fallen and broken her left ankle. She stated, "I had a sore on my ankle, but it is all better now." She was wearing a CAM boot at the time of the interview. This was removed by the caregiver and an observation revealed a healed PU area. A medical record review, on 11/18/14 at 10:00 a.m., found the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission nurse's progress note, dated 07/21/14, revealed the resident had "Multiple bruising to bilat arms and hands, bruising to left side and under left breast, bruising to left hip and lateral thigh from fall, left ankle half cast and wrapped with ace." On 07/23/14, the orthopedic physician changed the cast because of wound drainage, and noted the area was ecchymotic (bluish/purplish discoloration). A consultation report from the orthopedic physician, dated 08/13/14, revealed the resident had the cast removed and a controlled ankle movement (CAM) boot was placed at the time of the visit. Recommendations for surgical wound care, non-weight bearing (NWB) status, dressing changes every three (3) days, and CAM boot removal for range of motion (ROM) and personal hygiene were also documented at this time. On 08/27/14 an evaluation by the orthopedic physician identified a raw area on the resident's left ankle. There was nothing which indicated the facility was aware of the orthopedic physician's recommendations of 08/13/14 or the physician's identification of a raw area on 08/27/14. On 09/14/14, a nurse's note indicated: " ...one dime sized area on heel bone noted to be pink in color. Possibly from brace rubbing..." A nurse's note dated 09/15/14 revealed, "This nurse was doing treatment to resident's left foot and observed open area on bone of inner ankle that looked unrelated to surgery...." A skin assessment sheet, dated 09/15/14, revealed documentation of an unstageable PU to the left inner ankle measuring 1.0 x 1.0 centimeter (cm), with treatment of [REDACTED]. A skin assessment sheet dated 09/22/14 documented the PU was a Stage III PU measuring 0.7 x 1.0 cm. On 11/18/14 at 1:00 p.m., review of the resident's care plan, dated 08/04/14, revealed a focus: "Resident is at risk for skin breakdown due to needing ext (extensive) assist with all ADLs due to limited mobility from fx (fracture) ankle." The interventions included, "pressure reducing mattress to bed." The care plan did not include a focus, goal, or intervention after the resident's cast was removed on 08/13/14, at which time a CAM boot was placed to prevent skin irritation and prevention of a PU. The next focus, goal and intervention was dated 09/15/14, regarding the resident's Stage III PU "r/t boot." In an interview, on 11/19/14 at 9:50 a.m., Physical Therapist (PT) #76 commented the resident did not complain of her CAM boot rubbing during therapy, but she was non-weight bearing (NWB) for a couple of weeks. The PT said therapy was "unaware of the PU because we depend on nursing to do visible checks and we were unaware of any skin issues until nursing notified us on 09/15/14." Employee #76 further stated, "Pads were placed to help with the pressure from the CAM boot after we were notified of the PU." On 11/20/14 at 9:30 a.m., in an interview with the assistant Director of Nursing (ADON), she stated the resident had a cast and then the boot which rubbed and caused the PU. After a review of the resident's care plan, she agreed there was no focus, goal or intervention related to the prevention of a PU or for skin monitoring. She further stated, "I'm not sure if it could have been avoided, maybe if it were monitored better." .