Every finding on record at Derby Health & Rehabilitation, LLC

The facility reported a census of 61 residents; the sample included five residents reviewed unnecessary medications. Based on observation, interview, and record review revealed the facility failed to obtain physician-ordered orthostatic blood pressures as part of an evaluation following complaints of dizziness and lightheadedness. Findings included:- R45's Electronic Medical Record (EMR) revealed the following diagnoses: anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and hypotension (low blood pressure). R45's 02/18/26 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognition. R45's Care Plan documented that R45 used an antihypotensive medication for hypotension; initiated on 03/08/26. The plan directed staff to monitor and document side effects and the effectiveness of the medication. R45's Care Plan instructed staff to verify blood pressure and pulse prior to giving this medication; initiated on 03/08/26. R45's Progress Note had an Encounter note dated 02/27/26 at 12:00 AM that documented R45 had low blood pressure and R45 stated they have always been low. The provider ordered orthostatic blood pressure (measurements of blood pressure and pulse taken with the patient in the supine, sitting, and standing positions to assess low blood pressure and possible blood pooling in the lower extremities resulting in dizziness) two times a day for three days. R45's Physician Orders in the EMR documented an order for orthostatic blood pressure two times a day for three days. lying, sitting, and standing. Send the provider a message in the EMR with the results; started on 02/28/26. R45's Electronic Medication Administration Record (EMAR) documented on 02/28/26 one blood pressure reading of 100/64 millimeters of mercury (mm Hg). It lacked the lying, sitting, and standing blood pressures for the morning orthostatic blood pressures. R45's EMAR had no documentation for the evening orthostatic blood pressure order on 02/28/26. R45's EMAR documented NA for the lying, sitting, and standing blood pressures for the morning orthostatic blood pressure order on 03/01/26. R45's EMAR documented a 4 for the evening orthostatic blood pressure order on 03/01/26, which indicated to see the nurse's note. R45's Progress Note documented an eMAR- Medication Administration Note on 03/01/26 at 09:03 PM, for which the system would not allow her to enter the blood pressures in the boxes. The nurse documented a sitting blood pressure of 130/82 mm Hg, standing 125/78 mm Hg, and lying 126/70 mm Hg. R45's EMAR documented on 03/02/26 one blood pressure reading of 131/72 millimeters of mercury (mm Hg). It lacked the lying, sitting, and standing blood pressures for the morning orthostatic blood pressures. R45's EMAR had no documentation for the evening orthostatic blood pressure order on 03/02/26. On 03/11/26 at 10:31 AM, Certified Medication Aide (CMA) R stated the Certified Nurse Aide (CNA) got all the vital signs, including blood pressures, for residents in the mornings. The nurse later put the vital signs in the computer. CMA R stated that if a resident was on a heart medication, she would take vital signs before she gave the medication. She only had one resident who got vital signs before a medication, and it was not R45. On 03/11/26 at 10:49 AM, Licensed Nurse (LN) H stated that the CNAs usually got the vital signs, but she preferred to get the orthostatic blood pressures herself because the CNA did not always do it in the correct order. She wanted to make sure it was done correctly. When asked what the correct way to take an orthostatic blood pressure reading was, she said to take it lying, sitting, then standing, with no breaks in between. Have them lie down, then take the blood pressure, sit up, and immediately take the blood pressure, then stand and immediately take the blood pressure. On 03/11/26 at 12:28 PM, Administrative Nurse D stated that her expectation is that when the provider gave an order for orthostatic blood pressures, the nurse put the orders into the EMR. The nurse got the orthostatic blood pressure, then put it into the EMR. In the past, the provider had them send them to her, and she reviewed them. The documentation should be in PCC, and sometimes they go straight to Consultant HH. Unless it expires, they should be able to see the messages with the blood pressures. Staff were unable to find the messages with the blood pressure information. On 03/11/26 at 10:53 AM, Consultant HH stated she did not require blood pressure with all blood pressure medications. Consultant HH did not require blood pressure with midodrine. R45's blood pressure was low enough from the orthostatic to give the midodrine. The nurses were to check the orthostatic blood pressure two times a day for three days and tell her the results. No policy was provided.

The facility identified a census of 61 residents. The sample included 15 residents with three residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a written notification of transfer for facility-initiated transfers to Resident (R) 22, R77, and R78 and/or their representative for all applicable transfers/discharges. The facility further failed to notify the State Long Term Care Ombudsman (LTCO) of transfers/discharges for R22, R77, and R78. Findings included:- R22 admitted to the facility on [DATE], the facility transferred him to the hospital on [DATE], and he re-admitted to the facility on [DATE]. R77 admitted to the facility on [DATE], and the facility transferred her to the hospital on [DATE]. R77 did not readmit to the facility. R78 admitted to the facility on [DATE], and the facility transferred her to the hospital on [DATE]. R78 did not readmit to the facility. Upon request, the facility was unable to provide a written notification of transfer for R22, R77, and R78's hospital transfers. Upon request, the facility provided LTCO notification emails for discharges from March 2025 through February 2026. Review of the emails revealed the facility did not include the hospital transfers for R22, R77, and R78. On 03/11/26 at 07:47 AM, R22 sat in his wheelchair at the dining room table and ate breakfast. On 03/10/26 at 12:54 PM, Consultant GG stated the facility did not do written notification of transfers. On 03/11/26 at 11:34 AM, Licensed Nurse (LN) G stated that when a resident transferred to the hospital, she called their representative to notify them, but she did not do a written notification of transfer. On 03/11/26 at 11:38 AM, Social Services X stated that when a resident transferred to the hospital, she called and asked the family about a bed hold and completed a progress note. She stated she did not do a written notification of transfer and did not know what it was. Social Services X stated she completed an ombudsman report on the discharges from the facility, which included hospital transfers. She stated that if the resident admitted to the hospital after the transfer, then they would be discharged from the facility and would be included in the report. Social Services X stated she usually reviewed the list to make sure the report included the hospital transfers. The facility's Admission, Transfer, and Discharge Policy, dated 12/01/25, directed the facility to provide a 30-day advanced written notice, except in emergencies, that included the reason for the transfer/discharge, effective date, the receiving location, the LTCO contact, the State Agency (SA) contact, and the resident's appeal rights. The policy did not address a written notification of transfer for hospital transfers or LTCO notification of transfers.

The facility reported a census of 69 residents. The sample included seven residents with three residents reviewed for accident hazards. Based on observation, interview and record review, the facility failed to ensure an environment free from accident hazards for two residents, Resident (R)1 and R2 when staff failed to provide adequate hands-on stabilization of the resident from the second staff member during full body mechanical lift transfers. This deficient practice placed R1 and R2 at risk for accidents and injuries related to mechanical lift transfers. Findings included: - During an observation on 04/29/25 at 12:19 PM, Certified Medication Aide (CMA) G and Certified Nurse Aide (CNA) H performed a full body mechanical lift transfer for R1 from her recliner to a wheelchair. CMA G operated the controls of the lift with the legs positioned wide. CMA G raised R1 into the air using the lift. While R1 was in the raised position, CNA H released physical control and stabilization of R1, walked around the lift, R1 and CMA G and stood behind R1's wheelchair. CMA G then pushed the lift with R1 in the up and dangling position over to R1's wheelchair. CNA H then reached out and guided R1 down into the wheelchair as CMA G operated the control. CNA H and CMA G then unhooked the sling from the lift and repositioned R1 in her wheelchair. During an observation on 04/29/25 at 12:51 PM - CNA E and CNA F transferred R2 from her wheelchair to the bed using the full body mechanical lift. CNA E operated the controls with the legs positioned wide. Using the lift, staff raised R2 into the air and when R2 was in the up-position, CNA F let go of R2, opened the bathroom door that was positioned behind the wheelchair and moved the wheelchair into the bathroom. CNA F then walked around CNA E while R2 remained in the up and dangling position. CNA E then moved the legs of the lift into the narrow position and pushed the lift around to the side of R2's bed while lowering R2. CNA F then lifted R2's legs from beside the bed as CNA E pushed the lift into the final position over R2's bed. Staff lowered R2 onto the bed and disconnected the sling from the lift. During an interview on 04/29/25 at 12:28 PM, CMA G and CNA H revealed that they would not have performed the lift task differently. CMA G and CNA H then confirmed that CNA H had let go of R1 to walk around and stand behind R1's wheelchair while CMA G pushed the lift with R1 in the up position . During an interview on 04/29/25 at 12:30 PM, Licensed Nurse (LN) D revealed that mechanical lifts should always be operated with two staff members, one to operate the controls, and the other to ensure resident safety. LN D said the staff who ensured the resident remained safe should not let go of the resident to manipulate other objects or walk around the lift and the other staff member. During an interview on 04/29/25 at 12:58 PM, CNA E and CNA F reported they would not have performed the lift task differently. CNA E and CNA F then confirmed that CNA F let go of R2 while CNA E narrowed the legs of the lift and moved the resident while the lift was being lowered. During an interview on 04/29/25 at 02:58 PM, Administrative Nurse B revealed two staff should operate mechanical lifts with one staff operating the controls and the other maintaining hands-on contact with the resident to ensure safety; additionally, the legs of the lift should always be in the wide position for safety and stability. The facility's undated Hoyer Mechanical Lift policy lacked documentation related to positioning of the legs of mechanical lift. Further, the policy lacked documentation related to staff ensuring resident safety by maintaining contact with resident while lift was in operation.

The facility had a census of 61 residents. The sample included 15 residents. Based on observation, interview, and record review the facility failed to ensure hazardous chemicals were stored safely. This placed the five residents identified by the facility as cognitively impaired and independently mobile at risk for accidents and hazard-related injuries. Findings included: - On 04/24/24 at 08:13 AM, observation in the 300-household revealed an unlocked housekeeping closet with the following hazardous items with Keep out of reach of children instructions stored on a waist-high shelf: One small can of fiberglass resin. One quart bottle of tile sealer. One spray bottle of ant killer. One spray can of ant and roach killer. On 04/24/24 at 08:15 AM, Certified Nurse Aide (CNA) M verified the findings. On 04/24/24 at 09:01 AM, Administrative Nurse D verified staff should ensure housekeeping closets were locked when not under supervision. The facility's Chemical Storage policy, dated 03/12/24, stated all chemicals that are deemed hazardous to residents would be stored in a locked area or used under supervision. This was defined as any chemical that would cause harm or stated to keep away from children. The facility failed to ensure hazardous chemicals were stored safely, placing the five residents identified by the facility as cognitively impaired and independently mobile at risk for injury.

The facility had a census of 61 residents. Based on observation, interview, and record review the facility failed to store, prepare, and serve food in a sanitary manner for residents in two of four kitchens and dining rooms. This deficient practice placed residents at risk for food-borne illness. Findings included: - On 04/24/24 at 09:07 AM, observation in the 100-household kitchen freezer revealed a bag of chicken tenders, undated, and a box of hamburger patties opened, and the plastic bag torn leaving the patties open to air. On 04/24/24 at 12:17 PM, observation in the 300-household dining room revealed Certified Nurse Aide (CNA) M served plated food to residents. CNA M touched a resident's shoulders and chair, rubbed his face, and did not wash or sanitize his hands before serving more residents' plates. CNA M wiped his hands on his clothing, scratched his hair rubbed his face numerous times, and continued serving all 12 residents in the dining room without washing or sanitizing his hands. On 04/24/24 at 02:15 PM, observation of the 100 and 300 household kitchens revealed both kitchen toasters had numerous dried crumbs on top and edges, and both oven doors had dried food spills. On 04/29/24 at 12:10 PM, observation of the dining room service in 200-household revealed two staff served residents' meals. CNA M scratched his head and beard, rubbed his eyes, and did not wash or disinfect his hands before handling the residents' coffee cups or glasses. The April 14-20/2024 Cleaning Schedule directed staff to clean the toaster and microwave daily, and the ovens weekly. Staff had initialed as completed cleaning of the toasters and microwave in three days but not the oven. On 04/24/24 at 09:07 AM, Dietary Staff BB verified the findings in the freezers and stated staff were to date items when opened. On 04/24/24 at 02:15 PM, Dietary Staff BB verified the ovens and toasters should have been cleaned. On 04/29/24 at 12:32 PM, DM BB verified staff should wash or disinfect their hands if they have touched their hair or face and clothing before serving residents beverages and meals. The facility's Food Preparation and Sanitation policy, dated 03/14/24, stated any food handlers would perform hand hygiene regularly after touching ears, nose, mouth, or hair. The Dietary Food Storage policy, dated 03/13/24, stated all food items should be labeled with the name and discard date. The policy directed staff to wrap food properly and never leave any food item uncovered and not labeled. The facility's Sanitation of Dining and Food Service Areas policy, dated 03/13/24, stated a cleaning schedule would be posted for all cleaning tasks and would be held responsible for all cleaning tasks. The facility failed to serve food in a sanitary manner for residents in two of the dining rooms and kitchens, placing the residents at risk for food-borne illness.

The facility had a census of 61 residents. The sample included 15 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to hold Resident (R) 47's blood pressure medication per the physician-ordered blood pressure parameters. This deficient practice placed R47 at risk for unnecessary medications and related complications. Findings included: - R47's Electronic Medical Record (EMR) documented diagnoses including end-stage renal disease (ESRD-a terminal disease of the kidneys), atrial fibrillation (rapid, irregular heartbeat), and hypocalcemia (abnormally low level of calcium in the blood). The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R47 required supervision for eating and was dependent on staff assistance for toileting, bathing, and dressing. R47 received antianxiety (a class of medications that calm and relax people) and opioid (narcotic) medications. R47's Care Plan dated 03/29/24 directed staff to provide one or two-person assistance for activities of daily living. The plan documented R47 received hemodialysis (a procedure where impurities or wastes were removed from the blood) on Mondays, Wednesdays, and Fridays and received high-risk medications. The Physician Order, dated 04/05/24, directed staff to administer midodrine (a drug used to treat low blood pressure),10 milligrams (mg), three times daily. Hold if systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was greater than (>)130. R47's EMR recorded the following blood pressures which exceeded the ordered parameter and the midodrine was incorrectly administered: 04/07/24 at 08:06 am, 139/83 millimeters (mm) of mercury (Hg) 04/07/24 at 09:28 PM, 132/83 mm/Hg 04/08/24 at 09:24 AM, 132/83 mm/Hg 04/13/24 at 10:56 AM, 145/79 mm/Hg 04/14/24 at 08:37 AM, 141/85 mm/Hg 04/14/24 at 08:58 PM, 172/119 mm/Hg 04/15/24 at 07:33 AM, 143/84 mm/Hg 04/16/24 at 07:30 AM, 141/84 mm/Hg 04/18/24 at 09:07 AM, 138/84 mm/Hg 04/18/24 at 09:49 PM, 141/83 mm/Hg 04/19/24 at 11:33 AM, 146/79 mm/Hg 04/21/24 at 10:16 PM, 138/70 mm/Hg 04/22/24 at 10:10 AM, 138/84 mm/Hg 04/23/24 at 08:19 AM, 135/85 mm/Hg 04/23/24 at 08:59 PM, 137/81 mm/Hg 04/24/24 at 04:46 PM, 136/80 mm/Hg 04/25/24 at 09:07 AM, 139/80 mm/Hg The Physician Assistant Note, dated 04/23/24, stated R47 was seen that day. The report did not mention anything regarding R47's midodrine or blood pressure. R47's EMR lacked evidence the physician was notified of the midodrine administration outside of the physician-ordered parameters. On 04/25/24 at 09:17 AM, observation revealed R47 in bed eating breakfast. Certified Medication Aide (CMA) R administered medications, including 10 mg midodrine, to R47. CMA R gave the pills whole in applesauce and when asked what R47's blood pressure was, CMA R stated at 09:07 AM R47's blood pressure was 139/80 mm/Hg. On 04/24/24 at 01:25 PM, CMA R stated if R47's SBP was greater than 130, staff were to hold the midodrine. CMA R verified she should have held R47's midodrine because R47's SBP was 139. On 04/25/24 at 01:31 PM, Administrative Nurse E verified staff were to hold R47's midodrine if the SBP was greater than 130. She verified staff had administered the midodrine when they should have held it numerous times. The facility's Medication Administration policy, dated 03/14/24, stated staff were to document and follow holding or notification parameters for ordered medications. The facility failed to hold a blood pressure medication per the physician-ordered parameters, placing R47 at risk for unnecessary drugs and related complications.

The facility had a census of 61 residents. The sample included 15 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure the Consultant Pharmacist identified and reported Resident (R) 47's blood pressure medication administered outside the physician-ordered blood pressure parameters. This deficient practice placed R47 at risk for unnecessary medications and related complications. Findings included: - R47's Electronic Medical Record (EMR) documented diagnoses including end-stage renal disease (ESRD-a terminal disease of the kidneys), atrial fibrillation (rapid, irregular heartbeat), and hypocalcemia (abnormally low level of calcium in the blood). The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R47 required supervision for eating and was dependent on staff assistance for toileting, bathing, and dressing. R47 received antianxiety (a class of medications that calm and relax people) and opioid (narcotic) medications. R47's Care Plan dated 03/29/24 directed staff to provide one or two-person assistance for activities of daily living. The plan documented R47 received hemodialysis (a procedure where impurities or wastes were removed from the blood) on Mondays, Wednesdays, and Fridays and received high-risk medications. The Physician Order, dated 04/05/24, directed staff to administer midodrine (a drug used to treat low blood pressure),10 milligrams (mg), three times daily. Hold if systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was greater than (>)130. R47's EMR recorded the following blood pressures which exceeded the ordered parameter and the midodrine was incorrectly administered: 04/07/24 at 08:06 am, 139/83 millimeters (mm) of mercury (Hg) 04/07/24 at 09:28 PM, 132/83 mm/Hg 04/08/24 at 09:24 AM, 132/83 mm/Hg 04/13/24 at 10:56 AM, 145/79 mm/Hg 04/14/24 at 08:37 AM, 141/85 mm/Hg 04/14/24 at 08:58 PM, 172/119 mm/Hg 04/15/24 at 07:33 AM, 143/84 mm/Hg 04/16/24 at 07:30 AM, 141/84 mm/Hg 04/18/24 at 09:07 AM, 138/84 mm/Hg 04/18/24 at 09:49 PM, 141/83 mm/Hg 04/19/24 at 11:33 AM, 146/79 mm/Hg 04/21/24 at 10:16 PM, 138/70 mm/Hg 04/22/24 at 10:10 AM, 138/84 mm/Hg 04/23/24 at 08:19 AM, 135/85 mm/Hg 04/23/24 at 08:59 PM, 137/81 mm/Hg 04/24/24 at 04:46 PM, 136/80 mm/Hg 04/25/24 at 09:07 AM, 139/80 mm/Hg The Progress Note, dated 04/22/24, stated the Consultant Pharmacist medication review stated available chart data was reviewed and no significant irregularities were noted. The recommendation indicated to refer to the nursing recommendation. The Physician Assistant Note, dated 04/23/24, stated R47 was seen that day. The report did not mention anything regarding R47's midodrine or blood pressure. R47's EMR lacked evidence the physician was notified of the midodrine administration outside of physician-ordered parameters. The Pharmacist Recommendation Report for 04/01/24 to 04/23/24 stated, Please review recent Medication Administration Record/Treatment Administration Record (MAR/TAR) for potential holes. The patient's midodrine order currently includes a hold parameter. Please add the blood pressure assessment and documentation to the MAR for this medication. The report lacked comment on the administration of midodrine when the SBP was out of the ordered parameters. On 04/25/24 at 09:17 AM, observation revealed R47 in bed eating breakfast. Certified Medication Aide (CMA) R administered medications, including 10 mg midodrine, to R47. CMA R gave the pills whole in applesauce and when asked what R47's blood pressure was, CMA R stated at 09:07 AM R47's blood pressure was 139/80 mm/Hg. On 04/24/24 at 01:25 PM, CMA R stated if R47's SBP was greater than 130, staff were to hold the midodrine. CMA R verified she should have held R47's midodrine because R47's SBP was 139. On 04/25/24 at 01:31 PM, Administrative Nurse E verified staff were to hold R47's midodrine if the SBP was greater than 130. She verified staff had administered the midodrine when they should have held it numerous times. On 04/29/24 at 09:27 AM, Administrative Nurse E verified the consultant pharmacist had not noted the midodrine error in the monthly review. On 04/29/24 at 12:51 PM, Administrative Nurse D stated she expected the CP to note the administration of midodrine when a SBP was out of the parameters and bring it to her and the physician's attention. The Consultant Pharmacist Services Provider Requirements policy, dated 03/13/24, stated the consultant pharmacist provides pharmaceutical care services including: Reviewing the medication regimen of each elder at least monthly, incorporating federally mandated standards of care in addition to other applicable professional standards, and documenting the review and findings in the elder's clinical record. Communication of the potential or actual problems detected related to medication therapy orders to the responsible physician and the director of nursing. Reviewing the MARS and physician orders monthly at the facility to ensure proper documentation of medication orders and administration of medication to elders. Communicating recommendations for changes in medication therapy and monitoring of medication therapy. Submitting a written report of findings and recommendations resulting from the review. The facility failed to ensure the CP identified and reported the administration of midodrine when staff should have held it, placing the resident at risk for unnecessary medications and related complications.

The facility had a census of 61 residents. The sample included 15 residents of which two were reviewed for the gastrostomy tube (G-tube: surgical creation of an artificial opening into the stomach through the abdominal wall) feeding management. Based on observation, record review, and interview, the facility failed to provide G-tube care per the physician's orders for Resident (R)41 when staff failed to administer the required amount of water prior to the nutritional feeding through the G-tube. This placed the resident at risk for G-tube related complications. Finding included: - R41's Electronic Health Record (EHR) revealed diagnosis of dysphasia (swallowing difficulty), cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia (paralysis of one side of the body), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R41's Quarterly Minimum Data Set (MDS), dated [DATE], documented R41 had moderately impaired cognition. R41 was dependent on staff for toileting, dressing, and personal hygiene. R41 was dependent on staff for mobility and transfers. The MDS recorded the resident had a feeding tube. R41's Care Plan, dated 02/02/24, recorded R41 required a tube feeding for nutritional maintenance. The plan directed the staff to administer tube feedings of Jevity 1.5 (nutritional liquid supplement), one carton four times a day, per G-tube with water flushes of 45 milliliters (ml) before and after feedings. The care plan recorded staff would monitor R41's weight and make nutritional interventions as needed. R41's Physician Order. dated 01/17/23, directed the staff to administer Jevity liquid, one carton through the tube four times a day; provide 45 ml water flush before and after feedings, with an additional 175 ml free water six times a day. On 04/29/24 at 12:00 PM, observation revealed Licensed Nurse (LN) G administered one carton of Jevity through the G-tube followed by 45 ml of water. LN G did not administer the 45 ml water flush prior to administering the medications and feeding, per the physician's order. On 04/29/24 at 02:00 PM, Consultant GG verified the nursing staff should administer the water flushes before and after the nutritional feeding per R41's physician's order. The facility's Enteral Nutrition policy, dated 02/07/2022, documented the staff would provide the residents with enteral feedings to provide nutrients and fluids using the gastrointestinal tract to provide an individual's nutritional needs. The policy documented that the bolus route required that the resident had a functioning stomach that could handle a larger amount of fluid infused at one time the resident's tolerance. The policy documented the formula is administered using a 60 ml syringe and given at a rate based on the nutritional feeding order would contain the name of the formula, flow rate, hours of administration, route of administration and total ml to be delivered per 24-hour period with additional water to meet hydration needs to be given via free water flush. The facility failed to flush R41's G-tube with 45 ml of water, before a nutritional feeding as ordered, placing the resident at risk for complications related to the G-tube.

The facility identified a census of 61 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure residents remained free from abuse when multiple residents' medications were misappropriated. This deficient practice placed all residents who had controlled medications stored in the facility at risk for further misappropriation and impaired care related to missing or stolen medications. Findings included: - The facility's investigation report 6803 dated 04/03/24 documented on 03/25/24, Administrative Nurse E noted Resident (R)162's entire card of oxycodone (schedule II opioid pain medication with high use for misuse or addiction) five milligrams (mg) tablets were missing. The pharmacy delivered the card on 03/22/24 and it was received by Licensed Nurse (LN) H. Per the log, the card had 12 pills. The pharmacy was contacted and confirmed that on 03/22/23 at 07:00 PM, LN H received and signed for three narcotic cards including oxycodone 5 mg (12 pills), oxycodone-acetaminophen 5/325 mg (20 pills), and hydrocodone-acetaminophen (opioid pain medication mixed with Tylenol) 5/325 mg (30 pills). The report documented the facility was unable to locate the medications after a search of the medication carts in all four households was conducted. The report documented that upon identification of the missing medications, Administrative Nurse D contacted LN H via phone and LN H stated she was out of town but she remembered she received the narcotics and thought she could have accidentally placed them in the shred box with the medication labels. Administrative Nurse D verified the shred box was searched and no narcotics, labels, or narcotic sheets were found. LN H was asked to come to the facility and fill out a witness statement and stated she would come to the facility on Friday. LN H then sent a text stating she would not be back in town until the following Monday and that she would come to the facility to fill out the witness statement. On Monday 04/01/24, LN H came to the facility and filled out a witness statement, then provided a urine sample. During the investigation, it was determined the three narcotic cards that were delivered on 03/22/24 were missing along with the narcotic count sheets. The facility contacted the police department and gathered statements from the facility staff. Administrative Nurse D reported the following residents were affected by the misappropriation: R162's oxycodone 5 mg, 12 tablets. R163's oxycodone-acetaminophen 5-325 mg, 20 tablets. R164's hydrocodone-acetaminophen 5-325 mg, 30 tablets. On 04/24/24 at 08:20 AM, a review of the nurse's medication cart on the 400 house revealed the narcotic medications were stored in a locked metal box affixed to the medication cart, which was also locked when not in use. On 04/30/24 at 08:10 AM, a review of the nurse's medication cart on the 100 house revealed the narcotic medications were stored in a locked metal box affixed to the medication cart, which was also locked when not in use. On 04/30/24 at 08:20 AM, a review of the nurse's medication cart on the 200 house revealed the narcotic medications were stored in a locked metal box affixed to the medication cart, which was also locked when not in use. On 04/30/24 at 08:30 AM, a review of the nurse's medication cart on the 300 house revealed the narcotic medications were stored in a locked metal box affixed to the medication cart, which was also locked when not in use. On 04/30/24 at 11:00 AM, Administrative Nurse D stated the staff were to receive the narcotic medications and place them in the medication room or cart and a narcotic count sheet would also be in the narcotic book along with the narcotic medication. Administrative Nurse D stated the residents in the facility were to remain free of all forms of abuse, neglect, and exploitation. The facility's Abuse, Neglect and Exploitation policy, undated, documented the facility had developed and implemented the policy and procedure to prohibit mistreatment, neglect, and abuse of all elders and misappropriation of elder property by any perpetrator including but not exclusive to; any staff member other elders. exploitation means misappropriation of elder property or intentionally taking unfair advantage by the use of undue influence, coercion, harassment, duress, deception, false representation or pretense by a caretaker or another person. Facility staff will not use or allow others to use; verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The policy is to ensure that all elders of the facility would be free of physical, emotional, and sexual abuse, neglectful treatment, and misappropriation of funds. The facility failed to ensure residents remained free from abuse when multiple residents' medications were misappropriated. This deficient practice placed all residents who had controlled medications stored in the facility at risk for further misappropriation, abuse, and lack of pain care management related to missing or stolen medications.

The facility had a census of 61 residents. The sample included 15 residents. Based on record review and interview, the facility failed to provide Resident (R)8, R11, and R160, or their representative, the completed Centers for Medicare and Medicaid (CMS) Skilled Nursing Facility Advanced Beneficiary Notices (ABN) Form 10055. This placed the resident at risk of uninformed decisions about their skilled services. Findings included: - The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. A review of the ABN provided to R8 revealed the resident received the wrong form. R8 received the CMS-R-131 instead of CMS Form 10055. The resident's skilled services ended on 04/05/24. A review of the ABN provided to R11 revealed the resident received the wrong form. R11 received the CMS -R-131 instead of CMS Form 10055. The resident's skilled services ended on 02/13/24. A review of the ABN provided to R160 revealed the resident received the wrong form. R160 received the CMS -R-131 instead of CMS Form 10055. The resident's skilled services ended on 02/12 /24. On 04/25/24 at 12:05 PM, Social Services X verified she had been employed at the facility for a year and the CMS-R-131 was the form she provided to R8, R11, and R160, and/or their representative, not the Form 10055. On 04/25/24 at 12:45 PM, Consultant GG verified the facility provided the CMS-R-131 form to R08, R11, and R160, and/or their representative, and failed to provide the 10055. The facility's Medicare Denial Notices (Advance Beneficiary Notices-ABN) policy, dated March 13, 2024, recorded the facility would inform each resident before, or at the time of admission, and periodically during the resident's stay of services not covered under Medicare for the facility's per diem rate. The facility would provide each resident with a written description of legal rights which includes a description of the manner of protecting personal funds. The facility would provide written notification to residents with the necessary information to decide whether to appeal a decision to terminate Medicare care and services at least three days before the planned change in payor status or discharge. The SNFABN would provide information to the resident or representative to enable them to decide if the resident would choose to continue receiving skilled services that may not be covered under Medicare. The facility would inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for the services. The facility failed to provide R8, R11, and R160, or their representatives, the correct 10055 form when discharged from skilled care. This placed the residents at risk of uninformed decisions about their services.

The facility reported a census of 69 residents with two residents reviewed for labeling of insulin pens. Based on observation, interview and record review, the facility failed to ensure correct expiration dating/labeling of insulin (a medication used to lower blood sugar levels) for sampled residents (R) 29 and R17. Findings included: - Observation, on [DATE] at 09:02 AM, revealed resident (R)17's Novolog flex pen, (a device containing insulin for the administration of insulin), contained a label in which staff documented the open date of [DATE] and the expiration date written as [DATE]. The resident's Lantus Solostar insulin pen lacked a label from the pharmacy as required and staff wrote the dates on them. Observation, on [DATE] at 09:15 AM, revealed staff documented the open date of [DATE] on R29's Lantus Solostar insulin pen and documented the expiration date of [DATE]. The resident's Humalog insulin pen contained and open date of [DATE], with the expiration date written as [DATE]. Interview, on [DATE] at 09:20 AM, with Licensed Nurse (LN) H, confirmed the above. LN H stated there was a guide that contained the expiration dates for the insulin pens once opened and did not know why staff used the manufacturer's expiration date for unopened pens. Interview, on 11:,d+[DATE] at 09:25 AM, with Administrative Nurse E, revealed she would expect staff to label the expiration date of the insulin according to the guide that indicated the number of days before the opened insulin expired and not the manufacturer's date of expiration for unopened insulin. Administrative Nurse E indicated each medication room contained the guide hanging on the wall. Administrative Nurse E stated R17's insulin pen should have a pharmacy label as required. The policy Medication Administration, dated [DATE], instructed staff to administer medication in a safe and sanitary manner. The facility guide [NAME] Long-Term Care Medications with Shortened Expiration Dates After First Opened undated, instructed staff to ensure that medications, once opened may lose stability, sterility and of efficacy sooner than the expiration date listed on the manufacturer's packaging. This guide instructed staff that Novolog flex pen, Lantus Solostar and Humalog insulin pen after first use, use pen within 28 days. The facility failed to correctly document the expiration date for three opened insulin pens for these two residents and failed to ensure one insulin pen contained a pharmacy label as required to ensure safe and effective administration of medication.

The facility reported a census of 69 resident with 20 selected for review which included three residents reviewed for urinary catheter/urinary tract infections. Based on observation, interview and record review, the facility failed to ensure sanitary catheter care for two of the three sampled resident's (R)30 and R55, to prevent urinary tract infections. Findings included: - Review of Resident (R)30's Physician Order Sheet, dated 10/16/22, revealed diagnoses included heart failure, cerebral vascular disorder (stroke) aphasia (condition with disordered or absent language function) and neuromuscular dysfunction of the bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function, required extensive assistance of one staff for dressing, toilet use and personal hygiene. The resident had an indwelling urinary catheter. The Dehydration/Fluid Maintenance Care Area Assessment (CAA), dated 07/31/22, assessed the resident was on antibiotic for urinary tract infection and pneumonia. Staff advised to monitor the resident for increase signs of urinary tract infection. The Baseline Care Plan, dated 10/16/22, instructed staff the resident required assistance of one staff for grooming/hygiene and had a urinary catheter. The Significant Change MDS, dated [DATE], was in progress. Observation, on 11/01/22 at 02:57 PM, revealed the resident seated in his wheelchair in his room. Approximately eight inches of the catheter tubing lay directly on the floor with the urine collection bag in a privacy bag suspended from the bottom of the wheelchair. Observation, on 11/08/22 at 08:57 AM, revealed the resident seated in his wheelchair in the dining room eating breakfast. Approximately four inches of the catheter tubing lay directly on the floor near the resident's feet. Interview, on 11/08/22 at 09:26 AM, with Certified Nurse Aide (CNA) P, confirmed the tubing did lay on the floor at times and staff tried to keep it off the floor but the resident often self-propelled himself in his wheelchair with his legs/feet, the tubing did move out of the urine collection bag. Observation, on 11/08/22 at 01:30 PM, revealed the resident used an exercise machine in a seated position. Approximately eight inches of catheter tubing lay directly on the base of the machine. Interview, on 11/08/22 at 01:40 PM, with Licensed Nurse (LN) H, revealed staff should keep the catheter tubing off the floor. Interview, on 11/08/22 at 02:20 PM, with Administrative Nurse D, revealed she would expect staff to keep the catheter tubing off the floor. The facility policy for Indwelling Catheter Protocol, approved 02/22/22, included: Staff should take measures to reduce the chance of the tubing touching the floor. The facility failed to monitor for sanitary placement of this resident's catheter tubing to ensure the tubing remained off the floor to prevent urinary tract infections. 34056 - Review of Resident (R)55's electronic medical record (EMR), included a diagnosis of neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had a urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) and required extensive assistance of staff for toileting. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 10/19/22, documented the resident admitted to the facility with the urinary catheter due to a diagnosis of neurogenic bladder. The care plan, dated 10/13/22, instructed staff the resident required total care with toileting and had a urinary catheter. On 11/01/22 at 01:38 PM, the resident sat in his wheelchair with the catheter collection bag hanging from underneath the wheelchair. The catheter tubing rested directly on the floor beneath the wheelchair. On 11/02/22 at 08:25 AM, Certified Nurse Aide (CNA) M and CNA N gave morning cares to the resident in his room. The resident's catheter tubing rested directly on the floor beneath the wheelchair as staff brought the resident out of his room for breakfast. On 11/01/22 at 01:47 PM, CNA N stated the catheter tubing should not be on the floor. CNA N stated she was unaware the tubing was on the floor. On 11/02/22 at 08:25 AM, CNA M stated the catheter tubing should be coiled up and kept inside of the dignity bag. The tubing should never be on the floor. On 11/08/22 at 11:15 AM, Licensed Nurse (LN) G stated catheter tubing should not be on the floor. On 11/08/22 at 08:15 AM, Administrative Nurse D stated the catheter tubing should be kept off the floor at all times. The facility policy for Indwelling Catheter Protocol, approved 02/22/22, included: Staff should take measures to reduce the chance of the tubing touching the floor. The facility failed to take appropriate care of this dependent resident's catheter tubing to keep it off of the floor and prevent urinary tract infections.

The facility reported a census of 69 residents with 20 residents sampled, including four residents reviewed for accidents. Based on interview, record review and observation, the facility failed to initiate the planned intervention for one of the four sampled, Resident (R)2, with the use of a motion alarm placed under the resident in bed/chair/wheelchair, to prevent further falls. Findings included: - Review of Resident (R)2's electronic medical record (EMR), included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. She required extensive assistance of one staff for transfers and walking and had impairment on her bilateral upper extremities. She used a walker or a wheelchair for locomotion. She had one non-injury fall since admission. The Falls Care Area Assessment (CAA), dated 10/16/22, documented the resident was at risk for falls related to weakness. She required extensive assistance with transfers and ambulation. The Temporary Admission Care Plan, dated 10/10/22, instructed staff the resident was cognitively impaired and required assistance of two staff for transfers and assistance with ambulating and locomotion. The resident used a wheelchair. The fall care plan, updated 10/26/22, instructed staff to place an alarm pad under the resident when she was in a supine or sitting position. Review of the resident's EMR, included fall assessments which placed the resident at a risk for falls on 11/01/22, 10/28/22, 10/23,22, 10/19/22 and 10/18/22. Review of the resident's EMR, revealed a Progress Note, dated 10/28/22, which documented staff observed the resident on the floor of her room on her left side facing her recliner. Staff observed the motion alarm on the resident's bed and not on the recliner where the resident had been sitting before the fall. The resident had facial bruising as a result of the fall. On 11/03/22 at 06:47 AM, Certified Medication Aide (CMA) R stated the resident will get restless and attempt to get up on her own. Staff are to ensure the motion alarm pad was always underneath her to alert staff when she would attempt to get up on her own. When she fell and got the facial bruising, the motion alarm pad was not in place. On 11/03/22 at 07:50 AM, Certified Nurse Aide (CNA) M stated staff were to always have the motion alarm pad beneath her in bed, in her recliner and in her wheelchair, to notify the staff when she attempted to get up on her own. The resident had a fall from her recliner which caused facial bruising and the staff had not placed the motion alarm pad underneath her, at that time. On 11/08/22 at 11:15 AM, Licensed Nurse (LN) G stated staff should have had the motion alarm pad underneath the resident while she was in the recliner but failed to move it from the bed to the recliner on 10/28/22 when the resident fell from her recliner. On 11/08/22 at 08:15 AM, Administrative Nurse D stated it was the expectation for the staff to have placed the motion alarm pad underneath the resident when she moved from her bed to her recliner. The facility policy for Falls Management, revised 01/05/22, included: Staff will identify and implement appropriate interventions to reduce the risk of falls and to minimize serious consequences if a fall occurs. The facility failed to place the planned use of the motion alarm pad underneath this dependent, confused resident when they moved her from her bed to her recliner, which resulted in a fall with facial bruising.

The facility reported a census of 69 residents. Based on observation, interview and record review, the facility failed to ensure the daily staff postings included the actual hours worked by the nursing staff as required. Findings included: - Review of the Daily Staffing for August, September and October 2022 columns for staff number and hours with daily total documented for RN, LPN and CNA. None of these sheets contained the actual hours worked. The one dated 09/16/22, revealed two RN (registered nurse) unit managers from 08:00AM to 05:00PM, day shift RN indicated one, with hours worked as 12, and one night shift RN with 12 hours. The daily total of RN's was four, and the total hours was 48. Review of the nursing schedule provided by the facility which did not include the two nurse managers, revealed no RN coverage for the day. Interview, on 11/02/22 at 02:13 PM, with Administrative Staff A, revealed she updated the daily staff posting as needed. Interview, on 11/09/22 at 02:59 PM, with Administrative Nurse D, revealed on 09/16/22 the daily staff posting, included the 24 hours worked by the two RN unit managers and confirmed one RN did not work the day shift for 12 hours as indicated on the daily posting but one RN worked from 06:00PM to 06:00AM, and so the total for RN's was three instead of the reported four, and the hours worked was 36 actually instead of the 48 reported on the daily staff posting. The facility did not provide a policy for daily staff posting. The facility failed to ensure daily staff posting included the actual hours worked by staff as required.

The facility reported a census of 64 residents, with three residents sampled for cardiopulmonary resuscitation (CPR, emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning, etc.). The facility identified 31 residents with full code status, indicating the residents wishes for life saving measures to be utilized in emergent situations, to include CPR. Based on interview and record review, the facility staff failed to implement CPR on a non-responsive full-code hospice Resident (R1) on [DATE] at 06:00 AM, when staff found the resident without respirations and pulseless. The staff assumed the resident was a DNR due to her hospice status and staff did not identify her full code status until the hospice nurse asked for a copy of her face sheet over 45 minutes later. Due to the lack of an effective code system in place to identify full code and do not resuscitate (DNR) residents and the failure of staff to perform CPR on a full code resident, the facility placed 31 full code residents in immediate jeopardy. Findings included: - The Review of R1's signed History and Physical dated [DATE] revealed the following Diagnosis: [REDACTED].) Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. Review of the Baseline Care Plan dated [DATE] revealed a code status of DNR (Do-Not-Resuscitate) on the front page of the care plan (handwritten) but all subsequent pages had FC (Full Code) listed. Review of the resident's hospice company Current Plan of care as of [DATE] noted R1 was not a DNR. Review of the Physician order [REDACTED]. Review of the Transfer/Discharge Report dated [DATE] noted R1's advance directive as FULL CODE. Review of the Nursing Progress Note dated [DATE] at 06:12 AM by Licensed Nurse (LN) C revealed that around 06:00 AM, Certified Nurse Aide (CNA) D notified LN C the resident was not breathing. LN C went to R1's room and observed R1 was not breathing and notified the resident's hospice company and the on-coming nurse, who took over the shift. LN C did not identify R1 as a full code and did not initiate CPR when she observed R1 not breathing or pulseless. Review of the hospice company's Transfer/Discharge/Death Summary dated [DATE] revealed the hospice Licensed Nurse (LN) F arrived to the facilty on [DATE] at 06:45 AM and noted in her comments This nurse spoke with patient spouse (name omitted) upon arrival to the LTCF, he was lying in his bed in the same room as pt. This nurse notified spouse of patients passing, he states that he knew 'she was getting bad.' (R1's spouse) asked to get up in his w/c to sit next to pt, this nurse spoke with staff Review of R1's Clinical Records found no Advance Directive filled out and placed in R1's medical chart. Review of the facility reported incident investigation #0693, provided by the facility on the State of Kansas Reportable form revealed XXX[DATE] (R1), on hospice and end of life care, passed peacefully in her sleep between ,[DATE] am. Nurse, (LN C), thought (R1) was a DNR and did not check status. Hospice was notified as was family. Body released to mortuary. It was identified that (R1) was a full code but no documentation from hospice that this was discussed with family due to (R1)'s terminal condition . The documentation noted the facility informed the family and the family of R1 noted understanding and said they would not have wanted you to do CPR. The investigation stated the facilty suspended LN C and Talked with (LN C) at length and educated on code statuses and verification. Complete audit done to ensure all code status were correct in computer/EMR . Under the section noting the corrective actions taken by the facility in response to the incident, noted Nurse Suspended and educated. Nurse will resume regular schedule since education done. Complete audit done to ensure correct code statuses in EMR. Under the section for the facility plan for monitoring the on-going effectiveness of the corrective action plan the facility wrote: All nurses educated on Code Status and DNR's. Will perform audits to ensure accuracy and monitor all hospice code status documentation. The investigation was signed on [DATE] by Administrative Nurse B. The investigation included the Basic Life Support verification of LN C as current. Review of the Entity Reports and Complaint Data Collection page submitted with the facility reported incident investigation number 0693 regarding R1 revealed on [DATE] .Aide entered room approximately 6am and resident appeared to not be breathing - notified nurse. Nurse entered room, assessed resident, and verified absence of vital signs. Nurse confirmed that resident was deceased . Notified hospice and oncoming nurse. Hospice was in building at approximately 6:50. Hospice spoke with spouse and called family. Hospice nurse requested face sheet from dayshift nurse and the dayshift nurse noticed resident was listed as a full code. CPR was not started on resident . Review of LN C's signed witness statement dated [DATE] revealed .Around 6am aide notified this nurse that resident not breathing this nurse went to resident's (room), assessed resident radial pulse and carotid pulse didn't find. Resident's face was pale, no chest rise noted. (Hospice company) notified and on coming nurse took over the shift. While hospice nurse was on the way. This nurse was unaware about the code status until (Administrative Nurse B) called this nurse and educated about code. Education given about code status for everyone, including hospice . During an interview on [DATE] at 10:49 AM CNA D stated she checked on R1 around 06:00 AM on [DATE] and found her mouth open but R1's chest did not rise to indicate that she was breathing. CNA D stated she went to get LN C, who checked R1's pulse on her neck and found no pulse. CNA D stated she would ask the nurse to know a resident's code status and said the residents care plan books and medical charts were located at the nurse's station but said she has never looked in them. She stated the facility had not educated her on the facility policy on how to determine the code status of a resident and she did not know of any indicator to know a resident's code status. During an interview on [DATE] at 08:47 AM, CNA E stated the nurse should know if a resident was a DNR and thought the care plan notebook should list this information but was not able to locate it. Stated she had never seen a DNR posting in any resident room. CNA E stated she has not received any CPR education from the facility, not even at orientation. During an interview on [DATE] at 10:30 AM, LN C stated on [DATE] at around 06:00 AM CNA D told her R1 was not breathing. LN C stated when she checked R1, she found her facial color as pale, she did not have any pulse, and was not breathing. LN C stated she did not initiate CPR as she assumed R1 was a DNR since she was on hospice. During an interview on [DATE] at 12:10 PM, Administrative Nurse B stated she expected nursing staff to verify a resident's code status and begin CPR if the staff found a resident pulseless and not breathing and listed as a full code. Administrative Nurse B stated an Advance Directive should have been completed for R1 to indicate her code status. Review of the Cardiopulmonary Resuscitation policy dated [DATE] revealed: CPR will be initiated: When [MEDICAL CONDITION] occurs for a resident who has requested CPR in the Advance Directive (or) When a resident has not formulated an Advance Directive (or) When the resident does not have a valid DNR order from a licensed physician or professional practitioner. The facility failed to have an effective code status system to ensure nursing staff correctly identified the code status of R1 and failed to initiate CPR when staff found R1 not breathing and pulseless. These failures placed 31 residents with full code status in immediate jeopardy. On [DATE] at 04:11 PM, the Administrator and Director of Nursing were provided with the IJ template and notified that the failure to implement CPR on a non-responsive full-code hospice Resident (R1) when staff found the resident without respirations and pulseless. and the failure to ensure an effective code status systems was in place, and the failure of facility staff to initiate CPR on a full code resident, placed residents in immediate jeopardy at F678. The facility presented an acceptable plan for removal of the immediate jeopardy on [DATE] at 10:20 AM by implementing the following actions: 1. Educated staff on how to identify a resident's code status prior to staff working on the floor with residents and posted a resident code status sheet at each nurses' station. 2. All care plans were being reviewed for accuracy specifically code status, all activated DNRs checked to ensure they were on the front of charts readily accessible, and chart audits were being performed to ensure all DNR paperwork in EMR and code status are correct. 3. Posted a list of CPR certified staff at each nurses' station. During a subsequent onsite visit, the surveyor verified the implementation of the plan for removal of the immediacy on [DATE] at 12:30 PM. The deficient practice remained at a E (pattern with no actual harm with potential for more than minimal harm) scope and severity following the removal of the immediate jeopardy.

The facility census totaled 71 residents and 3 residents were sampled for medication administration. Based on interview and record review, the facility failed to ensure one sampled resident received sliding scale insulin according to physician orders [REDACTED]. (#5) Findings included: - Review of resident #5's signed physician's orders [REDACTED]. Review of the nurse's admission assessment dated [DATE] revealed the resident had intact cognition and communicated easily with staff. The minimum data set (MDS) assessment was not completed due to the resident's recent admission. Review of the temporary care plan initiated 4/16/17 revealed the resident had diabetes and took insulin. Review of the signed physician orders [REDACTED]. The order directed staff to administer additional sliding scale insulin when the resident's blood sugar exceeded 150 milligrams per deciliter (mg/dL). Review of the April 2017 medication administration record (MAR) indicated the resident's blood sugars exceeded 150 mg/dL and lacked documentation of administration of sliding scale insulin: - On 4/17/17 with blood sugar reading 160 mg/dL when fasting. - On 4/18/17 with blood sugar reading 173 mg/dL following the evening mealtime. - On 4/19/17 with blood sugar reading 211 mg/dL following the morning mealtime. - On 4/19/17 with blood sugar reading 244 mg/dL following the evening mealtime. - On 4/20/17 with blood sugar reading 184 mg/dL following the noon mealtime. - On 4/22/17 with blood sugar reading 182 mg/dL following the evening mealtime. - On 4/23/17 with blood sugar reading 194 mg/dL following the evening mealtime. During an interview on 4/20/17 at 2:41 PM administrative nursing staff K confirmed the MAR lacked documentation of PRN sliding scale insulin on 4/17/17 during fasting, 4/18/17 following supper, and 4/19/17 fasting and following supper. During an interview on 4/20/17 at 2:50 PM licensed nursing staff J confirmed that he/she did the blood sugar monitoring on 4/17/17 during fasting time and on 4/19/17 following breakfast, but the MAR lacked documentation of PRN sliding scale insulin administration. During an interview on 4/24/17 at 3:05 PM licensed nursing staff L said he/she did the blood sugar monitoring and PRN sliding scale insulin administration on 4/22/17 and 4/23/17 evening times. He/she did not know why the blood sugar monitoring appeared on the MAR and the PRN sliding scale insulin administration did not. During an interview on 4/24/17 at 2:25 PM administrative nursing staff A said he/she realized the MAR lacked documentation for PRN sliding scale insulin given on several administration times. He/she already received medication error reports from the 4/17/17 and 4/19/17 doses. He/she expected staff to follow the physician orders [REDACTED]. During an interview on 4/24/17 at 3:16 PM consultant nursing staff M said he/she thought the lack of documentation on the MAR was because staff documented the PRN sliding scale insulin in the administrative one-time dose charting and not in the PRN charting. He/she accessed PRN sliding scale insulin charting via an administrative charting process in the electronic record, however, non-administrative staff could not access that charting. He/she confirmed that the amounts of sliding scale insulin given to the resident should be accessible by all nursing staff. The facility failed to provide a policy regarding sliding scale insulin administration as requested on 4/25/17. The facility failed to administer sliding scale insulin for one resident over 7 days at 7 different times.

The facility census totaled 71 residents with 5 residents included in the sample. Based on observation, Interview, and record review, the facility failed to notify the physician or his/her designee immediately after a significant change in status for two sampled resident's; resident #2 after a decline in the resident's level of consciousness and increased lethargy and resident #3 after he/she reportedly had prolonged vomiting with black/brown emesis. Findings included: - Resident #2's pertinent [DIAGNOSES REDACTED].). Review of the admission minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment. The resident required the extensive assist of two staff for bed mobility, transfer, dressing, and toilet use. Review of the activities of daily living (ADL) CAA (care area assessment) dated 2/22/17 revealed the resident had a self-care deficit secondary to weakness after hospitalization for a left [MEDICAL CONDITION]. The resident had plans to discharge home after continuing to work with the physical and occupational therapy staff. The resident's care plan lacked any guidance regarding hospital preference, if the resident had declared him/herself a do not resuscitate status, or any pertinent prior medical history. Review of a nursing progress note dated 3/7/17 at 8:15 PM revealed the resident complained of dizziness during transfers. Staff placed the resident on supplemental oxygen and administered medication to help with loose stools and nausea. Staff documented the resident had been resting comfortably and family member(s) were at the resident's bedside. Staff reported they would continue to monitor the resident. Review of a daily skilled charting note dated 3/7/17 at 8:19 PM revealed the resident was alert to person, place, and time but with intermittent confusion and complaints of dizziness, nausea, vomiting, and loose stools. Staff administered an as needed anti-nausea medication, which was not effective. Resident #2 displayed increased lethargy (tiredness or sluggishness) and staff placed the resident on supplemental oxygen. Staff then documented they would continue to monitor the resident. A nursing progress note dated 3/8/17 at 1:14 AM revealed the resident continued to have increased confusion and lethargy. Resident #2 continued to complain of dizziness, nausea, and vomiting and requested a transfer to the emergency department for further evaluation. Staff notified the on-call physician extender of the resident's condition and the resident's request for transfer to the emergency department. The physician extender gave a verbal order to transfer the resident to the emergency department of the resident's choice related to the increased altered mental status and fluctuation of blood pressure. Review of the emergency medical services (EMS) report, dated 3/8/17, revealed the facility placed a phone call at 2:24 AM requesting assistance in transferring the resident to the hospital. The documentation revealed the resident was alert with confusion and per the resident's family, when they left the resident around 6 PM, there was no changes with the resident's mentation. The facility staff advised EMS staff the resident had become more confused during the evening and the resident had no medication changes. Review of the emergency department physician's assessment, dated 3/8/17, revealed the resident presented with weakness with an onset of 9 hours prior. The resident denied any chest pain but did have signs/symptoms of nausea, headache, dizziness, and confusion. The physician diagnosed the resident as having a non-ST segment elevation [MEDICAL CONDITION] infarction (NSTEMI- one type of [MEDICAL CONDITION] infarction also called [MEDICAL CONDITION]) and transferred the resident to another acute care hospital able to better monitor the resident's condition. Interview with direct care staff E on 4/18/17 at 12:52 PM revealed he/she remembered the resident but he/she did not know what occurred prior to the resident leaving the facility. He/she reported if there was a change in one of the residents, he/she would alert the nurse immediately. Interview with licensed nursing staff D on 4/18/17 at 1:49 PM revealed he/she remembered the resident, but did not work during the time the resident required transfer to the hospital. He/she stated if he/she noted a change in the resident's level of consciousness, he/she would perform a complete assessment and notify the physician or physician extender immediately. Interview with licensed nursing staff C on 4/24/17 at 2:03 PM revealed he/she would notify the physician and/or the physician extender after he/she stabilized the resident. Interview with physician extender B on 4/20/17 at 9:22 AM revealed he/she would have expected notification to the on-call physician or physician extender immediately after the change in the resident's condition. Review of the facility undated policy for nurse notification of the physician, elder and surrogate decision-maker revealed it was the responsibility of the licensed nursing staff to notify the physician whenever a significant change in the health, mental, or psychosocial status occurred such as deterioration in health status in either life-threatening condition or clinical complications. The facility failed to notify the on-call physician for 5 hours while resident #2's mental status continued to decline. The resident then required admission to an acute care hospital with a [MEDICAL CONDITION]. - Resident #3's pertinent [DIAGNOSES REDACTED]. Review of the quarterly minimum data set ((MDS) dated [DATE] revealed the resident had severely impaired cognition for daily decision making. The resident received 51% or more of his/her nutrition and hydration via percutaneous endoscopic gastrostomy tube (PEG- a flexible feeding tube placed through the abdominal wall and into the stomach; feeding tube). Review of the significant change MDS dated [DATE] revealed the resident was severely impaired for daily decision-making. The resident received 51% or more of his/her nutrition and hydration via PEG tube. Review of the feeding tube care area assessment (CAA) dated 3/21/17 revealed the resident could not receive anything by mouth. He/she received nutritional intake and fluids per PEG tube secondary to dysphagia. Review of the cognitive loss CAA dated 3/21/17 revealed the staff rarely understood the resident. He/she would occasionally state a few words, and had cognitive deficits due to [MEDICAL CONDITION] disease (any abnormal condition characterized by dysfunction of the heart and blood vessels). Staff reported the resident could answer some yes/no questions when he/she chose to do so. Review of the resident's care plan, initiated on 5/27/16, guided staff to monitor/document/report to the physician as needed: aspiration (when food or fluids go into the lungs), fever, tube dislodged, infection at the tube site, tube dysfunction or malfunction, abnormal breath sounds, abnormal laboratory values, abdominal pain, distension, tenderness, constipation and/or fecal impaction, diarrhea, nausea, vomiting, and dehydration. Review of a nursing progress note dated 12/26/16 at 6:50 AM revealed the resident's feeding tube clogged and staff could not flush it. The resident received the nutritional support through his/her PEG tube, but the licensed staff could not administer medications and/or water. The licensed staff attempted to flush the PEG tube unsuccessfully and then the resident started to vomit. Staff described the emesis as grainy and dark brown to black in color (often a sign of gastro-intestinal bleeding) and the resident had projectile vomiting for several hours. Staff administered a medication rectally to try and slow down the vomiting and it was ineffective. Staff reported calling the resident's hospice provider since they could not get the vomiting to stop. The hospice agency staff came out, assessed the resident, and then called the on-call physician extender who ordered the PEG tube feedings held until the physician extender saw the resident that morning. The resident continued vomiting the rest of the shift and licensed staff reported they would continue to monitor the resident, vital signs, and the feeding tube. Review of a nursing note dated 12/26/16 at 2:23 PM revealed the resident had 3 brown emesis during that shift. The resident's tube feedings remained on hold per the orders from the on-call physician extender. Hospice ordered an X-Ray to evaluate the resident's abdominal status on 12/26/16 and the findings from the radiologist revealed the resident's feeding tube had coiled upon itself in a slightly distended stomach and there was no evidence of obstruction or perforation (hole). Review of a nursing note dated 12/26/16 at 6:41 PM revealed the resident's family members were notified about the results and the facility awaited word on what they would like to do for the resident. Review of the nursing note dated 12/27/16 at 5:58 AM revealed the resident did not have any emesis but was still nauseated. Review of the nursing note dated 12/27/16 at 6:33 PM revealed the resident went to the emergency department for feeding tube replacement. At 11:54 PM, another nursing note revealed the resident admitted to the hospital with [REDACTED]. Review of the hospital discharge note dated 1/10/17 revealed the resident admitted for hematemesis (bloody vomit) and malfunctioning feeding tube that were resolved. Observation on 4/29/17 at 8:32 AM revealed the resident lay in bed with his/her eyes shut. The feeding pump sat next to the resident and connected to the feeding tube. The resident did not display any signs/symptoms of discomfort. Interview with direct care staff H on 4/20/17 at 9:16 AM revealed he/she had not noticed any recent changes with the resident, but would report to the nurse immediately any concerns he/she had. Interview with licensed nursing staff C on 4/24/17 at 2:03 PM revealed he/she would notify the physician of a change after stabilizing the resident. He/she would want to get the resident to a place where it would be safe for the nurse to walk out of the room. For instance if the resident had intractable hematemesis (hard to control vomiting of blood), he/she would make sure to turn off the tube feeding, elevate the head of the bed, and place the resident on his/her side and then he/she would notify the physician. Review of the facility undated policy for nurse notification of physician, elder and surrogate decision-maker revealed it was the responsibility of the licensed nursing staff to notify the physician when there had been a significant change in the health, mental, or psychosocial status such as deterioration in health status in either life-threatening condition or clinical complications. The facility failed to notify the physician or the physician extender, for several hours per the documentation, licensed staff notified the hospice agency first and waited to have their representative come to assess the resident prior to notifying the on-call physician for resident #3 when he/she had projectile dark brown/black emesis.

The facility census included 54 residents. Based on observation and interview, the facility failed to ensure dietary staff served food handled in a sanitary manner in 1 out of 4 kitchens and that food was stored to prevent contamination of foods in the refrigerator past expiration dates in 2 of 4 kitchens, and safely stored canned food stored in the main pantry which provided food to all residents. Findings included: - Observation on 9/15/16 at 7:59 AM revealed opened prune juice dated 8/16/16 and opened tomato juice dated 8/12/16 found in the shared refrigerator of the 100 and the 200 hall kitchens. Observation on 9/15/16 at 8:16 AM revealed an open container of juice dated 9/6/16 in the 200 Hall Kitchen refrigerator. Interview on 9/15/16 at 8:01 AM dietary staff Q stated opened juice should be removed from the refrigerator after 4 days. Interview on 9/15/16 8:16 AM Dietary staff R stated juice could be in the fridge for 7 days after opened. Review of the policy dated 2016 for food storage revealed that food be discarded after the expiration date or after 7 days of being prepared by the facility and being stored under proper refrigeration. The policy revealed that leftover contents of cans and prepared food be stored in covered, labeled and dated containers in refrigerators and/or freezers. The facility failed to discard expired opened items. - Observation on 9/15/16 at 8:00 AM revealed raw brisket thawing in pan in the refrigerator located between the 100 and 200 kitchens hanging over the pan and on top of hamburger in another pan. On the bottom shelf of the refrigerator and to the side of the meat sat a box of bulk bacon and a Quart container of Sunny Fresh Drink. Interview on 9/15/16 at 8:09 AM dietary staff Q stated all the meat should be in the pan. Interview on 9/15/16 at 8:25 AM Dietary staff S stated the brisket should have been in the pan completely. Review of the policy dated 2016 for food storage revealed raw meat should be stored separately from cooked and ready-to-eat food or be stored or shelves beneath cooked and ready to eat foods. The policy also revealed raw meat should be stored in drip proof containers. The facility failed to store raw meat in a safe and sanitary manner. - Observation on 9/15/16 at 8:05 AM revealed a large spinach can had a dent on top of the lid between 300 and 400 hall kitchens and an undated pan of apple cobbler was partially covered with foil in the large refrigerator. Interview on 9/15/16 at 8:17 AM Dietary staff U reported he/she planned to discard the apple cobbler and then observed he/she discarded it in the trash. Review of the policy dated 2016 for food storage revealed that food be discarded after the expiration date or after 7 days of being prepared by the facility and being stored under proper refrigeration. The policy revealed leftover contents of cans and prepared food should be stored in covered, labeled and dated containers in refrigerators and/or freezers. The facility failed to properly store food in a sanitary manner. - Observation on 9/20/16 at 11:23 AM revealed dietary staff T prepared food items in the 200 hall kitchen. Dietary staff T wore gloves and with his/her gloved hand and took the warmed bread and with his/her gloved hand placed it on the plate and gave it to a direct care staff to serve a resident. Dietary staff T then opened the oven to check the french fries and opened a cabinet and then returned and served more plates of food taking bread out the warmer without changing his/her gloves. Staff T also touched the food surfaces on the plates before placing food on them. Interview on 9/20/16 at 12:40 PM with Dietary staff T stated he/she should wash his/her wash hands before and after handling ready to eat food. He/she stated the artisan bread was designed for tongs or can use gloved hands. Dietary staff T stated he/she should change gloves if touched anything else before or after he/she handled the bread or touched any food area on the plates. Interview on 9/20/16 at 12:52 PM with Dietary staff S stated staff should use tongs when serving bread. Gloved hands can be used to touch the bread if nothing else is touched. Staff stated his/her expectation is for staff to hold plates on the edges and not touch the food surfaces. Staff stated the food surfaces can be touched with gloved hands as long as nothing else was touched. Review of the undated facility policy for proper handling of food in order to prevent food contamination and to maintain food quality revealed when using gloves, no non-food items or surfaces should be touched. If so, discard the gloves, wash your hands and use a clean pair. The facility failed to ensure residents received food that is handled in a sanitary manner. - Observation on 9/20/16 at 12:32 PM revealed water dripping out of overhead cooling vents that fell on to a trash can and onto a clean upper level countertop approximately 1 inch from the edge in the 100 kitchen during observation of the food preparation. Interview on 9/20/16 at 10:45 AM Dietary staff S reported he/she would notify maintenance about the dripping condensation onto kitchen counter. Interview on 9/21/16 at 10:05 AM Environmental staff AA stated he/she checked the kitchen overhead vents every day and had noticed the overhead vents in the kitchen dripped water condensation onto the countertop. Stated the 100 house thermostat would be turned up for warmth for the long term care residents and the houses air conditioner on the roof was computerized and would convert to air conditioning and caused the drips due to the 60% humidity. Staff stated because the air conditioning changed the air out quickly and returned the outside humidity had caused the dripping condensation. Environmental staff AA checked the vents every month and cleaned them as needed. The facility failed to ensure condensation did not drip onto food preparation surfaces. - Observation on 9/20/16 at 1:38 PM revealed the main pantry that serves all residents contained 1 dented can of 3 bean salad with a large dent in the side stored on the shelf with other similar cans that were not dented. There were 12 cans of tuna, 15 cans of pitted prunes and 15 cans of jellied cranberry on the top shelf and not labeled with the manufacturer use by date on the cans. Interview on 9/15/16 at 8:11 AM Dietary staff U stated the dented cans should be put in the pantry and set to the side to be returned. Interview on 9/20/16 at 1:44 PM Dietary staff S reported when dented canned foods were found by the staff they should peel back the label to see if the dent was on a seam or the rim and if a significant dent was found, the can would be returned. Staff stated cans taken out of boxes that did not have an expiration date on them would be expired in a year. He/she could verify the time ordered and documentation on the invoices. Review of the policy dated 2016 for food storage revealed to discard dented cans and dented cans be set aside in a separate labeled area of the storeroom to be discarded according to vendor procedure. The facility failed to ensure sanitary food service by the failure to remove dented cans from potential food service. - Observation on 9/21/16 at 11:18 AM revealed the 100 House snack refrigerator had 1 individual serving container of jello opened and not dated. Interview on 9/21/16 at 11:19 AM Environmental staff BB stated cooks stock the snack refrigerator and the aides get the snacks out of the refrigerator for the residents and also general public. Interview on 9/21/16 at 11:25 AM Dietary staff S reported any individual serving item in snack refrigerator that had been opened should discarded and not put it back into the refrigerator. Review of the policy dated 2016 for food storage revealed that food be discarded after the expiration date or after 7 days of being prepared by the facility and being stored under proper refrigeration. The policy revealed that leftover contents of cans and prepared food be stored in covered, labeled and dated containers in refrigerators and/or freezers. Review of the policy dated 2016 for food storage revealed that food be discarded after the expiration date or after 7 days of being prepared by the facility and being stored under proper refrigeration. The policy revealed that leftover contents of cans and prepared food be stored in covered, labeled and dated containers in refrigerators and/or freezers. The policy revealed raw meat be stored separately from cooked and ready to eat food or be stored or shelves beneath cooked and ready to eat foods. The policy revealed to discard dented cans and dented cans be set aside in a separate labeled area of the storeroom to be discarded according to vendor procedure. The facility failed to ensure food served to the residents was free from contamination.

The facility census totaled 54 residents and had 4 households. Based on observation, interview, and record review the facility failed to establish an infection control program to prevent the transmission of scabies (a contagious skin disease marked by itching and small raised red spots, caused by the itch mite) by the failure to implement personal protective equipment related to an outbreak for residents (#15, #61, and #100) in 1 of 4 households. This had the potential to affect all 14 residents who lived in that household. Findings included: - Review of a fax to the county health department office of surveillance and epidemiology dated 7/22/16 revealed 3 residents (#61, #100, and #15) with suspected scabies (a contagious skin disease marked by itching and small raised red spots, caused by the itch mite). Review of resident #61's quarterly MDS (minimum data set) dated 5/19/16, revealed the resident required extensive assistance of two staff with bed mobility and transfers and 1 person assist with transfers. Signed physician orders [REDACTED]. 4/21/16 - [MEDICATION NAME] HCL (an anti-itch medication) 10 milligrams (mg) every 6 hours for skin rash/itching. 6/4/16 -Apply [MEDICATION NAME] 5% (an antiparasitic medication) cream. Apply ½ tube to the entire body from the jaw line down for signs and symptoms of scabies. Repeat in 1 week. The physician recommended treating the resident's roommate (resident #100), too. 7/21/16 - Ivermectin (an antiparasitic medication) Tablet give 5 ½ tablets (16.8 mg) orally one time for [MEDICATION NAME] (preventive) (scabies) treatment. During an observation on 9/21/16 at 7:47 AM direct care staff K and direct care staff F assisted resident #61 to get up for the morning and observation revealed the resident's skin had the appearance of multiple scarred type areas on his/her trunk and under both arms. The resident also had red scratches on his/her arms. Staff K reported the resident wore arm protectors to help keep him/her from scratching. Review of resident #100's quarterly MDS dated [DATE], revealed the resident required extensive to total assistance of staff for ADLs (activities of daily living) including dressing, bed mobility, and toileting. Signed physician orders [REDACTED]. 6/4/16- [MEDICATION NAME] 5% cream due to roommate (#61) with signs and symptoms of scabies. Apply ½ tube to the entire body from the jaw line down and repeat in 1 week. 7/21/16- Ivermectin 16 mg one time [MEDICATION NAME] for (scabies) treatment. Review of resident #15's annual MDS dated [DATE] revealed the resident required extensive assistance of 1-2 staff for ADLs. Signed physician orders [REDACTED]. 7/21/16 - Ivermectin Tablet give 4 tablets by mouth one time [MEDICATION NAME] for (scabies) treatment. Observation on 9/21/16 at 10:30 AM revealed resident #15 had the appearance of scarred areas on his/her left side. During an interview on 9/15/16 at 1:51 PM administrative nurse L reported to control infections related to scabies, staff completed weekly assessment on all residents. When a resident first moved into the facility, the nurse completed a skin assessment daily for the first 2 days to make sure there were no changes with their skin. Staff L stated they had one resident recently diagnosed with [REDACTED]. Staff L stated the first resident, #61, went to the dermatologist and returned with a [DIAGNOSES REDACTED].#61 to a private room and deep cleaned his/her room. The resident received hospice services, so hospice also came in and provided a different mattress and other supplies for the resident. Staff L reported resident #61 had very sensitive skin, and currently had a rash but not scabies. On 9/15/16 at 4:05 PM administrative nurse L reported the timeline for the initial observations of a rash to the [DIAGNOSES REDACTED]. On 3/22/16 -Resident #61 had a trunk rash and orders for Vitamin A&D cream, [MEDICATION NAME] (anti-inflammatory) creams as well and [MEDICATION NAME] (an [MEDICATION NAME] medicine to reduce itching). Staff avoided all perfume and double rinsed his/her clothing during the wash, and the rash did not change. On 6/4/16 the resident went to the dermatologist and received an order for [REDACTED].#100) and staff repeated the treatment on 6/11/16. Staff obtained information about treatment for [REDACTED]. On 7/20/16 resident #61's roommate (#100) had a suspicious rash and so staff treated him/her with Ivermectin and moved him/her to a different room and deep cleaned the room. The only thing the residents (#61, #100, and #15) all had in common was receiving hospice services. Facility staff and hospice staff collaborated and determined a hospice aide had scabies and the resident got scabies from him/her. On 7/22/15, resident #15 had a rash the physician extender stated the rash looked like the others and gave orders to treat him/her for scabies which made 3 residents treated. At that point, staff L reported the facility notified the county health department office of surveillance and epidemiology and got orders to treat each of the 14 residents in the household, deep cleaned each room, and switched out each mattress and other equipment. The residents were all treated with Ivermectin. Staff L also stated they offered all staff that worked in the 100 house treatment and gave them information on the medications and scabies. On 8/28/16 staff re-treated resident #61 with Ivermectin and on 9/6/16 staff treated the whole unit again with the cream twice. Staff L stated the residents were not symptomatic but the facility decided to re-treat the residents since there were a couple of staff with rashes. One staff member went to the dermatologist on his/her own and the facility sent 2 more to see the dermatologist for possible scabies. Staff L stated the scabies were contained in one house and there were no further rashes after the last treatment with cream. During an interview on 9/15/16 at 3:47 PM, direct care staff O reported resident #61 had scabies first and the facility did not initially offer any treatments to staff. Staff O reported staff thought the resident had an allergic reaction or other rash but the itching got worse and he/she went to the dermatologist. Staff O stated the staff were not offered treatment. Staff O reported he/she and other staff started to get a rash and then the facility gave staff some pills to take for it. Staff O stated the facility gave him/her the cream again for the second treatment. The facility ended up treating all of the residents and then the staff working in that house. Staff O stated they did not have any training related to the prevention and spreading of scabies, did not put anything on the outside of the door like to see the nurse before entering. Staff O stated all staff assumed the resident had scabies and wore gloves as usual when providing care. Staff O stated the facility did not set up any gowns or other personal protective equipment (PPE) outside of the resident's room. During an interview on 9/15/16 at 4: 39 PM direct care staff P revealed staff treated all residents for scabies prevention with a cream. During an interview on 9/15/16 at 3:19 PM licensed nurse N reported a few months ago, resident #61 went to the physician who identified the resident had scabies. Staff N reported he/she also contracted scabies and received treatment. Interview on 9/15/16 at 3:57 PM with licensed nurse G revealed scabies started with resident #61. Staff treated him/her and his/her roommate (#100) [MEDICATION NAME]. Staff G reported staff did not wear precaution gowns since scabies spread by skin-to-skin contact. During an interview on 9/21 /16 at 3:20 PM administrative nurse L reported he/she looked on the CDC website for guidelines on what to do for the prevention of spreading scabies and did not see the need to have gowns since scabies spread through prolonged skin-to-skin contact and staff wore gloves and used good hand washing. According to the CDC website, for the prevention of scabies for single cases: Early detection, treatment, and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks. Institutions should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies, even if characteristic signs or symptoms of scabies are absent (e.g. no itching). Appropriate isolation and infection control practices (e.g. gloves, gowns, avoidance of direct skin-to-skin contact, etc.) should be used when providing hands-on care to patients who might have scabies. Review of the facility infection control policy dated 7/6/15 revealed the facility would implement isolation of patients with communicable diseases when appropriate. Individual patient factors were important determinants of infection transmission risks. The policy failed to identify specifics regarding the need for personal protective equipment to prevent the spread of scabies infections. The facility failed to establish an effective infection control program which included implementation of transmission based precautions, including disposable gown use to prevent skin-to-skin contact, to prevent the spread of scabies. This affected all 14 residents residing in the 100 neighborhood.

The facility census totaled 54 residents. Based on observation during initial tour, interview, and record review the facility failed to ensure resident beds for 4 residents were free of accident hazards.(#33, #42, #51, #62) Findings included: - During an initial tour of the facility on 9/19/16 from 8:03 AM- 9:19 AM, there were 4 residents whose beds had unsafe gaps between the mattress and side rails: An observation on 9/19/16 at 8:03 AM revealed resident #42's bed had a 6 1/2 inch gap between the bedrail and the mattress. An observation on 9/19/16 at 8:45 AM revealed resident bed in #51's bed had a 6 1/4 inch gap between the bedrail and the mattress. An observation on 9/19/16 at 8:49 AM revealed resident #62's bed had a 5 inch gap between the bedrail and the mattress. An observation on 9/19/16 at 9:19 AM revealed resident #33's bed had a 5 inch gap between the bedrail and the mattress. An additional observation on 9/20/16 at 10:16 AM revealed the head of resident #33's bed remained up and had a rolled gel type foam pillow wedged in between the rail and the mattress. One third of the space between the lower rail and the mattress was not protected by the pillow. During an interview on 9/19/16 at 8:50 AM direct care staff U reported resident #62 had too large of a gap between the bedrail and he/she would report it. Staff stated the rersident needed extensive assistance and could have rolled over into the gap or might have pinched his/her arm in the gap and could have hurt him/herself. During an interview on 9/19/16 at 9:19 AM direct care staff V reported he/she thought resident #33 got a new mattress and staff should have checked for gaps when installing the mattress. During an interview on 9/19/16 at 10:39 AM resident #33 reported staff had placed the pillow between the mattress and the rail that morning. During an interview on 9/19/16 at 4:26 PM direct care staff W reported resident #42 used his/her bedrails to hold him/her up and move about in bed. During an interview on 9/21/16 at 7:00 AM direct care staff F reported resident #42 had not rolled or gotten stuck in the gap between his/her side rail and mattress. During an interview on 9/21/16 at 7:59 AM licensed staff X reported staff should notice if resident beds had gaps between the bedrail and the mattress and report it and put a foam wedge between the gap and the mattress to close the gap. Staff X did not think resident #42 had not ever gotten stuck or caught in the 6 ½ inch gap found on the bed during initial tour of the facility. During an interview on 9/21/16 at 9:41 AM licensed staff CC reported maintenance were supposed to be checking the distance between the mattress and the bed rail. During an interview on 9/21/16 at 1:47 PM administrative nursing staff B reported maintenance usually checked for gaps when they installed mattresses. Review of the facility's Use of Side Rails Safely policy dated May 2016 revealed gap measurements will be performed to ensure safety from potential entrapment following FDA (Food and Drug Administration) guidelines for acceptable gaps. Review of the Table 3 Summary of FDA Hospital Bed Dimensional Limit Recommendations revealed a gap between a bed rail and mattress should be no greater than 4 ¾ inches. The facility failed to ensure 4 resident's beds were free of unsafe gaps between the rails and mattresses of the beds.