Every finding on record at Evergreen Health and Rehabilitation Center

Based on staff interview, clinical record review, and facility document review, the facility staff failed to report an allegation of abuse for one of eight residents in the survey sample, Resident #8.The findings include:For Resident #8 (R8), the facility staff failed to report an allegation of abuse related to a verbal altercation between R8 and Resident #3 (R3) on 5/2/26.A review of R3's clinical record revealed the following progress note dated 5/2/26: Nursing Note [Resident #3] walked on his 3 prong cane down to [R8's] room and began arguing and cursing at [R8] because he was yelling earlier in the day. This note was written by LPN (licensed practical nurse) #1.Further review of R8's and R3's clinical records and of facility documents revealed no evidence that this incident was reported to management or to the State Agency (SA) as an allegation abuse.On 5/5/26 at 2:30 p.m., LPN #1 was interviewed. She stated that R8 yells loudly and frequently, and that he can be heard all up and down the hallway. She stated she discovered after the altercation between R8 and R3 that R8 had actually been yelling for most of the time the previous evening and night. She stated that she heard R3 yelling and walked to R8's room to see what was happening. She found R3 standing in R8's doorway initially, then eventually walking further into the room closer to where R8 was sitting on his bed. She explained that R8 was not able to stand or walk on his own. She stated R3 and R8 were engaged in a heated argument and that R3 was yelling and cursing at R8. She explained that R8 must have been irritated. She stated she immediately separated the residents and she wrote a note in R3's clinical record about what she witnessed. She stated that in hindsight, she sees that this was potential verbal abuse. She added that she reported this incident to a supervisor but could not remember when she reported or to whom she reported it.On 5/5/26 at 2:28 p.m., LPN #2 was interviewed. She confirmed that if she observed one resident yelling and cursing at another resident, the verbal altercation could be considered verbal abuse and should be immediately reported for the overall safety of residents.On 5/6/26 at 12:11 p.m., the Administrator was interviewed. He stated that when he heard about the incident between R3 and R8 from LPN #1, he was not certain how accurate her account was. He stated he asked LPN #1 if she had reported this incident to the weekend supervisor, and LPN #1 indicated that she had. However, the weekend supervisor denied ever learning about the incident from LPN #1. The Administrator stated that this information should have been conveyed to him, and this definitely is an allegation of verbal abuse that should have been reported to the SA and investigated.A review of the facility policy, Abuse Investigation and Reporting, revealed, in part: All reports of resident abuse.shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management.If an incident or suspected incident of resident abuse.is reported, the Administrator/designee will assign the investigation to an appropriate individual.All alleged violations involving abuse.will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: The stated licensing/certification agency responsible for surveying/licensing the facility.No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of eight residents in the survey sample, Resident #6.The findings include:For Resident #6 (R6), the facility staff failed to review and revise his care plan following two episodes of intoxication in [DATE].R6 was admitted to the facility on [DATE]. One of the resident's diagnoses on admission was alcohol abuse.A review of R6's clinical record revealed the following progress notes: [DATE] 22:54 (10:54 p.m.) Resident came down from upstairs visually intoxicated. Writer witnessed resident pull a bottle out from inside his pants in the groin area. Resident slurring his speech, cursing at staff and talking to self. MOD (manager on duty) notified. Asked to get a set of vitals (resident refused) and write a note. NP (nurse practitioner) made aware through communication book. [DATE] 14:30 (2:30 p.m.) NP Note Staff reported intoxication.Alcohol/Caffeine/HydrationAlcohol: current use. Staff reported patient acted intoxicated on [DATE] with smell of alcohol. Previously noted acting giggly with reports from another resident that alcohol is being brought to him at the facility.Assessment and Plan.ALCOHOL ABUSE, UNCOMPLICATED: Staff reported patient acted intoxicated on [DATE] with smell of alcohol noted. History of ongoing alcohol abuse with previous reports of alcohol being brought to him at the facility. Continue vitamin support per active orders: thiamine (vitamin B1) 100 mg (milligrams) by mouth once daily, folic acid 1 mg by mouth once daily, and multivitamin with minerals 1 tablet by mouth once daily. Continue facility monitoring/supervision per protocol. [DATE] 13:30 (1:30 p.m.) NP Note History of Present Illness [R6], [AGE] years old male, is seen today for order review. The patient was found intoxicated yesterday, passed out with a vodka bottle under his chair in a water bottle. There are no changes to his medications at this time.Alcohol/Caffeine/Hydration Alcohol: current use. Patient found intoxicated yesterday, passed out with vodka under chair in water bottle. Staff previously noted patient acting giggly and reports from another resident that alcohol is being brought to him at the facility. Patient placed in book for supervised leave only due to alcohol use.Assessment and Plan.ALCOHOL ABUSE, UNCOMPLICATED: Patient found intoxicated yesterday, passed out with vodka bottle under chair in water bottle. Patient placed in book for supervised leave only due to alcohol use. Continue vitamin support per active orders: thiamine (vitamin B1) 100 mg by mouth once daily, folic acid 1 mg by mouth once daily, and multivitamin with minerals 1 tablet by mouth once daily. Continue facility monitoring/supervision per protocol. [DATE] 13:00 1:00 p.m. NP Note History of Present Illness [R6], [AGE] years old male, is seen today for recertification visit. The patient has no acute complaints at this time. Conducted a 30-minute counseling session regarding Alcohol Abuse. Reviewed the incidents on 03/09 and 03/12 where the patient was found intoxicated. Discussed how alcohol use directly interferes with his hypertension management (BP [blood pressure] 147/92) and significantly increases his risk for are current stroke/CVA (cerebrovascular accident) and aspiration due to his chronic dysphagia (difficulty swallowing). Previously, the patient was seen on [DATE] when he was found intoxicated, passed out with a vodka bottle under his chair in a water bottle. Prior to that, on [DATE], staff reported that the patient acted intoxicated with smell of alcohol noted.Assessment and Plan.ALCOHOL ABUSE, UNCOMPLICATED Patient found intoxicated on [DATE], passed out with vodka bottle under chair in water bottle. Patient placed in book for supervised leave only due to alcohol use. Continue vitamin support per active orders: thiamine (vitamin B1) 100 mg by mouth once daily, folic acid 1 mg by mouth once daily, and multivitamin with minerals 1 tablet by mouth once daily. Continue facility monitoring/supervision per protocol.A review of R6's care plan dated [DATE] revealed, in part: Hx (history) of alcoholism. [R6] is at risk for complications due to a history of alcoholism.Administer medications as ordered.Observe resident for any signs and symptoms of intoxication or withdrawal from alcohol such as tremors, nausea/vomiting (severe), sweating and notify [provider] as indicated.Vitals as needed. This review revealed no information related to the [DATE] or [DATE] episodes of intoxication.On [DATE] at 2:30 p.m., LPN (licensed practical nurse) #2 was interviewed. She stated she works almost exclusively on R6's unit and knows the resident well. She described R6 as a drinker, adding that he most often drinks on the weekends when there is very little management staff in the building. She stated that she does not often document R6's intoxication symptoms because she feels like she can't. She described R6's behavior under the influence of alcohol as sexually seeking, loud, and vulgar. She stated she believed management has had some conversations with R6 about his behaviors, but she was not certain.On [DATE] at 4:04 p.m., LPN #3 was interviewed. She stated that there was group of former and current residents, some of whom are deceased , who frequently use alcohol in the facility. She stated she suspects some of the residents are allowed to leave the facility and bring the alcohol back for other residents, but she has no evidence to verify this. She stated she frequently smells alcohol on R6, and usually these episodes correspond to when the resident has visitors from the community. She stated she was working on [DATE] when R6 was intoxicated and pulled the bottle of liquor from inside the front of his pants. She stated she alerted the weekend supervisor, who did not go to the unit to help her. She explained the supervisor told her to simply take his vital signs and write a note. She added that R6 would not allow her to take his vital signs.On [DATE] at 4:15 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated she smells pervasive alcohol on R6 every once in a while. She explained that she did not know where R6 was getting his alcohol.On [DATE] at 1:15 p.m., LPN #4 was interviewed. She stated that the purpose of a care plan is to instruct the staff on the best way to care for each resident, and to include the resident's needs and preferences in the plan of care. She stated the care plan includes the resident's diagnoses, orders, diets, and anything else that significantly impacts the resident's life at the facility. She stated that floor nurses do not have the ability to update a care plan, and that the unit manager is responsible for doing this. On [DATE] at 1:53 p.m., the Administrator, the Director of Nursing, and the Regional Nurse Consultant were informed of these concerns.A review of the facility policy, Comprehensive Person-Centered Care Planning, revealed, in part: The comprehensive care plan will incorporate identified problem areas, incorporate risk factors associated with identified problems.Aid in preventing or reducing declines in the resident's functional status and/or functional levels.Promote resident safety.The care Planning/Interdisciplinary Team is responsible for the review and updating of care plans.When there has been a significant change in the resident's condition.When the desired outcome is not met.No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide behavioral health services for one of eight residents in the survey sample, Resident #6.The findings include:For Resident #6 (R6), the facility staff failed to offer behavioral health services related to his substance use disorder (SUD) following two episodes of intoxication in [DATE].R6 was admitted to the facility on [DATE]. One of the resident's diagnoses on admission was alcohol abuse.A review of R6's clinical record revealed the following progress notes: [DATE] 22:54 (10:54 p.m.) Resident came down from upstairs visually intoxicated. Writer witnessed resident pull a bottle out from inside his pants in the groin area. Resident slurring his speech, cursing at staff and talking to self. MOD (manager on duty) notified. Asked to get a set of vitals (resident refused) and write a note. NP (nurse practitioner) made aware through communication book. [DATE] 14:30 (2:30 p.m.) NP Note Staff reported intoxication.Alcohol/Caffeine/HydrationAlcohol: current use. Staff reported patient acted intoxicated on [DATE] with smell of alcohol. Previously noted acting giggly with reports from another resident that alcohol is being brought to him at the facility.Assessment and Plan.ALCOHOL ABUSE, UNCOMPLICATED: Staff reported patient acted intoxicated on [DATE] with smell of alcohol noted. History of ongoing alcohol abuse with previous reports of alcohol being brought to him at the facility. Continue vitamin support per active orders: thiamine (vitamin B1) 100 mg (milligrams) by mouth once daily, folic acid 1 mg by mouth once daily, and multivitamin with minerals 1 tablet by mouth once daily. Continue facility monitoring/supervision per protocol. [DATE] 13:30 (1:30 p.m.) NP Note History of Present Illness [R6], [AGE] years old male, is seen today for order review. The patient was found intoxicated yesterday, passed out with a vodka bottle under his chair in a water bottle. There are no changes to his medications at this time.Alcohol/Caffeine/Hydration Alcohol: current use. Patient found intoxicated yesterday, passed out with vodka under chair in water bottle. Staff previously noted patient acting giggly and reports from another resident that alcohol is being brought to him at the facility. Patient placed in book for supervised leave only due to alcohol use.Assessment and Plan.ALCOHOL ABUSE, UNCOMPLICATED: Patient found intoxicated yesterday, passed out with vodka bottle under chair in water bottle. Patient placed in book for supervised leave only due to alcohol use. Continue vitamin support per active orders: thiamine (vitamin B1) 100 mg by mouth once daily, folic acid 1 mg by mouth once daily, and multivitamin with minerals 1 tablet by mouth once daily. Continue facility monitoring/supervision per protocol. [DATE] 13:00 1:00 p.m. NP Note History of Present Illness [R6], [AGE] years old male, is seen today for recertification visit. The patient has no acute complaints at this time. Conducted a 30-minute counseling session regarding Alcohol Abuse. Reviewed the incidents on 03/09 and 03/12 where the patient was found intoxicated. Discussed how alcohol use directly interferes with his hypertension management (BP [blood pressure] 147/92) and significantly increases his risk for are current stroke/CVA (cerebrovascular accident) and aspiration due to his chronic dysphagia (difficulty swallowing). Previously, the patient was seen on [DATE] when he was found intoxicated, passed out with a vodka bottle under his chair in a water bottle. Prior to that, on [DATE], staff reported that the patient acted intoxicated with smell of alcohol noted.Assessment and Plan.ALCOHOL ABUSE, UNCOMPLICATED Patient found intoxicated on [DATE], passed out with vodka bottle under chair in water bottle. Patient placed in book for supervised leave only due to alcohol use. Continue vitamin support per active orders: thiamine (vitamin B1) 100 mg by mouth once daily, folic acid 1 mg by mouth once daily, and multivitamin with minerals 1 tablet by mouth once daily. Continue facility monitoring/supervision per protocol.A review of R6's clinical record revealed a social services quarterly assessment dated [DATE]. This assessment contained no information related to R6's two intoxication incidents in [DATE].Further review of R6's clinical record revealed no evidence of any type of investigation into how R6 obtained the alcohol which caused his two episodes of intoxication in [DATE].A review of R6's psychiatry NP notes revealed no evidence that R6 was seen by the provider between [DATE] and [DATE]. The facility provided no evidence that the psychiatry NP was aware of the two intoxication incidents in [DATE].A review of R6's care plan dated [DATE] revealed, in part: Hx (history) of alcoholism. [R6] is at risk for complications due to a history of alcoholism.Administer medications as ordered.Observe resident for any signs and symptoms of intoxication or withdrawal from alcohol such as tremors, nausea/vomiting (severe), sweating and notify [provider] as indicated.Vitals as needed.A review of R6's providers' orders revealed the following order dated [DATE]: Activity: May not have alcohol. There was no order related to the resident's requiring supervised leave of absences.On [DATE] at 2:30 p.m., LPN (licensed practical nurse) #2 was interviewed. She stated she works almost exclusively on R6's unit and knows the resident well. She described R6 as a drinker, adding that he most often drinks on the weekends when there is very little management staff in the building. She stated that she does not often document R6's intoxication symptoms because she feels like she can't. She described R6's behavior under the influence of alcohol as sexually seeking, loud, and vulgar. She stated she believed management has had some conversations with R6 about his behaviors, but she was not certain.On [DATE] at 4:04 p.m., LPN #3 was interviewed. She stated that there was group of former and current residents, some of whom are deceased , who frequently use alcohol in the facility. She stated she suspects some of the residents are allowed to leave the facility and bring the alcohol back for other residents, but she has no evidence to verify this. She stated she frequently smells alcohol on R6, and usually these episodes correspond to when the resident has visitors from the community. She stated she was working on [DATE] when R6 was intoxicated and pulled the bottle of liquor from inside the front of his pants. She stated she alerted the weekend supervisor, who did not go to the unit to help her. She explained the supervisor told her to simply take his vital signs and write a note. She added that R6 would not allow her to take his vital signs.On [DATE] at 4:15 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated she smells pervasive alcohol on R6 every once in a while. She explained that she did not know where R6 was getting his alcohol.On [DATE] at 9:02 a.m., the Administrator stated that the facility currently employs a Director of Social Services, but they have had difficulty steadily employing a Social Services Assistant. He stated the large facility is a very heavy load for one Social Worker.On [DATE] at 9:40 a.m., NP #1 was interviewed. She stated that her understanding of the facility protocol for someone with a diagnosis of alcoholism and a current substance abuse issue is that the facility will restrict the resident's ability to leave the facility unsupervised. She explained that she is aware of past situations where residents leave the facility and return drunk. She stated: I don't know what they do. I have ordered specific things in the past, but I don't know what their policy is. She stated that she is uncertain about the wholistic approach the facility staff is taking to address SUD. She stated that soon after R6's admission, she attempted to test his urine and his blood for multiple substances, but the resident refused. She added that she doesn't know what options there are to address SUD in a long term care facility and that she has never had to deal with these kinds of issues before in this setting. She stated she believes R6's SUD is chronic and that he has no interest in stopping. She explained her experience is that R6 is continually trying to hide his behavior. She explained that alcohol can have a negative impact on several of R6's comorbidities including his heart arrhythmia, his risk of having another stroke, his high blood pressure, and his diabetes.On [DATE] at 11:35 a.m., the Director of Social Services was interviewed. He stated that he sometimes has a role in addressing a resident's SUD, but that most often, nursing takes the lead. He added that sometimes he is never even brought into the loop of a resident's SUD. He stated he had no knowledge of R6's alcohol use and that nothing related to R6's being intoxicated at the facility had ever been reported to him. He explained that the only psychological services the facility offers is medication related. He stated: We don't have any options for talk therapy of any kind. If someone is drinking, it is not really my call. It is up to the NPs. It is a medical issue.On [DATE] at 12:28 p.m., NP #1 stated she did not have any details to add about the incident which she documented took place on [DATE] when R6 passed out. She stated she believed this happened during an activity and that the activities staff told her about it.On [DATE] at 12:53 p.m., the Director of Activities stated she was not aware of R6 ever passing out at an activity, that she had checked with her staff, and that none of her staff was aware of any such incident.On [DATE] at 1:53 p.m., the Administrator, the Director of Nursing, and the Regional Nurse Consultant were informed of these concerns.A review of the facility policy, Behavioral Health Services, revealed, in part: Residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care.Substance Use Disorder is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment such as health problems or disability.Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care.Residents who exhibit signs of emotional/psychosocial distress will be offered services and support that address their individual needs and goals of care.A review of the facility policy, Substance Use Disorder, revealed, in part: The purpose of this policy is to identify patients/residents prior to admission and discharge processes as they relate to substance use disorder. To identify all appropriate diagnoses or specific services needed as they relate to substance abuse/use on addiction and to determine risk for relapse and the level of supervision needed.The facility will conduct a substance use disorder assessment of the patient/resident within 48-72 hours of admission to identify risk and put a plan of care in place.Social services will possibly have the patient/resident sign a contract upon admission and/or anytime during the patient's/resident's stay to alert the patient/resident that if the team feels that they are at risk for illicit drug use, then a search of their belongings may be warranted.The PCP (primary care physician) or NP will need to see patients/residents at risk and address concerns of relapse in their plan while collaboratively working with the interdisciplinary team.Social services will work on the possibilities of setting up support groups in collaboration with the Activities department to provide adequate support to the current population.Social services will work to get other support services, if possible, as added support for the residents.The nursing staff and social services department will provide education on relapse risk and prevention to provide adequate support.No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide medically related social services for one of eight residents in the survey sample, Resident #6.The findings include:For Resident #6 (R6), the facility staff failed to offer medically related social services related to his substance use disorder (SUD) following two episodes of intoxication in [DATE].R6 was admitted to the facility on [DATE]. One of the resident's diagnoses on admission was alcohol abuse.A review of R6's clinical record revealed the following progress notes: [DATE] 22:54 (10:54 p.m.) Resident came down from upstairs visually intoxicated. Writer witnessed resident pull a bottle out from inside his pants in the groin area. Resident slurring his speech, cursing at staff and talking to self. MOD (manager on duty) notified. Asked to get a set of vitals (resident refused) and write a note. NP (nurse practitioner) made aware through communication book. [DATE] 14:30 (2:30 p.m.) NP Note Staff reported intoxication.Alcohol/Caffeine/HydrationAlcohol: current use. Staff reported patient acted intoxicated on [DATE] with smell of alcohol. Previously noted acting giggly with reports from another resident that alcohol is being brought to him at the facility.Assessment and Plan.ALCOHOL ABUSE, UNCOMPLICATED: Staff reported patient acted intoxicated on [DATE] with smell of alcohol noted. History of ongoing alcohol abuse with previous reports of alcohol being brought to him at the facility. Continue vitamin support per active orders: thiamine (vitamin B1) 100 mg (milligrams) by mouth once daily, folic acid 1 mg by mouth once daily, and multivitamin with minerals 1 tablet by mouth once daily. Continue facility monitoring/supervision per protocol. [DATE] 13:30 (1:30 p.m.) NP Note History of Present Illness [R6], [AGE] years old male, is seen today for order review. The patient was found intoxicated yesterday, passed out with a vodka bottle under his chair in a water bottle. There are no changes to his medications at this time.Alcohol/Caffeine/Hydration Alcohol: current use. Patient found intoxicated yesterday, passed out with vodka under chair in water bottle. Staff previously noted patient acting giggly and reports from another resident that alcohol is being brought to him at the facility. Patient placed in book for supervised leave only due to alcohol use.Assessment and Plan.ALCOHOL ABUSE, UNCOMPLICATED: Patient found intoxicated yesterday, passed out with vodka bottle under chair in water bottle. Patient placed in book for supervised leave only due to alcohol use. Continue vitamin support per active orders: thiamine (vitamin B1) 100 mg by mouth once daily, folic acid 1 mg by mouth once daily, and multivitamin with minerals 1 tablet by mouth once daily. Continue facility monitoring/supervision per protocol. [DATE] 13:00 1:00 p.m. NP Note History of Present Illness [R6], [AGE] years old male, is seen today for recertification visit. The patient has no acute complaints at this time. Conducted a 30-minute counseling session regarding Alcohol Abuse. Reviewed the incidents on 03/09 and 03/12 where the patient was found intoxicated. Discussed how alcohol use directly interferes with his hypertension management (BP [blood pressure] 147/92) and significantly increases his risk for are current stroke/CVA (cerebrovascular accident) and aspiration due to his chronic dysphagia (difficulty swallowing). Previously, the patient was seen on [DATE] when he was found intoxicated, passed out with a vodka bottle under his chair in a water bottle. Prior to that, on [DATE], staff reported that the patient acted intoxicated with smell of alcohol noted.Assessment and Plan.ALCOHOL ABUSE, UNCOMPLICATED Patient found intoxicated on [DATE], passed out with vodka bottle under chair in water bottle. Patient placed in book for supervised leave only due to alcohol use. Continue vitamin support per active orders: thiamine (vitamin B1) 100 mg by mouth once daily, folic acid 1 mg by mouth once daily, and multivitamin with minerals 1 tablet by mouth once daily. Continue facility monitoring/supervision per protocol.A review of R6's clinical record revealed a social services quarterly assessment dated [DATE]. This assessment contained no information related to R6's two intoxication incidents in [DATE].Further review of R6's clinical record revealed no evidence of any type of investigation into how R6 obtained the alcohol which caused his two episodes of intoxication in [DATE].A review of R6's psychiatry NP notes revealed no evidence that R6 was seen by the provider between [DATE] and [DATE]. The facility provided no evidence that the psychiatry NP was aware of the two intoxication incidents in [DATE].A review of R6's care plan dated [DATE] revealed, in part: Hx (history) of alcoholism. [R6] is at risk for complications due to a history of alcoholism.Administer medications as ordered.Observe resident for any signs and symptoms of intoxication or withdrawal from alcohol such as tremors, nausea/vomiting (severe), sweating and notify [provider] as indicated.Vitals as needed.On [DATE] at 2:30 p.m., LPN (licensed practical nurse) #2 was interviewed. She stated she works almost exclusively on R6's unit and knows the resident well. She described R6 as a drinker, adding that he most often drinks on the weekends when there is very little management staff in the building. She stated that she does not often document R6's intoxication symptoms because she feels like she can't. She described R6's behavior under the influence of alcohol as sexually seeking, loud, and vulgar. She stated she believed management has had some conversations with R6 about his behaviors, but she was not certain.On [DATE] at 4:04 p.m., LPN #3 was interviewed. She stated that there was group of former and current residents, some of whom are deceased , who frequently use alcohol in the facility. She stated she suspects some of the residents are allowed to leave the facility and bring the alcohol back for other residents, but she has no evidence to verify this. She stated she frequently smells alcohol on R6, and usually these episodes correspond to when the resident has visitors from the community. She stated she was working on [DATE] when R6 was intoxicated and pulled the bottle of liquor from inside the front of his pants. She stated she alerted the weekend supervisor, who did not go to the unit to help her. She explained the supervisor told her to simply take his vital signs and write a note. She added that R6 would not allow her to take his vital signs.On [DATE] at 4:15 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated she smells pervasive alcohol on R6 every once in a while. She explained that she did not know where R6 was getting his alcohol.On [DATE] at 9:02 a.m., the Administrator stated that the facility currently employs a Director of Social Services, but they have had difficulty steadily employing a Social Services Assistant. He stated the large facility is a very heavy load for one Social Worker.On [DATE] at 11:35 a.m., the Director of Social Services was interviewed. He stated that he sometimes has a role in addressing a resident's SUD, but that most often, nursing talks the lead. He added that sometimes he is never even brought into the loop of a resident's SUD. He stated he had no knowledge of R6's alcohol use and that nothing related to R6's being intoxicated at the facility had ever been reported to him. He explained that the only psychological services the facility offers is medication related. He stated: We don't have any options for talk therapy of any kind. If someone is drinking, it is not really my call. It is up to the NPs. It is a medical issue.On [DATE] at 1:53 p.m., the Administrator, the Director of Nursing, and the Regional Nurse Consultant were informed of these concerns.A review of the facility policy, Substance Use Disorder, revealed, in part: The purpose of this policy is to identify patients/residents prior to admission and discharge processes as they relate to substance use disorder. To identify all appropriate diagnoses or specific services needed as they relate to substance abuse/use on addiction and to determine risk for relapse and the level of supervision needed.The facility will conduct a substance use disorder assessment of the patient/resident within 48-72 hours of admission to identify risk and put a plan of care in place.Social services will possibly have the patient/resident sign a contract upon admission and/or anytime during the patient's/resident's stay to alert the patient/resident that if the team feels that they are at risk for illicit drug use, then a search of their belongings may be warranted.The PCP (primary care physician) or NP will need to see patients/residents at risk and address concerns of relapse in their plan while collaboratively working with the interdisciplinary team.Social services will work on the possibilities of setting up support groups in collaboration with the Activities department to provide adequate support to the current population.Social services will work to get other support services, if possible, as added support for the residents.The nursing staff and social services department will provide education on relapse risk and prevention to provide adequate support.A review of the facility job description, Director of Social Services, revealed, in part: Responsible for providing medically related social work services so that each resident may attain or maintain the highest practicable level of physical, mental, and psychosocial well-being.Identifies cognitive impairments, signs of mood problems, and psychosocial needs and follows up as needed.Maintains accurate and timely documentation.Makes appropriate referrals to other consultants, community agencies, or Center departments to facilitate the resident's maximum use of resources and promote increased social functioningNo additional information was provided prior to exit.

Based on observation, staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of eight residents in the survey sample, Resident #2.The findings include:For Resident #2 (R2), the facility staff failed to maintain an accurate clinical record regarding the resident's alcohol use.On 5/5/26 at 11:22 a.m., R2 was observed lying on his right side in bed. He was awake and alert, and there was no odor of alcohol anywhere in the room.A review of R2's clinical record revealed the following Nurse Practitioner (NP) progress note dated 2/5/26: Visit Type: Follow Up Visit.Social History.Alcohol/Caffeine/Hydration.Strong odor of alcohol noted during assessment, consistent with ongoing alcohol use.Further review of R2's clinical record revealed the identical documentation regarding the odor of alcohol on the following dates: 3/3/26, 3/13/26, 3/17/26, 4/10/26, 4/15/26, 4/22/26, 4/29/26, and 5/1/26.On 5/6/26 at 9:40 a.m., Nurse Practitioner (NP) #1 was interviewed. She stated her practice utilizes a software the incorporates AI (artificial intelligence) into providers' notes. She stated she dictates a note regarding her observations, assessment, and plan for a resident as soon as the visit is complete. The software, aided by AI, pulls other information together from the resident's entire record and creates a note. She stated she does not go back to read the complete note or check it for accuracy because of the volume of residents she sees each day.On 5/6/26 at 11:57 a.m., NP #2 was interviewed. She stated she was responsible for all the notes related to R2. She explained that the software system for providers' notes used by her practice is relatively new and incorporates AI. She stated she dictates new information based on her visit with a resident and the software synchronizes the new information with historical information in the entire clinical record. She stated the software even pulls information from the resident's previous hospital stays and other historical documentation. She stated that she attempts to look over the new information she has dictated once the note is finished and that she has discovered inaccuracies from time to time. She stated it is very difficult to try to read the entire note when she has upwards of 25 residents to see in one day, especially when the residents have complicated social histories. She stated she had never smelled alcohol on R2 at any point in time and felt strongly this information came perhaps from a hospital note prior to R2's admission to the facility. She stated: This is not an accurate record for this resident.On 5/6/26 at 1:53 p.m., the Administrator, the Director of Nursing, and the Regional Nurse Consultant were informed of these concerns.No additional information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement its policy to report an allegation of abuse for one of eight residents in the survey sample, Resident #8.The findings include: For Resident #8 (R8), the facility staff failed to implement its policy to report an allegation of abuse related to a verbal altercation between R8 and Resident #3 (R3) on 5/2/26.A review of R3's clinical record revealed the following progress note dated 5/2/26: Nursing Note [Resident #3] walked on his 3 prong cane down to [R8's] room and began arguing and cursing at [R8] because he was yelling earlier in the day. This note was written by LPN (licensed practical nurse) #1.Further review of R8's and R3's clinical records and of facility documents revealed no evidence that this incident was reported to management or to the State Agency (SA) as an allegation abuse.A review of the facility policy, Abuse Investigation and Reporting, revealed, in part: All reports of resident abuse.shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management.If an incident or suspected incident of resident abuse.is reported, the Administrator/designee will assign the investigation to an appropriate individual.All alleged violations involving abuse.will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: The stated licensing/certification agency responsible for surveying/licensing the facility.On 5/5/26 at 2:30 p.m., LPN #1 was interviewed. She stated that R8 yells loudly and frequently, and that he can be heard all up and down the hallway. She stated she discovered after the altercation between R8 and R3 that R8 had actually been yelling for most of the time the previous evening and night. She stated that she heard R3 yelling and walked to R8's room to see what was happening. She found R3 standing in R8's doorway initially, then eventually walking further into the room closer to where R8 was sitting on his bed. She explained that R8 was not able to stand or walk on his own. She stated R3 and R8 were engaged in a heated argument and that R3 was yelling and cursing at R8. She explained that R8 must have been irritated. She stated she immediately separated the residents and she wrote a note in R3's clinical record about what she witnessed. She stated that in hindsight, she sees that this was potential verbal abuse. She added that she reported this incident to a supervisor but could not remember when she reported or to whom she reported it.On 5/5/26 at 2:28 p.m., LPN #2 was interviewed. She confirmed that if she observed one resident yelling and cursing at another resident, the verbal altercation could be considered verbal abuse and should be immediately reported for the overall safety of residents.On 5/6/26 at 12:11 p.m., the Administrator was interviewed. He stated that when he heard about the incident between R3 and R8 from LPN #1, he was not certain how accurate her account was. He stated he asked LPN #1 if she had reported this incident to the weekend supervisor, and LPN #1 indicated that she had. However, the weekend supervisor denied ever learning about the incident from LPN #1. The Administrator stated that this information should have been conveyed to him, and this definitely is an allegation of verbal abuse that should have been reported to the SA and investigated.No additional information was provided prior to exit.

Based on staff interview and facility document review it was determined that the facility staff failed to evidence a continuous Quality Assurance and Performance Improvement (QAPI) program that monitored its performance and ensured that improvements were sustained, which had the ability to affect all Residents within the facility during quarter two (Q2) to quarter four (Q4) of 2022. The findings included: The facility staff failed to evidence QAPI sign-in sheets for meetings held between Q2 through Q4 of 2022. On 1/8/2024 at 12:05 p.m. during entrance conference a request was made to ASM (administrative staff member) #2, the director of nursing and ASM #3, the assistant director of nursing, for QAPI meeting attendance records from 4/14/2022 to the present. On 1/9/2024 at approximately 10:00 a.m., ASM #1, the administrator provided a binder containing QAPI meeting attendance records. Review of the attendance record failed to evidence any meetings prior to 2/28/2023. On 1/9/2024 at 11:59 a.m., a request was made to ASM #1 for evidence of QAPI meetings for Q2 through Q4 of 2022 for review. At that time an interview was conducted with ASM #1. ASM #1 stated that they had searched for the QAPI attendance records and were unable to locate any. She stated that she had been at the facility since late November of 2022 and had the records since she had started there. She stated that they had several interim administrators in the building prior to that and they did not know where they had put the records. She stated that she had been through everything in the office and could not find them. The facility policy, Quality Assurance Performance Improvement (QAPI) Committee documented in part, . The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program . A separate sign-in sheet will be maintained with the date of the meeting and Committee member name, title, and signature to be provided, as requested, to inspectors or auditors. QAPI information will be maintained for a minimum of three years . On 1/9/2024 at 4:18 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, and ASM #4, the regional director of clinical operations were made aware of the concern. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain an effective infection control program for two of 42 residents in the survey sample, Residents #124 and #122, and failed to maintain the infection control tracking logs. The findings include: 1. For Resident #124 (R124), the facility staff failed to put on PPE (personal protection equipment) when entering the room as the resident was on droplet isolation for influenza. Observation of dining was conducted 1/8/2024 at 5:11 p.m. of CNA (certified nursing assistant) #5 was passing meal trays on the 100 unit. She picked a tray off the dietary cart and proceeded to walk in to R124's room without donning PPE. There was an isolation cart outside the room with a sign indicating droplet precautions. At 5:13 p.m. CNA #5 was asked if R124 was on isolation, CNA #5 stated, she forgot to put on the PPE. She further stated she had previously, on her shift, entered the room and put on the PPE. CNA #5 stated, she just forgot. The physician orders dated, 1/8/2024, documented, Droplet isolation precautions for positive Flu (influenza) A, every shift until 1/13/2024. The care plan dated 1/8/2024, documented in part, Focus: The resident has Influenza A . Interventions: Droplet isolation. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing and ASM #4, the regional director of clinical operations, were made aware of the above concern on 1/9/2024 at 4:08 p.m. No further information was provided prior to exit. 2. For Resident #122 (R122), the facility staff failed to put on PPE (personal protection equipment) when entering the room as the resident was on droplet isolation for influenza. Observation of dining was conducted 1/8/2024 at 5:30 p.m. of CNA #6 passing meal trays on the 100 unit. She picked a tray off the dietary cart and proceeded to walk in to R122's room. She had a surgical mask on. There was an isolation cart outside the room with a sign indicating droplet precautions. CNA #6 proceeded to use the bed controller to elevate the resident's bed. She called to the nurse, LPN (licensed practical nurse) #4, who was walking past the door. LPN #4 entered the room with a surgical mask on. RN (registered nurse) #2, the unit manager, was walking down the hallway. When shown the two staff members in R122's room, she was asked what was not correct in the room, RN #2 stated they should have full PPE on as the resident is on droplet isolation for the flu. An interview was conducted with CNA #6 on 1/8/2024 at 5:36 p.m. When asked how she finds out who is on isolation, CNA #6 stated she asked the other CNAs or the supervisor. When asked why she didn't have PPE on when entering R122's room, CNA #6 stated he [the resident] had a skin tear on his arm and I called the nurse to come in to look at it, that's why the nurse came in. An interview was conducted with LPN #4 on 1/8/2024 at 8:43 p.m. When asked what type of isolation/precautions R122 was on, LPN #4 stated he was on droplet isolation. LPN #4 was asked why she didn't wear PPE when she entered his room, LPN #4 stated the resident was not positioned correctly for his meal tray, so she went in. When asked if the resident was in immediate risk of falling or in danger, LPN #4 stated, no. LPN #4 stated she forgot to put on the PPE. The physician order dated, 1/8/2024, documented, Droplet Isolation Precautions every shift for Flu A until 1/12/2024. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing and ASM #4, the regional director of clinical operations, were made aware of the above concern on 1/9/2024 at 4:08 p.m. No further information was provided prior to exit. 31753 3. The facility staff failed to evidence infection surveillance/tracking for June 2023 through November 2023. A review of the facility infection surveillance/tracking logs for 2023 failed to reveal any surveillance/tracking for June 2023 through November 2023. On 1/9/24 at 1:36 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated she realized infection surveillance/tracking logs were missing and the nurses who were responsible for them between June 2023 and November 2023 were no longer employed at the facility, so she reached out to them and asked that they bring those documents to the facility. On 1/9/24 at 2:56 p.m., an interview was conducted with RN (registered nurse) #1 and LPN (licensed practical nurse) #2 (the current infection control nurses). LPN #2 stated all infections are reviewed on a daily basis and they are tracked on an excel spreadsheet. On 1/9/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Surveillance for Infections documented, SPECIFIC PROCEDURE/GUIDANCE: 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent further infections .Data Collection and Recording: 4. For targeted surveillance using facility-created tools, the facility will follow these guidelines: a. Daily (as indicated): Record detailed information about the resident and infection on an individual infection report form. b. Monthly: i. Collect information from individual resident infection reports and enter line listing of infections by resident for the entire month .

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that written RP (responsible party) and ombudsman notification was provided, for four of 42 residents in the survey sample who were transferred to the hospital, Residents #96, Resident #99, Resident #9 and Resident #125. The findings include: 1. The facility staff failed to evidence provision of required written RP (responsible party) and ombudsman notification at the time of discharge for Resident #96. Resident #96 was transferred to the hospital on 9/9/23. A review of the progress note dated 9/9/23 at 2:19 PM, revealed, Sent to ER (emergency room ) due to critical value WBC (white blood cell count) . A review of the progress note dated 9/9/23 at 6:48 PM revealed, Resident admitted to hospital . There was no evidence of written RP and ombudsman notification provided for Resident #96. On 1/9/24 at 1:30 PM, an interview was conducted with LPN (licensed practical nurse) #1. When asked who provides written notification to the RP and the ombudsman, LPN #1 stated, We call the RP, I do not know who gives written communication to either one. On 1/10/24 at 10:15 a.m., OSM (other staff member) #2, the social services assistant, was interviewed. She stated she had just been informed this week that she is responsible for the RP and ombudsman written notification when a resident is discharged to the hospital. She stated she could not locate any records or documentation that the ombudsman was notified of this hospital transfer for Resident #96. On 1/10/24 at 12:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing and ASM #4, the regional director of clinical operations was made aware of the findings. According to the facility's Facility Initiated Transfer and Discharge policy reveals, The written notice will include the following: reason for transfer or discharge, effective date of transfer or discharge, location to which the resident is transferred or discharged and the name/address of the Office of the State Long-Term Care Ombudsman. The facility will send a copy of the notice to the ombudsman at the same time as the notice is provided to the resident/resident representative. No further information was provided prior to exit. 2. The facility staff failed to evidence provision of required written RP and ombudsman notification at the time of discharge for Resident #99. Resident #99 was transferred to the hospital on 9/23/23. A review of the progress note dated 9/23/23 at 8:21 AM revealed, Sent to ED (emergency department) via EMS (emergency medical squad) for unresponsive . A review of the progress note dated 9/23/23 at 7:23 PM, revealed, admitted to ICU (intensive care unit) . There was no evidence of written RP and ombudsman notification provided for Resident #99. On 1/9/24 at 1:30 PM, an interview was conducted with LPN (licensed practical nurse) #1. When asked who provides written notification to the RP and the ombudsman, LPN #1 stated, We call the RP, I do not know who gives written communication to either one. On 1/10/24 at 10:15 a.m., OSM (other staff member) #2, the social services assistant, was interviewed. She stated she had just been informed this week that she is responsible for the RP and ombudsman written notification when a resident is discharged to the hospital. She stated she could not locate any records or documentation that the ombudsman was notified of this hospital transfer for Resident #99. On 1/10/24 at 12:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing and ASM #4, the regional director of clinical operations was made aware of the findings. No further information was provided prior to exit. 32642 3. For Resident #9 (R9), the facility staff failed to provide evidence of written notification to the responsible party (RP) and ombudsman regarding the resident's 9/30/23 discharge to the hospital. A review of R9's clinical record revealed she was discharged to the hospital on 9/30/23. Further review of the clinical record failed to reveal evidence that the RP and the ombudsman were notified in writing of this event. On 1/10/24 at 10:15 a.m., OSM (other staff member) #2, the social services assistant, was interviewed. She stated she had just been informed this week that she is responsible for the RP and ombudsman written notification when a resident is discharged to the hospital. She stated she could not locate any records or documentation that the ombudsman was notified of this hospital transfer for R9. On 1/9/24 at 4:17 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, and ASM #4, a regional director of clinical operations, were informed of these concerns. No further information was provided prior to exit. 4. For Resident #125 (R125), the facility staff failed to provide evidence of written notification to the responsible party (RP) and ombudsman regarding the resident's 10/19/23 discharge to the hospital. A review of R125's clinical record revealed she was discharged to the hospital on 10/19/23. Further review of the clinical record failed to reveal evidence that the RP and the ombudsman were notified in writing of this event. On 1/10/24 at 10:15 a.m., OSM (other staff member) #2, the social services assistant, was interviewed. She stated she had just been informed this week that she is responsible for the RP and ombudsman written notification when a resident is discharged to the hospital. She stated she could not locate any records or documentation that the ombudsman was notified of this hospital transfer for R125. On 1/9/24 at 4:17 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, and ASM #4, a regional director of clinical operations, were informed of these concerns. No further information was provided prior to exit.

Based on resident and staff interview, resident interview, clinical record review, and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 42 residents in the survey sample, Resident #99. The findings include: For Resident #99, the facility failed to provide nutritional management/bagged meals to take to the dialysis appointment, and failed to communicate with the dialysis facility for 20 of 47 days. Resident #99 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease). A review of the comprehensive care plan dated 9/21/23, which revealed, FOCUS: The resident has nutritional problem at nutritional risk related to ESRD, DM. Resident has ESRD and receives dialysis on Monday, Wednesday, and Friday. INTERVENTIONS: Provide, serve diet as ordered. renal, 1500 ml fluid rest Monitor intake and record every meal. Provide supplements as ordered. Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis on Monday, Wednesday, and Friday. A review of the physician's order dated 9/21/23, revealed, Renal diet Regular texture, Regular/Thin consistency, Diet: diabetic, renal Liquids 1500ml fluid restriction. Dialysis on Monday, Wednesday, and Friday. Pick up at 6am. A review of Resident #99's dialysis communication book and / or the EMR (electronic medical record) revealed no communication sheets for 9/25/23, 9/27/23, 9/29/23, 10/2/23, 10/4/23, 10/6/23, 10/9/23, 10/11/23, 10/13/23, 10/18/23, 10/20/23, 10/23/23, 10/27/23, 10/30/23, 11/2/23, 11/3/23, 11/6/23, 11/24/23, 12/25/23 and 1/3/24; the rest of dialysis communication forms were evidenced. An interview was conducted on 11/9/24 at 8:45 AM with Resident #99. When asked what items he took to dialysis, Resident #99 stated, There is a book I take. When asked if he takes a bagged meal, Resident #99 stated, No, I do not take a bagged lunch. I would like to take a lunch. On 1/10/24 at 7:50 AM an interview was conducted with LPN (licensed practical nurse) #3, when asked what is sent with a resident who goes to dialysis, LPN #3 stated they send communication sheets that have the resident's weight, vital signs, medications and time last eaten, as well as any issues. When asked the purpose of the communication form, LPN #3 stated, to share important information with the dialysis center. When asked if a bagged lunch is sent with the resident, LPN #3 stated, No, we do not send a meal. On 1/10/24 at 9:50 AM, an interview was conducted with OSM (other staff member) #11, the dietary manager. When asked the process for notification of residents needing a bagged lunch, OSM #11 stated, We require schedule of dialysis days from the nursing unit. The resident leaves by the kitchen for their transport to dialysis and we give them their bagged lunch then. OSM #11 explained that the bagged lunch consists of a sandwich, drink and a bag of chips. If residents are leaving early in the morning, they would still pick up their bagged lunch from the kitchen and they do not send it up the evening before. OSM #11 stated the nursing staff did not inform them of Resident #99's dialysis days. On 1/10/24 at 12:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing and ASM #4, the regional director of clinical operations was made aware of the findings. According to the facility's End Stage Renal Disease-Care of the Patient policy reveals, Agreements between this facility and the contracted ESRD facility will include all aspects of how the resident's care will be managed including but not limited to: the development of a comprehensive and integrated care plan, the communication process between the nursing facility and the dialysis center that will reflect ongoing communication, coordination and collaboration and nutritional/fluid management. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to maintain a sanitary environment in one of one kitchen. The findings include: The facility staff failed to maintain a clean main kitchen meat slicer, floors, microwave, and wet nesting of mugs. On 1/08/24 at 12:22. p.m., an observation was made of the main facility kitchen. The food slicer had food particles on the slicer. The microwave was visibly dirty with food particles. The floors had food particles and were greasy. The food trays and cups for residents were stacked on each other on a tray and had water droplets in between them. Cups had water droplets in them as well. On 1/08/24 at 12:23 p.m., OSM (other staff member) #11, the dietary manager stated that the cups were drying and ready for service and that they did not have enough drying racks to properly dry the residents' cups and trays. He stated that the floor has been an issue for some time, that the floor needs a power wash, and that it was not clean and needed to be cleaned this week. OSM #11 stated that the meat slicer did not look like it was cleaned properly and that the microwave needed to be wiped down. On 1/10/24 at 9:16 a.m., OSM #17, the assistant dietary manager, stated the staff are supposed to clean the microwave every day, and the slicer should be cleaned every time it is used. On 1/10/24 at 9:29 a.m., OSM#11 stated that the kitchen staff follow a cleaning schedule for when everything in the kitchen needs to be cleaned. A review of the facility document, Cook Station, revealed that floor and food stations are to be cleaned during every meal. Also, every meal tool should inverted. A review of a facility document revealed on Monday and Friday there is supposed to be a deep dive in kitchen. On 1/10/24 at 12:42 p.m., ASM (administrative staff member) #1, the administrator, ASM #2 the director of nursing, ASM #4 the regional director of clinical operations, and ASM #5 the regional director of clinical operations, were informed of these concerns. A review of the facility policy, Preventing Foodborne Illness - Food Handling, revealed in part, Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized .All food service equipment and utensils will be sanitized according to current guidelines and manufacturer's recommendations. No further information was provided prior to exit.

Based on staff interview and facility document review, it was determined the facility staff failed to have a written dialysis agreement for one of one dialysis residents in the survey sample, Resident #99. The findings include: The facility failed to evidence a written dialysis agreement for Resident #99 with one dialysis center. A review of the physician's order dated 9/21/23, included: Dialysis on Monday, Wednesday, and Friday. Pick up at 6am. During the entrance conference to the facility on [DATE], a request was made for the dialysis contracts or agreements to be provided. On 1/9/24 at 4:00 PM, ASM (administrative staff member) #2, the director of nursing stated, We do not have a dialysis contract for this company who has this resident. We have called them and are waiting for them to send it. The administrator thought she had it but she does not. On 1/10/24 at 12:45 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing and ASM #4, the regional director of clinical operations was made aware of the findings. According to the facility's End Stage Renal Disease-Care of the Patient policy reveals, Agreements between this facility and the contracted ESRD facility will include all aspects of how the resident's care will be managed including but not limited to: the development of a comprehensive and integrated care plan, the communication process between the nursing facility and the dialysis center that will reflect ongoing communication, coordination and collaboration and nutritional/fluid management. According to the facility's Consultants policy reveals, Our facility uses outside resources to furnish specific services provided by the facility. Written, signed and dated agreements are maintained for each consultant or consulting group. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to implement the COVID-19 vaccination policy for four of five resident immunization reviews, Residents #95, #10, #98, and #12. The findings include: The facility policy titled, COVID-19 Vaccination for Residents documented, 3) Residents will be encouraged to accept COVID-19 vaccinations in accordance with CDC (Centers for Disease Control) guidance. CDC recommends the 2023-2024 updated COVID-19 vaccines: Pfizer-BioNTech, Moderna, or Novavax, to protect against serious illness from COVID-19. This information was obtained from the website: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html For Residents #95, #10, #98, #12 and CNA (certified nursing assistant) #4, the facility staff failed to offer/provide the 2023/2024 COVID-19 vaccination. Resident #95 (R95) was admitted to the facility on [DATE]. A review of R95's clinical record revealed the most recent COVID-19 vaccination offered/provided to the resident was on 11/16/22. Resident #10 (R10) was admitted to the facility on [DATE]. A review of R10's clinical record revealed the most recent COVID-19 vaccination offered/provided to the resident was on 3/2/21. Resident #98 (R98) was admitted to the facility on [DATE]. A review of R98's clinical record revealed the most recent COVID-19 vaccination offered/provided to the resident was on 8/23/22. Resident #12 (R12) was admitted to the facility on [DATE]. A review of R12's clinical record revealed the most recent COVID-19 vaccination offered/provided to the resident was on 5/24/22. On 1/9/24 at 2:56 p.m., an interview was conducted with RN (registered nurse) #1 (the infection control nurse) and LPN (licensed practical nurse) #2 (the infection control assistant). RN #1 stated that at the beginning of the year, the facility staff realized they were behind on offering/providing COVID-19 vaccinations. RN #1 stated the facility staff has a plan and they are trying to catch up on vaccinations. LPN #2 stated she created a spreadsheet that documents when residents received their last COVID-19 vaccination, and the facility staff are going to begin obtaining consents for the latest vaccination on 1/15/24. On 1/9/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.

Based on staff interview and clinical record review, it was determined the facility staff failed to notify the physician or nurse practitioner, when medications were not available for administration for two of 42 residents in the survey sample, Resident #110 and #95. The findings include: 1. For Resident #110, the facility staff failed to notify the physician/nurse practitioner when the Tramadol (used to treat pain) was not available for administration. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/10/2023, the resident scored a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. The physician order dated, 12/21/2023, documented, Tramadol Oral Tablet 50 MG (milligrams); Give 1 tablet by mouth every 8 hours for wrist pain for 14 days. The MAR (medication administration record) for December 2023 documented the above order. On the following dates and times there was a 9 documented in the box for administration of the medication. A 9 indicates, Other/See progress notes. 12/23/2023 at 7:00 a.m.; 12/23/2023 at 11:00 p.m.; 12/24/2023 at 7:00 a.m.; 12/24/2023 at 3:00 p.m.; 12/25/2023 at 3:00 p.m. and 11:00 p.m.; 12/26/2023 at 7:00 a.m. and 11:00 p.m.; 12/27/2023 at 7:00 a.m.; 12/28/2023 at 7:00 a.m., and 12/30/2023 at 3:00 p.m. A 5 was documented on 1/25/2023 at 7:00 a.m. A 5 indicates Hold/ See progress notes. The Progress notes documented the following for the dates documented above: 12/23/2023 at 6:09 a.m. - On order. 12/23/2024 at 10:37 p.m. - nothing was documented why the medication was not given. 12/24/2023 at 5:42 a.m. - Med (medication) not available pending delivery. 12/24/2023 at 7:39 p.m. - nothing was documented why the medication was not given. 12/25/2023 at 6:28 p.m. - Medication not available awaiting from pharmacy. 12/25/2023 at 3:18 p.m. - Tramadol on order. 12/25/2023 at 10:58 p.m. - Med not available awaiting for pharmacy. 12/26/2023 at 6:07 a.m. - Not available. 12/26/2023 at 10:42 p.m. - nothing was documented why the medication was not given. 12/27/2023 at 6:11 a.m. - nothing was documented why the medication was not given. 12/28/2023 at 6:06 a.m. - nothing was documented why the medication was not given. 12/30/2023 at 1:54 p.m. - Unavail Review of the contents of the Omnicell (backup medication system) was reviewed. Tramadol 50 mg Tablets, quantity of 10 were in the Omnicell. An interview was conducted with LPN (licensed practical nurse) #2 on 1/10/2024 at 9:59 a.m. When asked the process for when medications are not available in the medication cart at the time of administration, LPN #2 stated they must get the medication out of the Omnicell, reorder it from the pharmacy. She stated she can go directly in PCC (computer program) and order the medication. When asked what if the medication is not in the Omnicell, what steps does she take, LPN #2 stated she would call the nurse practitioner and let her know and see if they can get it STAT. She stated she hasn't had many issues with things not being in the Omnicell. An interview was conducted with RN (registered nurse) #6 on 1/10/2024 at 10:16 a.m. When asked if a medication is not available for administration what steps does she take, RN #6 stated she looks in the Omnicell, she calls the pharmacy. RN #6 was asked if she needed to document that she called the pharmacy, RN #6 stated, Yes, we should document all of the steps we take. RN #6 stated she called the nurse practitioner too. On 1/10/2024 at 12:45 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the regional director of clinical operations, ASM #5, regional director of clinical operations, were made aware of the above concern. No further information was obtained prior to exit. 2. For Resident #95, the facility staff failed to notify the physician/nurse practitioner when the Debrox (used to help clear out ear wax impaction) was not available for administration. The physician order dated, 1/4/2024, documented, Debrox Solution 6.5% (carbamide peroxide) (used to soften ear wax) instill 5 drops in both ears two times a day, flush ears upon completion of treatment for 4 days. The nurse practitioner note dated, 1/4/2024 documented in part, Chief complaint: impacted ear wax .Plan: Order Debrox. The MAR (medication administration record) for January 2024 documented the above order. The MAR documented the following: 1/4/2024 at 4:00 p.m. - documented as administered. 1/5/2024 at 8:00 a.m. - documented as administered. 1/5/2024 at 4:00 p.m. - a 9 was documented indicating Other/see progress notes. 1/6/2024 at 8:00 a.m. and at 4:00 p.m. - a 9 was documented indicating Other/see progress notes. 1/7/2024 at 8:00 a.m. and at 4:00 p.m. - a 9 was documented indicating Other/see progress notes. 1/8/2024 at 8:00 a.m. - documented as administered. The nurse's notes dated 1/5/2024 at 6:54 p.m. documented, Coming from pharmacy. The nurse's note dated 1/6/2024 at 8:48 a.m. documented, on order. The nurse's note dated 1/6/2024 at 6:23 p.m. documented, Coming from pharmacy. There was no nurse's note for 1/7/2024 at 8:00 a.m. to explain why it wasn't administered. The nurse's note dated 1/7/2024 at 6:20 p.m. documented, Coming from pharmacy. An interview was conducted with LPN (licensed practical nurse) #2 on 1/10/2024 at 9:59 a.m. When asked the process for when medications are not available in the medication cart at the time of administration, LPN #2 stated they must get the medication out of the Omnicell, reorder it from the pharmacy. She stated she can go directly in PCC (computer program) and order the medication. When asked what if the medication is not in the Omnicell, what steps does she take, LPN #2 stated she would call the nurse practitioner and let her know and see if we can get it STAT. She stated she hasn't had many issues with things not being in the Omnicell. An interview was conducted with RN (registered nurse) #6 on 1/10/2024 at 10:16 a.m. When asked if a medication is not available what steps does she take, RN #6 stated she looks in the Omnicell, she calls the pharmacy. RN #6 was asked if she needed to document that she called the pharmacy, RN #6 stated, Yes, we should document all of the steps we take. RN #6 stated she called the nurse practitioner too. On 1/10/2024 at 12:45 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the regional director of clinical operations, ASM #5, regional director of clinical operations, were made aware of the above concern. No further information was obtained prior to exit.

Based on staff interview and clinical record review, it was determined that the facility staff failed to provide notice of Medicare non-coverage for one of three beneficiary protection notification resident reviews, Resident #413. The findings include: For Resident #413 (R413), the facility failed to provide the resident and/or the resident's representative with an ABN (Advance Beneficiary Notice of Non-coverage) waiver of liability when a change in coverage occurred. R413's last covered day of Medicare part A services was 10/3/2023. R413 was admitted to the facility with diagnoses that included but were not limited to acute CVA (cerebrovascular accident). On 1/10/2024 at 10:50 a.m., an interview was conducted with OSM (other staff member) #2, social services assistant. OSM #2 stated that as soon as they were notified that a resident was being cut from skilled services they reached out to the resident and/or the responsible party to notify them and provide the notice of non-coverage. She stated that they had them sign the notice and documented it in the clinical record and typically kept a copy in a filing cabinet in the office. She stated that R413 should have received a notice of non-coverage but they were unable to locate it and they could not provide any documentation to evidence that it was done. R413 was discharged to the community on 10/4/2023. The facility policy Advanced Beneficiary Notice (ABN) documented in part, . A Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if the resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination from their Quality Improvement Organization (QIO) . The notice shall be hand-delivered as possible to obtain beneficiary or representative signature. The notice shall be prepared with an original and at least two copies. The facility shall retain the original and give a copy to the resident/representative . On 1/10/2024 at 12:47 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the regional director of clinical operations and ASM #5, the regional director of clinical operations were made aware of the concern. No further information was presented prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided when three out of 42 residents in the survey sample were transferred to the hospital, Residents #96, Resident #99, and Resident #125. The findings include: 1. The facility staff failed to evidence provision of bed hold notification at the time of discharge for Resident #96. Resident #96 was transferred to the hospital on 9/9/23. A review of the progress note dated 9/9/23 at 2:19 PM revealed, Sent to ER (emergency room ) due to critical value WBC (white blood cell count) . A review of the progress note dated 9/9/23 at 6:48 PM, revealed, Resident admitted to hospital . There was no evidence that written bed hold information was provided for Resident #96. On 1/9/24 at 1:30 PM, an interview was conducted with LPN (licensed practical nurse) #1. When asked who provides the bed hold, LPN #1 stated, We send a bed hold paper but I do not know who follows up. We do not keep a copy of it. On 1/10/24 at 10:15 a.m., OSM (other staff member) #2, the social services assistant, was interviewed. She stated she had just been informed this week that she is responsible for issuing a bed hold notification when a resident is discharged to the hospital. She stated she could not locate any records or documentation that Resident #96 received a bed hold notification at the time of discharge to the hospital. On 1/10/24 at 12:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing and ASM #4, the regional director of clinical operations was made aware of the findings. According to the facility's Bed Hold Notice policy reveals, At admission and prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. No further information was provided prior to exit. 2. The facility staff failed to evidence provision of bed hold notice for Resident #99. Resident #99 was transferred to the hospital on 9/23/23. A review of the progress note dated 9/23/23 at 8:21 AM revealed, Sent to ED (emergency department) via EMS (emergency medical squad) for unresponsive . A review of the progress note dated 9/23/23 at 7:23 PM, revealed, admitted to ICU (intensive care unit) . There was no evidence of bed hold being provided for Resident #99. On 1/9/24 at 1:30 PM, an interview was conducted with LPN (licensed practical nurse) #1. When asked who provides the bed hold, LPN #1 stated, We send a bed hold paper but I do not know who follows up. We do not keep a copy of it. On 1/10/24 at 10:15 a.m., OSM (other staff member) #2, the social services assistant, was interviewed. She stated she had just been informed this week that she is responsible for issuing a bed hold notification when a resident is discharged to the hospital. She stated she could not locate any records or documentation that Resident #99 received a bed hold notification at the time of discharge to the hospital. On 1/10/24 at 12:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing and ASM #4, the regional director of clinical operations was made aware of the findings. No further information was provided prior to exit. 32642 3. For Resident #125, the facility staff failed to provide evidence that they issued a bed hold notice to the resident when she was discharged to the hospital on 10/19/23. A review of R125's clinical record revealed she was discharged to the hospital on 10/19/23. Further review of the clinical record failed to reveal evidence that the facility issued a bed hold notice to the resident at the time of the discharge. On 1/10/24 at 10:15 a.m., OSM (other staff member) #2, the social services assistant, was interviewed. She stated she had just been informed this week that she is responsible for issuing a bed hold notification when a resident is discharged to the hospital. She stated she could not locate any records or documentation that R125 received a bed hold notification at the time of discharge to the hospital. On 1/9/24 at 4:17 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, and ASM #4, a regional director of clinical operations, were informed of these concerns. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to accurately code an MDS (minimum data set) assessment for one of 42 residents in the survey sample, Resident #75. The findings include: For Resident #75, the facility staff incorrectly coded the resident, on the MDS, as receiving insulin during the look back period. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/8/2023, the resident scored a 0 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired for making daily decisions. In Section N - Medications, the resident was coded as receiving two insulin injections in the past seven days. Review of the physician orders dated 9/25/2023, documented, Trulicity Subcutaneous Solution Pen Injector 3 MG/0.5 ML (milligrams per milliliter); inject 3 mg subcutaneously in the afternoon every seven days related to type 2 diabetes. Review of the MAR (medication administration record) for December 2023, documented the above order. Resident #75 received the medication on 12/4/2023, during the look back period of seven days. An interview was conducted with RN (registered nurse) #5, the MDS coordinator, on 1/9/2024 at 3:42 p.m. RN #5 was asked to review Section N - Medication, in the MDS of 12/8/2023. When asked if Trulicity is considered insulin, RN #5 stated, no. RN #5 reviewed the clinical record and stated the resident was not on insulin and the MDS is miscoded. She stated they use the RAI (resident assessment instrument) manual as their reference. The RAI manual included: Steps for Assessment: 1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Determine if the resident received insulin injections during the look-back period. 3. Determine if the physician (or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) changed the resident's insulin orders during the look-back period. 4. Count the number of days insulin injections were received and/or insulin orders changed. Coding Instructions for N0350A: Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received. This information was obtained from the RAI manual dated October 2017 Version 1.17.1. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing and ASM #4, the regional director of clinical operations, were made aware of the above concern on 1/9/2024 at 4:08 p.m. No further information was provided prior to exit.

Based on observations, resident interview, staff interviews, and facility document review, it was determined the facility staff failed to implement the comprehensive care plan for one of 42 residents in the survey sample, Resident #99. The findings include: For Resident #99, the facility staff failed to implement the comprehensive care plan interventions for nutritional risk. Resident #99 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: ESRD (end stage renal disease). A review of the comprehensive care plan dated 9/21/23 included, FOCUS: The resident has nutritional problem at nutritional risk related to ESRD, DM. Resident has ESRD and receives dialysis on Monday, Wednesday, and Friday. INTERVENTIONS: Provide, serve diet as ordered. renal, 1500 ml fluid rest [restriction] Monitor intake and record every meal. Provide supplements as ordered. Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis on Monday, Wednesday, and Friday. A review of the physician's order dated 9/21/23, revealed, Renal diet Regular texture, Regular/Thin consistency, Diet: diabetic, renal Liquids 1500ml fluid restriction. Dialysis on Monday, Wednesday, and Friday. Pick up at 6am. An interview was conducted on 11/9/24 at 8:45 AM with Resident #99, and when asked what items he took with him to dialysis, Resident #99 stated, there was a book he took. When asked if he takes a bagged meal, Resident #99 stated, No, I do not take a bagged lunch. I would like to take a lunch. There was no evidence that the resident received breakfast prior to leaving for the dialysis appointments nor a bagged meal provided. On 1/10/24 at 7:50 AM an interview was conducted with LPN (licensed practical nurse) #3, when asked the purpose of the care plan, LPN #3 stated, the purpose of the care plan is to share information with the team on the goals and interventions that are needed for each resident. When asked if the resident is not provided a meal, is the care plan being followed, LPN #3 stated, no, it is not being followed. On 1/10/24 at 12:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing and ASM #4, the regional director of clinical operations was made aware of the findings. a According to the facility's Care Planning-Comprehensive Person Centered policy reveals, The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs as identified throughout the comprehensive resident assessment instrument (RAI) process. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the administration of medications, for one of 42 residents in the survey sample, Residents #110. The findings include: For Resident #110, the facility staff failed to administer Tramadol (used for pain) per the physician orders. The physician order dated, 12/21/2023, documented, Tramadol Oral Tablet 50 MG (milligrams); Give 1 tablet by mouth every 8 hours for wrist pain for 14 days. The MAR (medication administration record) for December 2023 documented the above order. On the following dates and times there was a 9 documented in the box for administration of the medication. A 9 indicated, Other/See progress notes. 12/23/2023 at 7:00 a.m.; 12/23/2023 at 11:00 p.m.; 12/24/2023 at 7:00 a.m.; 12/24/2023 at 3:00 p.m.; 12/25/2023 at 3:00 p.m. and 11:00 p.m.; 12/26/2023 at 7:00 a.m. and 11:00 p.m.; 12/27/2023 at 7:00 a.m.; 12/28/2023 at 7:00 a.m., and 12/30/2023 at 3:00 p.m. A 5 was documented on 1/25/2023 at 7:00 a.m. A 5 indicates Hold/ See progress notes. The progress notes documented the following for the dates documented above: 12/23/2023 at 6:09 a.m. - On order. 12/23/2024 at 10:37 p.m. - nothing was documented why the medication was not given. 12/24/2023 at 5:42 a.m. - Med (medication) not available pending delivery. 12/24/2023 at 7:39 p.m. - nothing was documented why the medication was not given. 12/25/2023 at 6:28 p.m. - Medication not available awaiting from pharmacy. 12/25/2023 at 3:18 p.m. - Tramadol on order. 12/25/2023 at 10:58 p.m. - Med not available awaiting for pharmacy. 12/26/2023 at 6:07 a.m. - Not available. 12/26/2023 at 10:42 p.m. - nothing was documented why the medication was not given. 12/27/2023 at 6:11 a.m. - nothing was documented why the medication was not given. 12/28/2023 at 6:06 a.m. - nothing was documented why the medication was not given. 12/30/2023 at 1:54 p.m. - Unavail Review of the contents of the Omnicell (backup medication system) was reviewed. Tramadol 50 mg Tablets, quantity of 10 were in the Omnicell. An interview was conducted with LPN (licensed practical nurse) #2 on 1/10/2024 at 9:59 a.m. When asked the process for when medications are not available in the medication cart at the time of administration, LPN #2 stated they must get the medication out of the Omnicell, reorder it from the pharmacy. She stated she can go directly in PCC (computer program) and order the medication. When asked what if the medication is not in the Omnicell, what steps does she take, LPN #2 stated she would call the nurse practitioner and let her know and see if they can get it STAT. She stated she hasn't had many issues with things not being in the Omnicell. The facility policy, Unavailable Medications, documented in part, Policy .The facility must make every effort to ensure that medications are available to meet the needs of each resident Procedures: The nursing staff shall: 1. Notify the attending physician(or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy(ies) available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or directions. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the regional director of clinical operations, ASM #5, regional director of clinical operations, were made aware of the above concern on 1/10/2024 at 12:45 p.m. No further information was obtained prior to exit.

Based on observations, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to assess one of 42 residents in the survey sample for safe self-administration of medications, Resident #134. The findings include: For Resident #134 (R134), the facility staff failed to assess the resident for self-administration of an Albuterol inhaler (1) that was left at the resident's bedside for as needed use. On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 11/15/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating that they were cognitively intact for making daily decisions. On 1/8/2024 at 3:11 p.m., an observation was made of R134 in their room. R134 was observed sitting in bed with the overbed table to their right side. An Albuterol inhaler was observed on top of the overbed table. At that time an interview was conducted with R134 who stated that they kept the Albuterol inhaler with them at all times and used it as needed when they became short of breath. R134 stated that the nurses were aware of the inhaler and had told them to let them know when they used it. Additional observations of the Albuterol inhaler on R134's overbed table were made on 1/8/2024 at 5:38 p.m. and 1/9/2024 at 9:26 a.m. Review of R134's clinical record failed to evidence an assessment for self-administration of medications or a physician's order for the Albuterol inhaler. On 1/9/2024 at 2:15 p.m., an interview was conducted with RN (registered nurse) #8. RN #8 stated that residents were allowed to self administer medications after they were assessed to ensure that they could safely perform the task. She stated that the nurses performed a self-administration assessment and observed the resident administer the medication prior to obtaining the physician's order. On 1/9/2024 at approximately 2:20 p.m., an observation was made with LPN (licensed practical nurse) #6 of R134's overbed table in their room and the Albuterol inhaler located on the table. LPN #6 stated that they were not aware of the inhaler and that a self-administration assessment should have been completed prior to the inhaler being left with the resident. The facility policy, Self Administration of Medications and Treatments undated, documented in part, .As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities and choice to determine whether self-administering medications and/or treatments is clinically appropriate for the resident . The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications/treatments . Staff shall identify and give to the licensed nurse any medications/treatment supplies found at the bedside that are not authorized for self-administration, for return to the family or responsible party . On 1/9/2024 at approximately 4:18 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, and ASM #4, the regional director of clinical operations were made aware of the concern. No further information was provided prior to exit. Reference: (1) Albuterol inhaler Albuterol is used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways). Albuterol inhalation aerosol and powder for oral inhalation is also used to prevent breathing difficulties during exercise. Albuterol inhalation aerosol (Proair HFA, Proventil HFA, Ventolin HFA) is used in adults and children 4 years of age and older. Albuterol powder for oral inhalation (Proair Respiclick) is used in children [AGE] years of age and older. Albuterol solution for oral inhalation is used in adults and children 2 years of age and older. Albuterol is in a class of medications called bronchodilators. It works by relaxing and opening air passages to the lungs to make breathing easier. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682145.html

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to prevent and treat pressure ulcers/injuries for three of 20 residents in the survey sample, Residents #6, #1, and #7. For Resident #6, who was admitted with a pressure/ulcer injury, the facility staff failed to initiate treatment to the pressure ulcer/injury for 20 days. The pressure ulcer/injury worsened, which resulted in harm. The findings include: 1. For Resident #6 (R6), who was admitted on [DATE], with a stage three pressure injury (2) to the sacrum, the facility failed to initiate treatment for the pressure injury until 4/20/23. The pressure ulcer/injury declined from stage three to unstageable (3). R6 was admitted to the facility on [DATE]. Admitting diagnoses included pressure injury, malnutrition, dementia, and anxiety disorder. A review of the resident's admission nursing assessment dated [DATE] revealed in part: Site: Sacrum, Type: Pressure, Length 1 cm (centimeter), Width 1 cm, Depth 1 cm, Stage 111 .Resident has dementia or other cognitive deficits that make them unable to answer questions. On 4/21/23 at 10:32 a.m., LPN (licensed practical nurse) #2 was observed to provide wound care to R6's sacral pressure injury. The wound bed was not visible; the wound base was covered in slough (4). The most recent wound measurements on 4/17/23 were 1 cm (centimeter) X 1 cm. The treatment was administered as ordered. A review of ASM (administrative staff member) #5's, the NP's (nurse practitioner's), progress notes dated 4/3/23, 4/4/23, 4/5/23, 4/10/23, and 4/13/23 revealed no information related to R6's pressure injury. Each of these progress notes documented, Skin: Warm and dry to touch. A review of nurse progress notes included: 4/11/23: Type: Skin only. Skin Evaluation: Skin warm & dry, skin color WNL (within normal limits), mucous membranes moist, turgor normal. No current skin issues noted at this time. 4/17/23: Type: Skin only .Skin issue: Pressure ulcer/Injury. Skin issue location: sacrum .Wound dr. (doctor) made aware and will follow. A review of the wound specialist progress notes revealed: 4/17/23 Wound Assessment. Wound #2 Sacral is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss pressure ulcer and has received a status of Not Healed .measurements are 1 cm length X 1 cm width with no measurable depth .There is a light amount of serous drainage noted which has no order. The wound margin is not attached to wound base. Wound bed has 76-100% slough .Cleanse/Protect Wound [with] Wound cleanser .Apply calcium alginate and foam mwf (Monday, Wednesday, and Friday)/prn (as needed). There was no evidence that the wound physician applied the treatment at the time of the assessment. As evidenced by the April 2023 treatment administration record (TAR), the wound care recommendation was not transcribed and/or implemented until 4/20/23. A review of R6's care plan dated 3/31/23 revealed, in part: The resident has . pressure ulcer .or potential for pressure ulcer development .Administer treatments as ordered and monitor for effectiveness. A review of R6's March and April 2023 TARs revealed no treatment orders for the pressure injury were implemented until 4/20/23. On 4/24/23 at 1:00 p.m., ASM (administrative staff member) #4, the wound physician, was interviewed. When asked if a pressure injury is worsening if it goes from having a measurable wound bed (stage 3) to having no measurable depth due to being covered with slough, he stated: Yes. It is worsening. He stated: You have moved yourself from a known depth to an unknown depth. The wound could possibly have become a stage 4, but you can't know it because you can't visualize it. On 4/24/23 at 2:13 p.m., LPN #2 was interviewed. She stated when a resident is admitted with a pressure injury, the resident should also come with orders for treatment of the pressure injury. LPN #2 stated the admitting nurse is responsible for transcribing the orders from the discharging facility to the facility's EMR (electronic medical record), and if the resident does not come in with any type of treatment orders, the admitting nurse should call the on-call provider [usually the nurse practitioner]. The nurse should advise the NP of the situation, and the NP will look at the pressure injury and write orders to be in place until the wound physician can assess the wound. On 4/24/23 at 2:18 p.m., ASM #5, the nurse practitioner was interviewed. She stated she does full skin assessments on new residents. She stated she asks a CNA (certified nursing assistant) to help her turn the resident so she can visualize the resident's entire body and she asks the nurse if there are skin issues. She stated if the resident is admitted with a pressure injury, she writes the same orders as the previous facility had in place until the wound physician can see the resident, and if there are no orders, she will write treatment orders to be followed until the resident can be assessed by the wound physician. When asked if a pressure injury will always need some type of treatment order, she stated: Yes. They always need an order. If you have a wound, you need to address it. We need to make sure it is care planned. ASM #5 did not provide a reason to why no orders were written upon initial assessment of the pressure ulcer/injury. On 4/24/23 at 2:58 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the assistant director of nursing, were informed of the findings, and of the concern for harm. ASM #2 stated at the time of R6's admission, the facility did not have a dedicated wound nurse, and the facility had subsequently identified concerns with pressure injuries and orders being implemented by a particular member of the nursing staff. The facility's improvement plan completion date was 4/18/23; however, R6's pressure injury treatment did not start until 4/20/23 therefore past non-compliance could not be considered. On 4/24/23 at 3:25 p.m., ASM #2 stated there was no additional information she could provide for R6's pressure injury treatment between 3/31/23 and 4/20/23. She stated the facility's EMR software automatically skips some time between when an order is entered and when the order appears on the TAR for administration. A review of the facility policy, Pressure Ulcer Prevention and Management, revealed, in part: Staff will be encouraged to promptly report any observation of a change in the resident's skin integrity .Weekly skin observations will be conducted by a licensed nurse and findings will be documented in the resident's medical record .Observations of new pressure ulcer/injury will be .reported to the physician/practitioner for further evaluation and treatment .referred to the designated wound nurse as appropriate .Treatments will be ordered by the physician/practitioner .Unless established and approved under standing orders .orders for pressure ulcer/injury treatment will be specific for each resident .Treatments, including preventive interventions, will be documented in the resident's medical record .If the resident develops .worsening pressure ulcer/injury, the facility will conduct an investigation to causative factors. No further information was provided prior to exit. References: (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. (2) Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This injury is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. (3) Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. This information is taken from the National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm. (4) 'The wound bed may be covered with necrotic tissue (non-viable tissue due to reduced blood supply), slough (dead tissue, usually cream or yellow in color), or eschar (dry, black, hard necrotic tissue). Such tissue impedes healing. This information is taken from the website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360405/ 2. For Resident #1 (R1), the facility staff failed to initiate treatment for pressure ulcer/injuries (1) present on the resident's admission on 6/3/22 until 6/11/22; and failed to initiate treatment for a right ischium pressure injury when the resident was readmitted to the facility from the hospital on 3/7/23. R1 was admitted to the facility on [DATE]. A review of R1's admission nursing assessment dated [DATE] revealed, in part: No skin issues. A review of the nurse progress note dated 6/3/22 revealed, in part: Received resident around 1456 (2:56 p.m.) via transport .Resident a/pleasant (alert and pleasant) with confusion .Per reporting from [name of previous facility] resident can be difficult with care. Resident skin was warm/intact with the exception of L (left) ischium opened, deep tissue wound 6.5 cm (centimeters) X 5.5 cm that tunnels and is undermining. No draining. R (right) ischium has what looks like is a pressure wound that is necrotic (dead tissue) and unstageable (2) but closed. No other skin alterations found. A review of the PA (physician assistant) progress note dated 6/7/22 revealed, in part: Skin: L ischium 6 X 5 cm open deep wound with tunneling. R ischium necrotic wound closed .Plan: Wound consult .pending wound doctor visit, pack, and clean wound with 1/2 X 5 yard packing strip iodoform Q2 (every two) days. Progress notes written by the PA and dated 6/10/22 and 6/13/22 documented the exact same information related to the resident's wounds and treatment order. A review of R1's orders revealed the following: 6/9/22 Pack open wound left buttock with 1/2 x 5yd iodofoam packing strip q 2 days every 48 hours related to PRESSURE ULCER OF LEFT BUTTOCK, UNSPECIFIED STAGE (L89.329) .D/c (discontinue) 6/13/22. The June 2022 TAR (treatment administration record) documented this treatment was not signed off as completed until 6/11/23. 6/14/22 Dakins (1/2 strength) Solution 0.25 % (Sodium Hypochlorite) Apply to Left hip and sacrum topically every day shift for Wound care cleanser left hip and sacrum with Dakins solution, pack with Dakins moist gauze cover with foam. A review of the June 2022 TAR revealed this treatment was administered as ordered beginning 6/14/22. 6/14/22 Cleanse right hip with wound cleanser, pat dry, apply Medihoney, cover with foam. every day shift for Wound care. A review of the June 2022 TAR revealed this treatment was administered as ordered beginning 6/14/22. Further review of R1's clinical record revealed she was readmitted to the facility from the hospital on 3/7/23. A review of the readmission nursing assessment revealed R6 had five pressure injuries: right hip, left hip, right buttock, right heel, and right sacrum. The resident was readmitted to the facility receiving hospice services. A review of R1's orders revealed no treatment orders for the right hip pressure injury between readmission on 3/7/23 and the time of discharge from the facility on 4/10/23. On 4/21/23 at 10:01 a.m., ASM (administrative staff member) #4 was interviewed and stated someone from his practice saw R1 after admission in June 2022. He stated the resident had three wounds on first assessment, with a wound on each hip and the sacrum. He stated (R1) was noncompliant with wound care and with all ADL (activities of daily living) care, and even in the middle of wound treatment by him, the resident would rip off the dressing he had just placed. He stated there was give-and-take with the wound progression. They would improve, then go back to zero. He stated he told the family early in the resident's admission that he would attempt to get the wounds to improve, but he was not sure it was a realistic goal. He stated the resident, from the beginning, was not eating or drinking much. He stated when the resident was readmitted to the facility after the March 2023 hospitalization , he told the daughter there was nothing more he could do to help the wounds improve. He stated the daughter elected for hospice care at that time. The PA who evaluated R1's wounds in June 2022, and the nurse who completed the admission assessment and progress note 6/3/22, were no longer employed by the facility therefore unable for interview. On 4/24/23 at 2:13 p.m., LPN #2 was interviewed. She stated when a resident is admitted with a pressure injury, the resident should also come with orders for treatment of the pressure injury. She stated the admitting nurse is responsible for transcribing the orders from the discharging facility to the facility's EMR (electronic medical record). She stated if the resident does not come in with any type of treatment orders, the admitting nurse should call the on-call provider (usually the nurse practitioner). The nurse should advise the NP of the situation, and the NP will look at the pressure injury and write orders to be in place until the wound physician can assess the wound. On 4/24/23 at 2:18 p.m., ASM #5, the nurse practitioner, was interviewed. She stated she does full skin assessments on new residents. She stated she asks a CNA (certified nursing assistant) to help her turn the resident so she can visualize the resident's entire body. She stated she asks the nurse if there are skin issues. She stated if the resident is admitted with a pressure injury, she writes the same orders as the previous facility had in place until the wound physician can see the resident. She stated if there are no orders, she will write treatment orders to be followed until the resident can be assessed by the wound physician. When asked if a pressure injury will always need some type of treatment order, she stated: Yes. They always need an order. If you have a wound, you need to address it. We need to make sure it is care planned. On 4/24/23 at 2:58 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the assistant director of nursing, were informed of these concerns. On 4/25/23 at 9:00 a.m., ASM #2 stated she could not locate any evidence that R1's wounds had been treated between admission on 6/3/22 and 6/14/22. She stated she was not working in the facility during this time and could not speculate as to the reasons for this omission. She stated she also could not locate any evidence that R1's right hip wound was treated from the time the resident was readmitted to the facility on [DATE] through the resident's discharge on 4/10/23. She stated the facility did not have a wound nurse at that time, and the unit manager was experiencing difficulties. She stated: We caught a few things, but this was something we didn't catch. No further information was provided prior to exit. NOTES (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. (2) Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. This information is taken from the National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm. 3. For Resident #7 (R7), the facility failed to accurately assess and initiate treatment for pressure ulcer/ injuries (1) present on the resident's admission on 3/30/23, until 4/18/23. A review of R7's admission assessment dated [DATE] revealed, in part: [R7] has Pressure Ulcer/s .Sacrum - Pressure; Length = 3.4 (centimeters), Width = 3.5, Depth = 2.1 - Stage Unstageable. The licensed practical nurse (LPN #3) who completed the admission assessment was no longer employed at the facility and therefore could not be interviewed. A review of ASM (administrative staff member-nurse practitioner) #5's progress note dated 4/3/23, 4/6/23, 4/7/23, 4/10/23, and 4/14/23, revealed no information related to R7's sacral pressure injury. A review of an attending physician's progress note dated 4/5/23 and 4/12/23 revealed no information related to R7's sacral pressure injury. A review of a nurse's note dated 4/14/23 revealed, in part: Skin only: Pressure Ulcer/Injury. Skin issue location: sacrum. Pressure Ulcer/Injury State: Stage II - partial thickness skin loss. Length 2 cm (centimeters) X Width 0.8; Depth 0.3. Wound exudate: None .Wound odor: No. Tunneling: No. A review of the wound doctor's note dated 4/17/23 revealed, in part: wound #1. Sacral is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss pressure ulcer and has received a status of not healed .measurements are 1 cm length X 1 cm width with no measurable depth .Wound bed has 76 - 100% slough .Wound cleanser .Apply honey/Foam QD (every day). A review of R7's TAR (treatment administration record) revealed the facility staff initiated this treatment order on 4/18/23. An attempt was made to observe wound care, however R7 refused to allow the surveyor to observe the treatment. On 4/24/23 at 1:00 p.m., ASM (administrative staff member) #4, the wound physician, was interviewed. When asked if a pressure injury is worsening if it goes from having a measurable wound bed (stage 3) to having no measurable depth due to being covered with slough, he stated: Yes. It is worsening. He stated: You have moved yourself from a known depth to an unknown depth. The wound could possibly have become a state 4, but you can't know it because you can't visualize it. On 4/24/23 at 2:13 p.m., LPN #2 was interviewed. She stated when a resident is admitted with a pressure injury, the resident should also come with orders for treatment of the pressure injury. She stated the admitting nurse is responsible for transcribing the orders from the discharging facility to the facility's EMR (electronic medical record). She stated if the resident does not come in with any type of treatment orders, the admitting nurse should call the on-call provider (usually the nurse practitioner). The nurse should advise the NP of the situation, and the NP will look at the pressure injury and write orders to be in place until the wound physician can assess the wound. On 4/24/23 at 2:18 p.m., ASM #5, the nurse practitioner, was interviewed. She stated she does full skin assessments on new residents. She stated she asks a CNA (certified nursing assistant) to help her turn the resident so she can visualize the resident's entire body. She stated she asks the nurse if there are skin issues. She stated if the resident is admitted with a pressure injury, she writes the same orders as the previous facility had in place until the wound physician can see the resident. She stated if there are no orders, she will write treatment orders to be followed until the resident can be assessed by the wound physician. When asked if a pressure injury will always need some type of treatment order, she stated: Yes. They always need an order. If you have a wound, you need to address it. We need to make sure it is care planned. On 4/24/23 at 2:58 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the assistant director of nursing, were informed of these concerns. ASM #2 stated at the time of R7's admission, the facility did not have a dedicated wound nurse, and the facility had subsequently identified concerns with pressure injuries and orders being implemented by a particular member of the nursing staff. On 4/24/23 at 3:25 p.m., ASM #2 stated there was no additional information she could provide for R7's pressure injury treatment between 3/31/23 and 4/20/23. She stated the facility's EMR software automatically skips some time between when an order is entered and when the order appears on the TAR for administration. On 4/24/23 at 3:25 p.m., ASM #2 stated there was no additional information she could provide for R7's pressure injury treatment between 3/30/23 and 4/18/23. She stated the facility's EMR software automatically skips some time between when an order is entered and when the order appears on the TAR for administration. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to provide supervision, assistive devices, and environment free of hazards to prevent injury for two of ten residents in the survey sample, (Resident #1 and Resident #7). 1. The facility staff failed to ensure Resident #1, with diagnoses including dementia and a stroke, who was mobile in a wheelchair, with wandering behaviors and a wander guard in place, and coded as severely impaired for cognition, was not able to exit the facility unsupervised through the front doors. On [DATE], at approximately 5:00 p.m., Resident #1 wandered off the unit where he resided, exited the facility in his wheelchair through the front doors onto the porch unsupervised, turned his wheelchair over, and fell down three steps, sustaining injuries including, a hematoma to his head and a fractured clavicle, resulting in harm. Staff interviews revealed the front door wander guard alarm never sounded. 2. The facility staff failed to implement Resident #7's fall mat on [DATE] and [DATE], per the comprehensive plan of care. The findings include: 1. Resident #1 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to: stroke (1), [CONDITION(S)] (paralysis affecting only one side of the body) (2), history of falls, [CONDITION(S)] (3), dementia and fracture left clavicle (collar bone). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of [DATE], coded the resident as scoring a 4 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for moving in the bed, transfers, locomotion on the unit, dressing, toileting, personal hygiene and bathing. Resident #1 was coded as requiring supervision after set up assistance was provided for eating. In Section E - Behaviors, the resident was not coded as having wandering behavior during the lookback period. The Facility Reported Incident (FRI) dated [DATE] documented in part, Incident Date: [DATE]. Injuries: (an X was documented beside) Yes . If yes, describe: un-displaced fracture of distal left clavicle acute. Describe incident including location and action taken: Resident observed out front of the facility at the bottom of the set of 3 stairs with wheelchair resting on his left side at the bottom of the stairs. The RN (registered nurse) supervisor immediately assessed resident for injury. Resident noted with abrasions to his left shoulder, elbow, and left knee. First aid rendered by RN. No changes noted in resident's cognitive status, resident did complain of discomfort in left elbow. Resident assessed with ROM (range of motion) within residents normal limits, no changed to ROM noted. Neuro (neurological) checks within normal limits. Assisted back into wheelchair and into facility. Resident had frequently in past sat on the front porch to visit with his family and when asked if that was what he was attempting to do resident stated 'yes.' The Nurse Practitioner on call made aware of the fall, abrasions and small closed hematoma to top of head, as well as resident on anticoagulant twice daily. No new orders obtained at time of fall. Residents' POA (power of attorney) also made aware of the fall. Neuro [neurological] checks completed throughout the evening per protocol and were within normal limits. Resident denied complaints of pain or discomfort. On [DATE], the Director of Nursing notified of the fall. Director of Nursing contacted Nurse Practitioner and discussed and decisions made, and order given to send resident to emergency room , via 911 for evaluation. Director of Nursing called ER (emergency room ) to check status of resident and was informed that the resident had gotten a CT (computerized tomography) of the head and some lab (laboratory) work and all were negative. Director informed that resident would be returning to facility. Resident returned to the facility and placed on Wing (number) per protocol. On [DATE], Resident complained of left shoulder pain with care. Nurse Practitioner notified and ordered an X-ray of the left shoulder. Results received at the facility at approximately 9:30 p.m., Nurse Practitioner and Director of Nursing notified of X-ray results showing un-displaced fracture of the distal left clavicle. Resident again sent to ER via 911 for evaluation and returned to the facility with sling on left arm. Resident seen by Nurse Practitioner on [DATE] and had complaints of pain in left shoulder. New order received for pain medication. POA aware of all of the above findings. Resident Care Plan to be reviewed and revised. Upon further investigation (Resident #1) is a [AGE] year old male with a history of CVA (stroke), right sided non dominant [CONDITION(S)], history of falls, [CONDITION(S)], dementia without behavioral disturbances and major depressive disorder. As noted above, resident was observed out front of the facility at the bottom of a set of 3 stairs resting on his left side. The RN supervisor assessed Resident and first aid was rendered. Resident denied complaint of pain or discomfort at the time, no guarding of body part, nor signs of nonverbal pain such as grimacing or wincing. He was noted to have abrasions to his left shoulder, elbow and knee. There was no noted deformity or [CONDITION(S)] to any body part. Resident was assisted into his wheelchair and taken back to his room. NP (nurse practitioner) was notified and order was received to send resident to ED (emergency department) for further evaluation. All testing was negative and resident was sent back to the facility. On [DATE] resident began to complaint of left arm and shoulder pain. The NP ordered an x-ray of the area results showed a non-displaced distal left clavicle fracture. The resident was again sent to the ER for further evaluation and returned to the facility with an order for an arm sling to be worn for resident comfort. Resident had a history of sitting in the lobby daily and would go out on the front porch to wait for his son to visit. Resident acknowledge (sic) he was trying to do that but appears he got to (sic) close to the edge and the wheel of the wheelchair slipped off the edge of the stair. The resident was wearing a wander guard to remind resident to ask for assistance to go outside but he was able to go out on his own. As the incident was unwitnessed, it is unclear if the wander guard stopped functioning or if someone had exited the building and he followed them outside. The wander guard was being checked each shift. Nursing staff had been educated to assist resident to high visibility area when out of bed in his wheelchair. Wander guard is on resident and is functioning. The incident report dated [DATE] at 17:04 (5:04 p.m.) documented in part, Incident Location: outside. Nursing Description: CNA informed this nurse that resident had fallen outside. This nurse observed resident lying on left side, wheelchair next to resident. Immediate Action Taken: Assessment reformed by this nurse. VSS. Resident alert, oriented to baseline. Verbal responses limited, 'yes/no.' C/o (complained of) pain to left elbow. PERRLA [pupil, equal, round, reactive to light and accommodation]. No jugular vein distention observed. Pulses palpable, even. No [CONDITION(S)] observed. Respirations even, non-labored on RA (room air). No cough or SOB (shortness of breath) observed. Abdomen soft non-tender. Right extremities moved at baseline, left side flaccid. Skin warm, dry. Abrasion to left scalp/left elbow observed. Supervising RN, NP and family notified. No additional orders received. First aid to wounds performed by RN. Neurological checks initiated. Assessment negative. Resident assisted back to wheelchair by staff. Mental Status: Checked were Oriented to Place and Oriented to Person .Predisposing Physiological Factors: Other was checked. Other info (information) wanderguard (sic) in place LLE [left lower extremity]. Predisposing Situation Factors: a check mark was next to Active Exit Seeker and Wanderer. Witnesses: No witnesses found. The nurse's note dated [DATE] at 6:45 p.m. documented, CNA (certified nursing assistant) notified this nurse that resident had fallen outside. The nurse observed resident lying on left side, wheelchair. Assessment performed by this nurse. VSS (vital signs stable). Resident alert, oriented to baseline. Verbal responses limited to 'yes/no' C/o (complained of) pain to left elbow. PERRLA (pupils equal, round, reactive to Light, Accommodation). No jugular vein distention observed. Pulses palpable, even. No [CONDITION(S)] observed. Respirations even, non-labored on RA (room air). No cough or SOB (shortness of breath) observed. Abdomen soft non-tender. Right extremities moved at baseline, left side flaccid. Skin warm, dry. Abrasion to left scalp/left elbow observed. Supervising RN, NP and family notified. No additional orders received. First aid to wounds performed by RN. Neurological checks initiated. Assessment negative. Resident assisted back to wheelchair by staff. The nurse's note dated [DATE] at 2:16 p.m. documented, Note text: 0930 (9:30 a.m.) resident was sent to hospital d/t (due to) s/p (status post) fall on [DATE] for checkup from fall ---supervisor (name of supervisor) informed son (name of son) of transfer. The nurse's note dated [DATE] at 4:55 p.m. documented, Late Entry: Resident return from hospital with no new orders. [CONDITION(S)] vaccine administer and updated in immunization record. All lab work was WNL (within normal limits) and CT negative. The nurse practitioner note dated [DATE] at 10:35 a.m. documented in part, Reason for visit - pt (patient) went out front door this weekend and ended up at bottom of steps in w/c (wheelchair). NP [nurse practitioner] on call notified and felt he was stable as long as neuro checks were obtained and stable. I received phone call letting myself know of the incident and decided to send to (initials of hospital) for evaluation since he currently on blood thinners to ensure he is stable to be in facility over weekend. He returned and CT [computed tomography] scan negative, VS (vital signs) stable and in chart .Assessment/Plan: fall down steps - sent to (initials of hospital) - CT was negative, he has superficial abrasion left elbow and left knee. New wander guard intact to ankle. The nurses' note dated [DATE] at 9:41 p.m. documented, Resident complaining of left shoulder pain and NP ordered x-ray from post fall day before. X-ray positive for left clavicle fx (fracture) and NP ordered to be sent back to ER, son (name of son) was called about updates and aware. The nurse's note dated [DATE] at 1:35 a.m. documented in part Resident returned from (initials of hospital) ED at this hour with 'closed nondisplaced fracture of acromial end of left clavicle.' Pt in sling to L (left) arm. Awake and alert. C/O of pain with transfer and turning but settles immediately after .Has order to follow up with (name of orthopedist) in one week. The physician order dated [DATE] documented, [MEDICATION(S)] Tablet (used help prevent strokes or blood clots in people who have [CONDITION(S)]) (4) 5 mg (milligram), give 1 tablet by mouth every 12 hours related to [CONDITION(S)]. The physician order dated [DATE] documented, Wander guard to LLE (left lower extremity), check placement and function every shift for elopement risk. Review of the TAR (treatment administration record) for [DATE] documented in part, Wander guard to LLE (left lower extremity), check placement and function every shift for elopement risk. All boxes for all shifts were documented as having been checked. The TAR for [DATE] documented in part, Wander guard to LLE (left lower extremity), check placement and function every shift for elopement risk. All but two night shift boxes were documented from [DATE] thru [DATE]. The Radiology Report dated, [DATE] documented in part, Findings: There is an undisplaced fracture of the distal clavicle acute. There may be a possible undisplaced fracture ,d+[DATE] cm (centimeters) proximal to the acute fracture at the distal left clavicle. The comprehensive care plan dated [DATE] and revised on [DATE] documented in part, Focus: On one occasion, resident wandered to the front door of the facility. Another entry dated [DATE], documented, Resident wandered to the front door of the facility and went out the front door. The Interventions/Tasks dated [DATE], documented, Wander Alert is in place for resident's safety LLE [left lower extremity]. Monitor location of resident and redirect as needed. Document wandering behavior and attempted diversional interventions in progress note. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: This was left blank. The care plan, dated [DATE], also documented in part, Focus: The resident had an actual fall [DATE] with injury. The Interventions/Tasks documented, Assist resident to high visibility area when in wheelchair. Continue interventions on the at-risk plan. Resident #1 was observed on [DATE] at 11:32 a.m. sitting in his wheelchair in the day room. He was seated at a table with a sling on his left arm and splints applied to his right arm. On [DATE] at 1:49 p.m., an interview was conducted with LPN (licensed practical nurse) #2, a nurse on the unit where Resident #1 resided. When asked if they had any residents that wandered, LPN #2 stated that they had one recently (Resident #1). LPN #2 stated, the resident [Resident #1] was used to sitting outside out front. When asked how the resident gets out front, LPN #2 stated he self-propels in his wheelchair. LPN #2 further stated that he had a wander guard on his left lower extremity. When asked who monitors the wander guards, LPN #2 stated that the 11:00 p.m. to 7:00 a.m. shift nurse makes sure they are functioning. LPN #2 stated she checks for placement only, she didn't check for functioning. When asked how Resident #1 got through the front door, LPN #2 stated, The wander guard should have gone off. When asked where the functioning checks are documented, LPN #2 stated in the TAR. At this time LPN #2 got up and redirected Resident #1 from self-propelling down the hallway. When asked how Resident #1 got out with a wander guard in place, LPN #2 stated she was not here when it happened. On [DATE] at 2:01 p.m. observation of the front entrance revealed two steps to get from the sidewalk to the first landing. Then a landing that is 62 inches deep and 101 - 103 inches wide between the two sets of iron railings. From this landing were three more steps to another landing and then the entrance into to the facility. Observation revealed a person can exit out of the building but cannot enter the building without being let in by a staff member due to the COVID [coronavirus] restrictions in place and screening of anyone that comes in the building. On [DATE] at 2:19 p.m., an interview was conducted with OSM (other staff member) # 2, the maintenance director, When asked how often the wander guards are checked for function, OSM #2 stated he does not check for that. When asked how often the doors are checked to ensure the wander guard system is working, OSM #2 stated he checks the doors, front door and Wing 3 door, twice a day, Monday through Friday. When asked if there had been any problems lately with the system, OSM #2 stated there had not been any concerns on his part. OSM #2 provided the documentation of his checking the wander guard system twice a day Monday through Friday. Review of the documentation provided revealed OSM #2 completed audits Monday through Friday twice a day as stated. No issues were documented. OSM #2 stated that when a resident with a wander guard gets close to the door, it should go off. It [the wander guard system] goes off within five or less feet from the door. At this time OSM #2 was observed testing the front door wander guard system and a loud alarm sounded evidencing the system was functioning. Further observation revealed a staff member coming out of an office down the hall in response to the alarm to see what was going on. On [DATE] at 2:55 p.m., an interview was conducted with RN (registered nurse) #1, who was assigned to Resident #1 on [DATE]. When asked to describe what happened on [DATE], RN #1 stated, She was not there when it happened. She was outside on the back patio with the residents that smoke. I saw three nurses and two aides were outside out the front door. I didn't realize it was (Resident #1). RN #1 stated, (Resident #1) had sneaked off the unit and the two aides were busy attending to other resident's needs. (LPN #4) was doing her medications. One of the aides asked where (Resident #1) was, and they searched his room, halls and then started looking off the unit for him. When asked if the alarm for the wander guard went off, RN #1 stated she didn't hear it. RN #1 stated, They brought him [Resident #1] back to his room. We assessed him, did neurological assessment, and pain assessment. I spoke with the nursing supervisor (RN #2). When asked if she checked the wander guard, RN #1 stated no one checked it at that time. RN #1 stated, She looked at the wander guard and it was expired. When asked the date of the wander guard, RN #1 stated, It said, [DATE]. RN #1 stated she figured it needed to be replaced. When asked if she replaced it, RN #1 stated, she did not, it had to be replaced on Monday and she had to request it. She stated she gave her report to the oncoming shift to let everyone know about it. When asked how staff check the placement and function of the wander guard, RN #1 stated she had not been taught to check the functioning of it, she knew how to check where it was but she had never been taught where to get the box to check it [to see if the wander guard was functioning]. When asked about the location of the box (the box is a silver grey box approximately 4 ½ inches in length, approximately 3 inches in width and approximately 1 ½ to 2 inches in depth), RN #1 stated it was now in the treatment cart. When asked if she had access to a new wander guard on the weekends, RN #1 stated the nurses told me it would be replaced on Monday. RN #1 stated that when the resident returned from the hospital, [DATE], she was shown how the box works and the new one [wander guard] that had been placed on his [Resident #1's] leg. Resident #1's TAR for June was reviewed with RN #1. She verified her initials. RN #1 was asked how she could sign off checking the function of the wander guard if she didn't check it. RN #1 stated, A nurse told her that as long as she saw it on him [Resident #1], she could sign it off. Resident #1's TAR documented RN #1 had signed off as completing Wander guard to LLE (left lower extremity), check placement and function every shift for elopement risk, on [DATE], [DATE], and [DATE]. An interview was conducted with LPN #3 on [DATE] at 3:51 p.m., regarding the process followed for an order to check for placement and functioning of a wander guard every shift. LPN #3 stated, The machine is in the treatment room. You take the box and scan it over the top of the wander guard and it flashes green it's functioning. When asked if both placement and functioning of a wander guard is checked if the order by the physician includes both, LPN #3 stated, yes. LPN #3 stated, She usually keeps a close eye on Resident #1 as he will take off when no one is looking. LPN #3 stated, Before COVID, he [Resident #1] would sit in the lobby. He wouldn't go outside, just sat there. LPN #3 stated she was not on duty when Resident #1 fell . When asked if staff should sign off something, they didn't do, LPN #3 stated, no, you should only sign off something that you did. On [DATE] at 4:11 p.m., an interview was conducted with CNA (certified nursing assistant) #1, a CNA assigned to Resident #1's unit on [DATE]. CNA #1 was asked to explain what happened with Resident #1 on [DATE]. CNA #1 stated there were two aides assigned to the unit that evening. She and the other aide were doing their rounds. At that time the resident [Resident #1] was sitting in the living room/day room. CNA #1 stated then I saw him [Resident #1] in the middle of the hallway at the nurse's station. CNA #1 stated she came out of a resident's room and didn't see him [Resident #1]. CNA #1 stated she called (CNA #2) and we went looking for him, in his room, down the halls, and then in the lobby. CNA #1 stated, We [CNA #2 and I] then saw him [Resident #1] outside down the steps; he had fallen out of his wheelchair and was on his side. When asked if CNAs do any checking of the wander guard systems, CNA #1 stated, no. When asked if she heard the wander guard alarm when Resident #1 went out the facility front door, CNA #1 stated she didn't hear the alarm. When asked if they can hear the alarm on the unit with the doors to the unit closed, CNA #1 stated, Yes, there is a box on the ceiling of the nurse's station and it's very loud. CNA #1 stated, If the alarm had gone off we would have been able to get to him. CNA #1 further stated that when they found Resident #1, his wheelchair was practically on top of him. On [DATE] at 4:15 p.m., an interview was conducted with LPN #4, the other nurse assigned to the wing where Resident #1 resided on [DATE]. When asked if she was involved when Resident #1 fell , LPN #4 stated, She was on the unit as a nurse. His nurse was taking the smokers outside to smoke. The CNAs came and got me stating that the resident [Resident #1] was lying outside on the ground. When asked if she heard the alarm for the wander guard, LPN #4 stated, She did not hear it, the other aide did not hear it but it [the wander guard] was in place on Resident #1's leg. When asked who checks the functioning of the wander guards, LPN #4 stated she did. LPN #4 stated, There is a box in the treatment cart. You place it near the wander guard and wait for the light to light up. If it's green it's okay but if it's red, the wander guard needs to be replaced. When asked what happened on that evening when Resident #1 fell , LPN #4 stated, She and other nurses and aides, brought him [Resident #1] back and his nurse [RN #1] and the supervisor stated it [Resident #1's wander guard] wasn't working. LPN #4 stated, When the CNAs came and got me we did an assessment of the resident prior to putting him in the wheelchair. On [DATE] at 4:19 p.m., an interview was conducted with CNA #2, assigned to the wing where Resident #1 resided on [DATE]. CNA #2 stated she did not witness what happened. CNA #2 stated that she and the other aide noted he [Resident #1] was not where he was before we went on our rounds. CNA #2 stated, We found him outside on the landing with the wheelchair practically on top of him. When asked if she heard the wander guard alarm, CNA #2 stated that they didn't hear it. CNA #2 stated she had brought this up to (RN #2) the supervisor, that they didn't hear the alarm. CNA #2 stated his nurse was out back with the smokers and no one heard the alarm. When asked if it was brought up that the resident's wander guard was expired, CNA #2 stated, the nurse (LPN #4) told us that the wander guard had expired. On [DATE] at 4:32 p.m., an interview was conducted with RN #2, the weekend supervisor. When asked to describe what happened to Resident #1 on [DATE], RN #2 stated, She didn't remember how she was called but she was called up front of the building. (Resident #1) was in his wheelchair at the front entrance. I was told he had gone down the first three steps, he was found on the first landing. When asked how he got into the wheelchair, RN #2 stated, The nurse (LPN #4) told me she had done an assessment and got him back in his wheelchair. RN #2 stated she did her own assessment. She stated the resident is aphasic and she asked if he was hurt and he told her no. RN #2 stated, The resident had scrapes on his shoulder, elbow and a hematoma forming on his head above his left ear. RN #2 stated she called the NP [nurse practitioner] on call. RN #2 stated she was not comfortable with the decision of the NP to not send him [Resident #1] to the hospital for evaluation. When asked if she heard the wander guard alarm go off, RN #2 stated she did not hear it. When asked if his wander guard was working at the time of the incident, RN #2 stated, We didn't realize it didn't work. RN #2 stated, Resident #1 wanders off but we catch him, normally. When asked how the wander guard is checked for placement and functioning, RN #2 stated we use the box to check it. When asked if someone signed it off and didn't check the function, RN #2 stated, That's not good. On [DATE] at 5:04 p.m., LPN #3 was observed testing Resident #1's wander guard. Resident #1's wander guard demonstrated a green light that indicated it was functioning. On [DATE] at 5:19 p.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. When asked if any staff member is at the reception desk during the weekend, ASM #1 stated, not unless the business office manager is the manager on duty and they will sometimes be at the desk. On [DATE] at 8:07 a.m., an interview was conducted with LPN #5, a nurse on Wing 3. When asked how she checks a wander guard for placement and functioning, LPN #5 stated the machine is in the medication cart. LPN #5 stated, She also has to check the expiration date [on the wander guard], as it won't function if it's expired. When asked where the nursing staff document that they have checked the placement and function of the wander guard, LPN #5 stated it is documented on the TAR. On [DATE] at 8:23 a.m., an interview was conducted with OSM #1, the supply staff member regarding the wander guards. OSM #1 stated, They [the wander guards] come with expiration dates and when that date comes up, I replace it and dispose of the old one. When asked if he had Resident #1's wander guard that was in place at the time of the fall, OSM #1 stated, No, it was discarded. They do not keep them (wander guards] they are thrown away when they expire. When asked if he checks the functioning of the wander guards, OSM #1 stated he does not. OSM #1 stated he does audits once a month to check the expiration dates. When asked if he had documentation of these checks, OSM #1 stated if he puts it [his monthly audits of the wander guards] on paper, he gives it [the paper] to the DON (director of nursing). OSM #1 stated that most of the time he doesn't write it [his monthly wander guard audits] down, as I just fix it as I go. When asked about Resident #1's wander guard, OSM #1 stated he is aware that he wears one. When asked if he knew when Resident #1's wander guard expired, OSM #1 stated, He was contacted over the weekend to give a code to go in supply to get a new one. He stated that the company usually calls him and tells him that some are about to expire and asks if I need to order more. When asked if the company had called him regarding Resident #1's wander guard expiring in June, OSM #1 stated they had not called. When asked for the manufacturer's information regarding how often the functioning of the wander guard is to be checked, OSM #1 stated he couldn't get through to the manufacturer to find that out. On [DATE] at 8:41 a.m. OSM #2, the maintenance director, was observed checking the alarm on Wing 3. The alarm functioned when he came near the door with an active wander guard. On [DATE] at 8:50 a.m., an interview was conducted with LPN #6, a nurse that responded to the incident regarding Resident #1 on [DATE]. When asked what her involvement was with Resident #1's fall outside the main lobby doors, LPN #6 stated that she was working on Wing 2 and had just gone outside to let the transportation staff in with a new admission. She saw everyone at the front door and offered her assistance. LPN #6 stated, Resident #1 was already in the wheelchair. (Name of RN #2) asked me to print the paperwork for Resident #1 for transport to the hospital. I went back and (RN #2) told me she didn't need it anymore. I went back to my unit (Wing 2). When asked if she heard the wander guard alarm go off, LPN #6 stated, She didn't. When asked if she would hear it on Wing 2, LPN #6 pointed to a box in the ceiling and stated it alarms here in the nurse's station. On [DATE] at 8:58 a.m., an interview was conducted with ASM #2, the interim director of nursing, regarding Resident #1 exiting the facility front doors and falling on [DATE]. ASM #2 stated, The nursing supervisor called me and left me a message on [DATE] that she wanted to update me and it could wait until the morning. ASM #2 stated she called her [the nursing supervisor] and was told what happened. ASM #2 stated she went into the facility. Spoke with their regular NP (who was on vacation and unavailable for interview during the survey) and got an order to send the resident out to the ER for evaluation. ASM #2 stated, She was worried as Resident #1 was on [MEDICATION(S)] ([MEDICATION(S)]) and was told he had scrapes on his shoulder and had a goose egg on his head. ASM #2 stated she called the ER and gave report to them. She stated Resident #1 was returned to the facility. ASM #2 stated on [DATE], she did not hear anything all day about (Resident #1), then in the evening she got a call that he had an x - ray that showed he had a fractured clavicle. ASM #2 stated, She obtained a physician order to send the resident to the ER for evaluation and the resident returned to the facility with a sling on his arm. When asked if the facility did an investigation into the fall, ASM #2 stated they had. When asked the outcome of that investigation, ASM #2 stated she in-serviced the staff that weekend on how to check the wander guard functioning and placement. When asked if any other things were found, ASM #2 stated that the boxes to check the wander guards did not have functioning batteries in them. They found two of the four units had batteries that were dead. When asked if one of those boxes was on (the wing where Resident #1 resided on [DATE]), ASM #2 stated, Yes. ASM #2 stated, We can't say when the wander guard stopped working but after the fall it was not functioning. ASM #2 stated, They can't say when the batteries, in the box to check the wander guards, stopped working. They were not working at the time of the in-services she performed. An interview was conducted with ASM #1, the administrator, on [DATE] at 9:33 a.m. When asked her involvement in the incident with Resident #1, ASM #1 stated she was out of town that weekend. When asked if anyone came to the facility to check the wander guard system after Resident #1's incident, ASM #1 stated, No, only the maintenance director (OSM #2), he checks it [the wander guard system]. We can check the functioning ourselves. On [DATE] at 12:42 p.m., ASM #2 was asked if the facility had a policy on how to manage/maintain the wander guard system, ASM #2 stated no they do not. When asked if they had a policy on checking the wander guard functioning, ASM #2 stated, No, they don't. The facility policy, Resident Elopement Policy documented, Purpose: To identify and intervene for those residents [NAME] to be at risk for elopement. Documentation: For all residents in the facility. Procedure: 1. Any resident to be found to be at risk for elopement will have measures taken to attempt and prevent any such occurrences. 2. A wander guard bracelet will be place (sic) on arm or ankle or wheelchair of resident at risk. 3. An incident report will be completed and discussed with the interdisciplinary care plan team with any elopement attempts will care plan updated as needed. 3. If the risk of elopement exceeds the monitoring capabilities of the facility, alternative plac [TRUNCATED]

Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to maintain and implement an infection prevention program for preventing and controlling infection and communicable diseases during an identified outbreak of Coronavirus (COVID 19), (1) for four of ten residents in the survey sample, Residents #1, #2, #3, and #4. The facility staff failed to ensure the implementation of infection control precautions for Resident #1, who had tested positive for COVID-19. The facility failed to ensure isolation of Resident #1 and allowed the resident to ambulate into common areas where other residents were sitting. Resident #1 was observed not socially distancing the recommended six feet from other residents, and was observed at times with a mask in place below her nose or completely off her face when in close proximity to other residents. Resident #1, wearing a mask positioned below her nose, sat down at a table in the dining room. Resident #4, who was COVID -19 negative, and not wearing a mask, was allowed to sit at the same table, less than six feet from Resident #1. Once both residents were seated, the staff did not redirect either resident. The facility staff, after touching the rim of Resident #1's cup failed to change gloves before serving another resident a lunch plate. Staff were observed wearing the same gown worn when in contact with Resident #1, when they later they provided care to, and served lunch to, other residents. The facility staff failed to ensure Resident #2 was wearing a mask and was socially distanced from other residents. Resident #2, who had tested negative for COVID-19, was observed sitting with her mask down in a row of chairs near the nurse's station. Resident #2 was frequently coughing. Staff were observed touching Resident #2 and did not change PPE (personal protective equipment). The facility staff failed to ensure Resident #3 was wearing a mask and following infection control protocol when he independently ambulated through the unit. Resident #3, who had tested negative for COVID-19, was observed ambulating in the hall without a mask. Resident #3 was coughing and intermittently wiping his runny nose. He was observed alternately using a tissue and his bare hands when wiping his nose, and then grasping the handrail while ambulating further down the hall. The resident was not redirected by staff at any time during the observation. The facility staff failed to assist Resident #4 to sanitize her hands after she sneezed into them. As a result of this failure, it was likely other residents were at risk of continued exposure and contracting COVID-19, which had already resulted in a COVID-19 positive status for 10 facility residents of the current resident population of 123. This failure resulted in Immediate Jeopardy. The findings include: Resident #1 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/02/20, Resident #1 was coded as being severely cognitively impaired for making daily decisions, having scored three out of 15 on the BIMS (brief interview for mental status. Resident #1 was coded as usually being understood by others and usually understanding others for communication. She was coded as requiring the supervision of one staff member for moving around the unit, and as using both a walker and a wheelchair for safety. A review of the clinical record for Resident #1 revealed the following nurses notes: - 11/23/2020 17:34 (5:34 p.m.) resident temp. (temperature) 102.7, cough, chills and headache. Given Tylenol (medication to reduce fever) 1000mg (milligram) PO (by mouth) Q6hrs (every six hours) today and temp. 102.2. NP (nurse practitioner) on call ordered ER (emergency room ) visit, family notified of transport. - 11/24/2020 01:20 (1:20 a.m.) Returned from (Name of Hospital) ER via ambulance on stretcher accompanied by two EMT's (emergency medical technician). Returned to facility room (Room number). Placed in bed via draw sheet method by EMT's and nursing staff, tolerated the transfer well. Placed in position of comfort. Returned to facility with DX (diagnosis) of COVID . - 11/24/2020 07:28 (7:28 a.m.) Resident family notified about her positive COVID test and her new room (Room number). Further review of Resident #1's clinical record failed to reveal a physician's order for contact and droplet precautions or isolation. A review of Resident #1's comprehensive care plan, dated 3/26/2020 and updated 7/1/2020, revealed, in part: Resident is at risk for exposure to and/or transmission of COVID-19 .Implement Standard, Contact, and Droplet precautions for symptoms/undiagnosed respiratory infections; follow facility policy .Resident will be encouraged to remain in his/her room if fever or respiratory symptoms occur .Resident is non compliant with COVID-19 precautions i.e. (that is) wearing face mask while out of room and social distancing .Resident will be encouraged to wear face mask .Staff will encourage resident to maintain a distance of 6 (six) feet from others. Resident #2 was admitted to the facility on [DATE] and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. On the most recent MDS, a quarterly assessment with an ARD of 9/25/2020, Resident #2 was coded as being severely cognitively impaired for making daily decisions. She was coded as always being understood by others and always understanding others for communication. She was coded as requiring extensive assistance of one staff member for moving around the unit. She was coded as needing no assistive devices for safety. The nursing notes for Resident #2 documented in part, 11/14/2020 10:17 (10:17 a.m.) tested for COVID. Results were negative. Further review of Resident #2's clinical record failed to reveal a physician's order for contact and droplet precautions. A review of Resident #2's comprehensive care plan, dated 3/26/2020 and updated 7/7/2020, revealed, in part, Resident is at risk for exposure to and/or transmission of COVID-19 .Resident is non compliant with COVID-19 precautions i.e. wearing face mask while out of room and social distancing .Resident will be reminded of the importance of compliance with COVID-19 precautions .Staff will encourage resident to maintain a distance of 6 (six) feet from others. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS, a quarterly assessment with an ARD of 9/16/2020, Resident #3 was coded as being severely cognitively impaired for making daily decisions. Resident #3 was coded as sometimes understanding others and as sometimes being understood by others for communication. Resident #3 was coded as requiring the assistance of staff for moving around the unit. He was not coded as requiring an assistive device for safety. The nursing notes for Resident #3 documented in part, 11/14/2020 10:13 (10:13 a.m.) tested for COVID. Results were negative. Further review of Resident #3's clinical record failed to reveal a physician's order for contact and droplet precautions. A review of Resident #3's comprehensive care plan, dated 3/26/2020 and updated on 7/7/2020, revealed, in part: Resident is at risk for exposure to and/or transmission of COVID-19 .Resident is non compliant with COVID-19 precautions i.e. wearing face mask while out of room and social distancing .Resident will be reminded of the importance of compliance with COVID-19 precautions .Staff will encourage resident to maintain a distance of 6 (six) feet from others. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. On the most recent MDS, a quarterly assessment with an ARD 9/16/2020, Resident #4 was coded as being severely cognitively impaired for making daily decisions, having scored three out of 15 on the BIMS. She was coded as always understanding others and as always being understood by others for communication. Resident #4 was coded being independent for moving around the unit. She was not coded as requiring assistive devices for safety. The nursing notes for Resident #4 documented in part, 11/14/2020 10:02 (10:02 a.m.) tested for COVID. Results were negative. Further review of Resident #4's clinical record failed to reveal a physician's order for contact and droplet precautions. A review of Resident #4's comprehensive care plan, dated 3/26/2020 and updated 7/7/2020, revealed, in part: Resident is at risk for exposure to and/or transmission of COVID-19 .Resident is non compliant with COVID-19 precautions i.e. wearing face mask while out of room and social distancing .Resident will be reminded of the importance of compliance with COVID-19 precautions .Staff will encourage resident to maintain a distance of 6 (six) feet from others . On 11/24/2020 at approximately 10:00 a.m., entrance to the facility was conducted and a meeting was held with ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing), and RN (registered nurse) #1, the infection preventionist. RN #1 stated the facility is laid out into four separate units. She stated Wings 1 and 3 currently had no COVID-19 positive residents. RN #1 stated Wing 2 had nine COVID-19 positive residents in the hot zone, and other residents who either had been exposed to COVID-19 or [MEDICAL CONDITION] status was unknown in the warm zone. She stated all residents on Wing 2 were on isolation requiring both contact (7) and droplet (8) precautions. RN #1 stated all residents on Wing 4 were also on contact and droplet precautions. She stated Wing 4 houses residents with dementia. RN #1 stated, We do what we can with the masks. We do distancing with dining. She stated the staff is trying to keep residents as separated as possible. RN #1 stated five or six residents had spiked a fever recently, and that one resident had been sent out to the hospital on [DATE]; this resident had tested positive for COVID-19. RN #1 stated one Wing 4 resident had been sent to the ER (emergency room ) the previous afternoon, had tested positive for COVID-19, had returned to the facility, and was now on Wing 4. She stated this was Resident #1. On 11/24/2020 at 11:05 a.m., Wing 4 was entered. Resident #1 was not in her room. The door to Resident #1's room was open to the hallway. On 11/24/2020 at 11:05 a.m., observation revealed CNA (certified nursing assistant) #1, who was wearing a mask, face shield, and gown, but was not wearing gloves, approached Resident #2. Resident #2, whose mask was down below her face, was seated in a row of chairs against a wall close to the nurse station. CNA #1 touched Resident #2's mask, and assisted her to tie the mask. CNA #1 sanitized her hands. On 11/24/2020 at 11:12 a.m., Resident #2 was observed with a wet cough and pulling down her mask. CNA #1 approached Resident #2 and again adjusted the resident's mask to a position over the resident's mouth and nose. CNA #1 did not assist Resident #2 to sanitize her hands. CNA #1 changed gloves and sanitized her hands. She did not change her gown. On 11/24/2020, at 11:14 a.m., observation revealed Resident #1 (COVID positive), not wearing a mask walking out of her room and down the hallway. Observation revealed Resident #1 was not socially distanced from CNA #1. CNA #1 did not redirect Resident #1 to put a mask on. CNA #1 redirected Resident #1 to go back to her room by putting her arm around the resident. At 11:15 a.m., CNA #1 exited Resident #1's room. She sanitized her hands, but did not change her gown. At 11:15 a.m., Resident #2 was observed with a wet cough, and was not wearing a mask. On 11/24/2020 from 11:11 a.m., to 11:14 a.m., Resident #3 was observed walking down the hallway. He was wearing a mask, and he stopped in the doorway of Resident #1's room. He did not enter the room. He continued down the hallway, stopping in doorways of other residents' rooms. Resident #3, who had continued to walk down the hallway, was observed touching a box of gloves on the supply cart. He put his bare hand down into the glove box, touching multiple gloves before leaving the cart. On 11/24/2020 at 11:16 a.m., Resident #1 came out of her room again and walked down the hallway. Resident #1 was not wearing a mask. CNA #1 took the resident's hand and led her back to her room, and was observed assisting Resident #1 to lie down in the bed. CNA #1 moved back and forth between both sides of Resident #1's bed, coming into close contact with Resident #1's bed linens. Observation revealed CNA #1 picking up Resident #1's blanket and folding it against her gown. CNA #1 exited Resident #1's room, changed gloves, and sanitized her hands, but did not change her gown. On 11/24/20 at 11:26 a.m., CNA #2 was observed walking down the hallway, holding Resident #3's hand. Observation revealed Resident #3 was wearing a mask. CNA #2 was wearing a gown and mask, but was not wearing gloves. CNA #2 led Resident #3 to within three feet of Resident #2, who was coughing, and was not wearing a mask. CNA #2 sanitized her hands. CNA #2 did not assist Resident #2 with putting on her mask or with sanitizing her hands. On 11/24/2020 at 11:29 a.m., Resident #1 (COVID 19 positive) left her room and walked through the day room (adjacent to the dining room). At this time, Resident #1 was not wearing a mask. Resident #1 was observed not socially distanced and came close to Resident #4, who was seated in the day room, not wearing a mask. On 11/24/2020 at 11:32 a.m., CNA #1 approached Resident #2 to speak to her. She did not encourage Resident #2 to put on her mask, and CNA #1 touched Resident #1's clothing with the same gown she was wearing when she came into close contact with Resident #1 (COVID-19 positive). Resident #2 talked with CNA #1 for a few moments; Resident #2 was not wearing her mask. Resident #2 approached Resident #1 in the day room, the two residents were observed talking, both without masks in place. At 11:34 a.m., CNAs #1 and #2 were observed standing nearby Resident #1 in the day room. Neither CNA encouraged Resident #1 to put on her mask or to return to her room. On 11/24/20 at 11:36 a.m., CNA #1 was observed cleaning off tables in the dining room in preparation for lunch. CNA #1 was still wearing the same gown that had come into direct contact with Resident #1 during care. Resident #2 was observed without a mask, wandering throughout the day room and dining room. No staff members redirected her. On 11/24/20, at 11:37 a.m., Resident #3 was observed without a mask walking down the hallway, stopping in each doorway to look in each room. He was observed coughing multiple times. On 11/24/2020 at 11:38 a.m., CNA #1 was observed in direct contact with Resident #2, who sat at a table in the dining room. Resident #2 was not wearing a mask and was coughing. On 11/24/20, at 11:43 a.m., Resident #1 sat down at a table in the dining room. Resident #1 was observed with a mask positioned below her nose. Resident #4 walked up to the table and sat down in a chair that was not socially distanced from Resident #1. Resident #4 was not wearing a mask and Resident #1's mask remained positioned below her nose. At 11:47 a.m., CNAs #1 and #2 were observed standing in the hallway near the dining room, talking. Neither CNA attempted to redirect Residents #1 or #4. At this time, Resident #3 walked by both CNAs as they stood in the hallway; he was not wearing a mask. Neither CNA redirected him. On 11/24/20, at 11:49 a.m., LPN (licensed practical nurse) #2, who was the charge nurse on Wing 4, was interviewed. She stated she did not usually work on Unit 4. She stated it is a challenge to work on this unit because it involves constant cleaning. She stated keeping them away from each other is so hard. When asked about changing PPE (personal protective equipment), LPN #2 stated, We only change gloves. We wear everything else all shift. We wear the same gown and mask. On 11/24/20, at 11:50 a.m., Resident #3 stood outside of another resident's room. He sneezed, wiped his nose with his bare hand, and then went down the hallway touching the handrail with his dirty hand. No staff member attempted to redirect him or were observed attempting to help him wash his hands. Observation revealed CNA #2 looking directly at Resident #3 while he wiped his nose with his hand. On 11/24/20, at 11:51 a.m., LPN #2 walked over to the dining room to observe residents. She stood adjacent to the table where Residents #1 (COVID-19 positive) and #4 (COVID -19 negative) were seated at the same table not socially distanced from each other. Resident #4 did not have a mask on and Resident #1's mask was positioned below her nose. LPN #2 did not attempt to redirect either resident to apply masks or socially distance 6 feet from each other. At 11:54 a.m., observation revealed CNA #2 cleaning up water that Resident #1 had spilled. CNA #2 touched the rim of Resident #1's water cup with her gloved hands. She replaced the water cup where Resident #1 was sitting at the table. CNA #2 then without removing gloves or washing her hands, continued to serve lunch plates and beverages to other residents. Neither CNA #2 nor CNA #1 changed gloves or washed hands between residents as they served lunch plates. On 11/24/2020 at 11:57 a.m., Resident #4, without a mask, was still sitting at the table with Resident #1. Both residents were seated in chairs that were not socially distanced from each other. Resident #1's mask was below her nose. Resident #4 wiped her nose, and continued talking with Resident #1. LPN #2, who was observing both residents, did not intervene or redirect the residents. On 11/24/20, at 12:20 p.m., LPN #3, who was the charge nurse on Wing 2, was interviewed. LPN #3 was asked about the PPE staff should wear when caring for residents who have tested positive for COVID-19. LPN #3 stated staff should wear full PPE, which included gown, gloves, mask, and, if possible, a face shield. When asked if staff should remove PPE after caring for a resident who is positive for COVID-19, LPN #3 stated, You definitely should change gloves and wash your hands. Change gowns if you have enough. She stated that if PPE is not plentiful, each resident should have one gown hung on a hook in his/her room, and that this gown should be worn by all staff, but only when caring for that particular resident. On 11/24/2020 at 12:36 p.m., CNA #3, who was working on Wing 2, was interviewed. When asked what PPE should be worn when caring for a resident who is positive for COVID-19, she stated the staff member should wear gown, gloves, goggles, and mask. CNA #3 stated the staff member should take off the gloves and gown when they leave the room, and wash hands. When asked if the same gown should be used when caring for more than one resident, CNA #3 stated, Only if both of those residents are COVID-19 positive or COVID-19 negative. She stated if the staff member is going between hot zones (all residents are COVID-19) positive and warm zones (residents who have been exposed to COVID-19 or [MEDICAL CONDITION] status is unknown), the staff member has to change gowns between every resident. On 11/24/2020 at 12:45 p.m., a meeting was conducted with ASM #1 (the administrator) and ASM #2, (the director of nursing). ASM #2 was asked to clarify what isolation precautions the residents in Wing 4 were currently on. ASM #2 stated they were on droplet and contact precautions. She reiterated that Resident #1 tested positive on the evening of 11/23/2020 at the ER (emergency room ). ASM #2 stated, She (Resident #1) came back here and we are still getting our ducks in a row down there (Wing 4 dementia unit). Some residents are running fevers. She stated that it is impossible to get the residents with dementia to wear masks or to stay in their rooms. ASM #2 stated, It is constant redirection and supervision. When asked what PPE should be worn by staff if they are caring for a resident who is COVID-19 positive. She stated the staff member should wear gown, gloves, face shield and a mask. When asked if staff members should change PPE when leaving a COVID-19 positive resident to care for a resident who is COVID-19 negative, or [MEDICAL CONDITION] status is unknown. ASM #2 stated the gowns should ideally be used only once. She stated the facility is doing pretty well with PPE supplies, and that the facility has been able to stockpile supplies over the last months when there has been no COVID-19 in the building. She added that residents in the hot zone on Wing 2 have a hook in their rooms, and that staff alternate wearing the one gown that is designated for those residents, changing gowns and gloves, and washing hands between residents. A review of the facility policy, Clinical Guidelines: Policy for Transmission (Based Precautions with Infection, revealed, in part: Transmission-based precautions will be implemented for any resident with an infection. The use of transmission-based precautions is a two-step process. Standard precautions are used for all residents; transmission-based precautions are added based on the route of transmission of the disease. Staff will refer to the CDC (Centers for Disease Control) Guidelines for Isolation Precautions: Prevention (sic) Transmission of Infectious Agents in Healthcare Settings to determine if transmission based precautions are required and the type and duration of the precautions .Per CDC guidelines, in the event of an undiagnosed respiratory infection, Standard, Contact, and Droplet Precautions with eye protection are recommended unless the suspected [DIAGNOSES REDACTED].For recommended Transmission-based precautions for resident with suspected or confirmed COVID-19, refer to (name of facility) COVID-19 Policy and the CDC site: https://www.cdc.gov/coronavirus/2019-ncov/infection-control-recommendations.html. (See references 9 and 10). A review of the facility policy, Infectious Disease (COVID-19) Preparedness and Response Plan revealed no information specific to staff and resident PPE usage and social distancing to prevent the spread of COVID-19. A review of the facility policy, COVID-19 (Coronavirus) Updated 7/17/2020, revealed, in part: Resident (sic) that are readmitted / admitted from a hospital stay will have a 14 day Quarantine to Wing 2 in the facility with isolation precautions provided. Resident (sic) that are admitted with previous positive Covid 19 [DIAGNOSES REDACTED]. Resident that is returning from ED (emergency department) will return to Wing 2 isolation area for 3 days. A review of the facility policy, Pandemic Policy: Managing Food Delivery, revealed, in part: Additional precautions are needed to prevent transmission of infections in healthcare settings. Staff interactions with resident needs clear guidelines to keep this vulnerable population safe as well as preventing staff from contracting and spreading [MEDICAL CONDITION] .Residents will receive hot meals in a timely manner. Staff will minimize transmission of infections during the dining service and delivery/pick up of meal trays. The CMS (Centers for Medicare and Medicaid Services) QSO-20-14-NH DATE: March 13, 2020 documents, in part, Guidance-Facility staff should regularly monitor the CDC website for information and resources . The CMS (Centers for Medicare and Medicaid Services) QSO-20-20-All March 23, 2020 documents, in part: On Friday, March 13, 2020, the President declared a national emergency, which triggers the Secretary's ability to authorize waivers or modifications of certain requirements pursuant to section 1135 of the Social Security Act (the Act). Under section 1135(b)(5) of the Act. https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page The CMS (Centers for Medicare and Medicaid Services) QSO 20-39-NH (Nursing Home) Date: September 17, 2020, documents in part: Background: Nursing homes have been severely impacted by COVID-19, with outbreaks causing high rates of infection, morbidity, and mortality.(1) The vulnerable nature of the nursing home population combined with the inherent risks of congregate living in a healthcare setting have required aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes. Additional Strategies Depending on the Facility's Reopening Status These strategies will depend on the stages described in the CMS Reopening Guidance . Guidance: . Core Principles of COVID-19 Infection Prevention o Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms o Hand hygiene (use of alcohol-based hand rub is preferred) o Face covering or mask (covering mouth and nose) o Social distancing at least six feet between persons o Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene) o Cleaning and disinfecting high frequency touched surfaces in the facility often, and designated visitation areas after each visit o Appropriate staff use of Personal Protective Equipment (PPE) o Effective cohorting of residents (e.g., separate areas dedicated COVID-19 care) o Resident and staff testing conducted as required at 42 CFR 483.80(h) (see QSO-20-38-NH) These core principles are consistent with the Centers for Disease Control and Prevention (CDC) guidance for nursing homes, and should be adhered to at all times. Communal Activities and Dining: While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur. Residents may eat in the same room with social distancing (e.g., limited number of people at each table and with at least six feet between each person). Facilities should consider additional limitations based on status of COVID-19 infections in the facility. Additionally, group activities may also be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, or with suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a face covering. 1 Information on outbreaks and deaths in nursing homes may be found at https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg. The CDC (Center for Disease control) Preparing for COVID-19 in Nursing Homes Updated Nov. 20, 2020, documents in part: Additional Strategies Depending on the Facility's Reopening Status. These strategies will depend on the stages described in the CMS Reopening Guidance. Source Control: Use of a cloth face covering or facemask to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Implement Universal Source Control Measures. If extended use of gowns is implemented as part of crisis strategies, the same gown should not be worn when caring for different residents unless it is for the care of residents with confirmed COVID-19 who are cohorted in the same area of the facility and these residents are not known to have any co-infections (e.g., Clostridioides difficile) .Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of [DIAGNOSES REDACTED]-CoV-2 testing. They should not be placed in a room with a new admission nor should they be moved to the COVID-19 care unit unless they are confirmed to have COVID-19 by testing. While awaiting results of testing, HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Cloth face coverings are not considered PPE and should only be worn by HCP (Healthcare Personnel) for source control, not when PPE is indicated. Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them) .Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. Cloth face coverings are not considered PPE and should not be worn when PPE is indicated .Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility; this could also be considered when there is sustained transmission in the community. The health department can assist with decisions about testing of asymptomatic residents. Implement Social Distancing Measures: Implement aggressive social distancing measures (remaining at least 6 feet apart from others): Cancel communal dining and group activities, such as internal and external activities. Remind residents to practice social distancing, wear a cloth face covering (if tolerated), and perform hand hygiene. Considerations when restrictions are being relaxed include: Allowing communal dining and group activities for residents without COVID-19, including those who have fully recovered while maintaining social distancing, source control measures, and limiting the numbers of residents who participate. This information is taken from the website referenced in the facility policy https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. On 11/24/2020 at 1:45 p.m., after the onsite visit was completed, the long term care supervisor was notified of the surveyor's observations. A conference call was conducted with the supervisor, and one other long term care supervisor. On 11/24/2020 at 2:41 p.m., it was determined that the facility's failure to implement infection control practices to prevent the spread of a communicable disease (COVID-19) resulted in a situation of IJ (immediate jeopardy). Two unsuccessful attempts were made by phone to contact and collaborate with the local health department. On 11/24/2020 at 3:14 p.m., the administrator was informed of the concern for IJ. Provider/Supplier IJ Abatement plan 1. On 11/23/20 Resident #1 went to acute care hospital for elevated temp at approximately 1730. Resident returned to facility at approximately 0130 on 11/24/20 and was assigned to Wing 2 room [ROOM NUMBER] the hospital reported she was COVID 19 positive. She remained there until 0900 am on 11/24/20 when DON and infection control nurse, following CDC guidelines as we understood them, moved her back to the Dementia unit on Wing 4 and decided to reevaluate following morning meeting. Approximately 1000 State Surveyor entered the building. In the afternoon of 11/24/20 we tested Wing 4. In addition, these residents tested positive on this round of testing. POC (plan of correction) Resident #1 POC Resident #2 POC Resident #3 POC Resident #4 Survey Sample Resident #9 POC Resident #6 POC Resid (TRUNCATED)

Based on staff interview, facility policy review, clinical record review, review of hospital records and in the course of a complaint investigation the facility staff failed to ensure that a Resident was free from a significant medication error for one of five Residents in the survey sample, Resident # 1. On November 6, 2013, Resident # 1 was administered 100 mg (milligrams) of *[MEDICATION NAME] instead of 10 milligrams on two occasions, 911 was called **[MEDICATION NAME] (an opioid antagonist) was administered and Resident # 1 was taken to local hospital and admitted . *[MEDICATION NAME] is a "narcotic [MEDICATION NAME] used to treat moderate to severe pain". "Use care when prescribing and/or administering [MEDICATION NAME] solutions. These products are available in different concentrations". "Warnings/precautions May cause respiratory depression, use with caution in patients (particularly elderly or debilitated)...". "Symptoms of overdose include respiratory depression, [MEDICAL CONDITION] and [MEDICAL CONDITION]". ** [MEDICATION NAME]? ([MEDICATION NAME] Injection, USP) Opioid Antagonist. [MEDICATION NAME] is used to prevent or reverse the effects of opiate (narcotic) overdose, including difficulty breathing, sleepiness, low blood pressure, and death. The findings include: Resident # 1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident # 1's most recent MDS (minimum data set), a 5-day assessment, with an ARD (assessment reference date) of 10/28/13 coded the Resident as being rarely/never understood. The resident had short-term and long-term memory deficits and was severely impaired cognitively. During the entrance conference on 12/2/13 at 12:55 p.m. a request was made for any facility reported incidents (FRI). A copy of the investigation (FRI) was received on 12/3/13 at approximately 9:00 a.m. from ASM (administrative staff member) # 1, the Administrator. This incident was reported to the state agency on 11/7/13 and the facility returned the five day follow up on 11/11/13. The follow up signed by ASM # 2, the director of nurses, is as follows: "(Name of Resident) returned to (name of facility) on comfort care. She had started to decline on the morning of November 6 with oxygen needing to be applied. The evening of November 6, the nurse administered 5 mls (milliliter) of [MEDICATION NAME] concentrate per the MD order with respirations of 51. Approximately 20 minutes later another 5 mls were administered with respirations of 47. Both times the exact amount of [MEDICATION NAME] consumed was unable to be determined due to the resident letting the liquid run out of her mouth. After administering the [MEDICATION NAME], the nurse realized that the incorrect amount of medication had been given. The MD examined the resident and 911 was called. The resident never loss (sic) consciousness. At the time of departure, the resident was conscious and her respirations were in the 20's. (Name of Resident) was admitted to the hospital with [REDACTED]." Review of the physician order sheet revealed a physician order dated 10/31/13 for: [MEDICATION NAME] 10mg (milligrams)/5 ml (milliliters) Oral Soln (solution), give 5 milliliters (10 mg) by oral route as needed every 15 minutes as needed (PRN). This order was signed electronically by the physician (ASM # 4, the medical director) on 10/31/13 at 11:09 p.m. Review of the E-MAR (electronic MAR - medication administration record) revealed that the medication ([MEDICATION NAME]) was entered on the E-MAR as follows: "[MEDICATION NAME] 10mg/5ml Oral Soln SIG "give 5 milliliters (10mg) by oral route as needed every 15 minutes as needed Start Date: 10/31/2013 06:47 pm" Review of the bottle label revealed the name of Resident # 1 and the following information: "[MEDICATION NAME] SUL 100MG/5ML (20MG/ML) SOL, TAKE 10 MG (0.5ML) UNDER THE TONGUE EVERY 15 MINUTES" Review of the nurses' notes dated 11/6/13 at 9:32 p.m. revealed: "Assessed resident to find elevated respirations at 51 per minute. Elevated HOB (head of bed) above 45 degrees and administered PRN [MEDICATION NAME] at 1725 (5:25 p.m.). Reassessed resident approximately 20 mins (minutes) later to find respirations were still elevated at 47 per minutes and at 1745 (5:45 p.m.) a second dose of PRN [MEDICATION NAME] was administered. Dr was notified of residents decline and ordered for 911 to be called for transport to the ER (emergency room ). Hospital ER report given POA (power of attorney) notified via voice mail." This note was signed by LPN (licensed practical nurse) # 1. Review of the facility investigation of this incident revealed the written statement of LPN # 1. This statement was reviewed with LPN # 1 during an interview on 12/3/13 at 3:45 p.m. LPN # 1 stated that his statement is accurate and it is recounted below: "At approximately 1715 I was informed by the CNA (CNA # 1 - designation made by LPN # 1) that the resident in room (room #) had respirations of 48 per minute. I immediately entered the residents (sic) room with CNA # 1 and another CNA on duty (CNA # 2 - designation made by LPN # 1). CNA # 2 counted the residents respirations at 53 per minute and I counted 51 per minute. Upon completion of monitoring the residents (sic) respirations I informed the wing 2 unit manager. She informed me to give the resident a dose of her PRN [MEDICATION NAME]. In the computer it read: [MEDICATION NAME] 10mg/5ML oral soln, give 5 ml (10 mg) by oral route as needed every 15 minutes as needed. I verbalized to the resident that I was about to administer some [MEDICATION NAME] since her respirations were high and this would also aid in any pain she may be feeling as she has not been able to verbalize any pain. I then began to administer the 5ML of [MEDICATION NAME] after I elevated her bed above 45 degrees. The resident was slowly attempting to accept the medication but most of the solution was spit up after her attempts to swallow seemed to be difficult. After completion of the medication I again counted the residents respirations and they were at 49 per minute. After approximately 20 minutes I re-evaluated the residents (sic) respirations and they were still at 47 per minute. At approximately 1745 I administered a second dose of 5ML of [MEDICATION NAME]. During the second administration the resident still struggled with swallowing and approximately half of the solution was spit up as the resident attempted to swallow. After completion of the administration of the [MEDICATION NAME] I noticed that it was odd there was only enough [MEDICATION NAME] for two administrations. After I reviewed the computer orders and the dosage on the bottle for the 7th time I realized the bottle was a different dosage then (sic) the computer order. The bottle read: [MEDICATION NAME] 100mg/5ml give 10mg 0.5ml. At this time I immediately informed the wing 2 unit manager and we both entered the residents (sic) room to check her respiration status. The resident had a respiration rate of 31 per minute. At this time the wing 2 manager went to inform the Director of Nursing of the situation along with the Medical Director who was on location at the time. The medical director soon entered the resident's room with the wing 2 unit manager and had me take the residents vitals and the (sic) were as follows: B/P 90/64, Respirations: 28, Pulse: 68, and SPO2: fluctuated between 76% and 82%. At approximately 1820 the rescue squad arrived on scene." During an interview on 12/3/13 at 2:30 p.m. with ASM # 4, the medical director, this incident was reviewed along with ASM # 4's progress note as noted below: Review of the physician note written and signed by ASM # 4, the medical director, dated 11/7/13 at 3:34 p.m.: "11-6-13: Came to bedside urgently when notified by DON (director of nurses - ASM # 2) of Pt's (Resident # 1) narcotic toxicity @ 6pm, 11-6-13. Pt. was inadvertently given wrong [MEDICATION NAME] dose @ 5pm & 5:45pm by floor nurse who quickly realized the error & reported it to the DON who then immediately reported it to me. [MEDICATION NAME] was given due to sever tachypnea to rate of 50 according to nurse. Pt. is on [MEDICATION NAME] q 15 min. PRN as per hospital MD since her recent hospitalization @ which she was placed on palliative care for terminal dementia w/obtundation. Hospital MD took Pt. off all previous elective meds. & placed her on liquid [MEDICATION NAME] & [MEDICATION NAME] (anti-anxiety medication). [MEDICATION NAME] has also been used for chronic pain control due to recent L. [MEDICAL CONDITION] due to fall requiring ORIF. At current exam. Pt. is @ RR 40 w/ Kussmaul respirations (deep rapid respirations) & O2 sat. (***oxygen saturation measure of how much oxygen the blood is carrying) of 80-83% on 3 liters. BP is 80/palp. (palpated) HR (heart rate) 90. Temp OK. Pt is non-responsive w/ somewhat narrowed pupils; non-reactive. No cerebral posturing. No carotid bruit or JVD (Jugular Vein Distention). Lungs clear bilat. Cor (coronary) w/o gallop or murmur. No clubbing, cyanosis, or [MEDICAL CONDITION]. Pulses intact. Facts show that 100mg [MEDICATION NAME] was given SL on 2 separated occasions 30 mins. apart 911 called immediately upon my assessment & they arrived w/I 5 mins. & administered 3 separate doses of [MEDICATION NAME] @ my order stat. Pt. was bag ventilated & given IV rehydration. She improved somewhat as evidenced by responsiveness & moving. Remained hemodynamically unstable but O2 & bp improved & RR came down to normal @ 22. Pt. was taken to (name of hospital) & subsequently treated in ER & then admitted to hospital unit. Report from hospital in am (morning) of 11-7-13: VSS & O2 OK. Pt. has been on rehydration & given several more doses of [MEDICATION NAME] @ hospital." HOSPITAL RECORD: Review of the emergency room Record (er) from the local hospital revealed the following under NURSING CHART: Current Visit: "Arrival time 11/06/13 18:55 (6:55 p.m.). Triage time: 11/06/13 18:59 (6:59 pm.). Assessment time: 11/06/13 18:48 (6:48 p.m.) ... Notes: ems (emergency medical service) called to nursing home for [MEDICATION NAME] overdose pt apparently given 200 mg of [MEDICATION NAME] within one hours ems found patient with resp rate of 6/min and began assisting ventilation iv was established and [MEDICATION NAME] 1.6 mg given iv with increased (sic)of resp (respirations) rate pt arrives to ER unresponsive with audible congestion." "Initial Vitals at Presentation: 11/06/13 19:00 (7:00 p.m.) ...BP " 153/76 ... P: 103 ...R: 32 ...O2 Sat: 88% on 15 L/min via NRB (non-rebreather) mask Note: pt unresponsive." Prehospital: "Prehospital interventions included the initiation of an IV ... and oxygen at 15 L/m via non-rebreather mask ... Prehospital medications given: [MEDICATION NAME] 0.4 MG/ML SOLN FOR INH Note: 1.6 mg iv." Triage Assessment: "Timing: The time of ingestion was unknown. Pt was given 200 mg of [MEDICATION NAME] over one hour per nursing home record pt. ordered 10mg/5ml q 15 min prn. The ingestion has occurred over a period of 1 hour(s). Severity: The severity of the symptoms was severe." Hospital Discharge Summary: "Hospital Course: The patient was admitted and in spite of getting several doses of p.r.n. [MEDICATION NAME] seemed to have significant effects of [MEDICAL CONDITION] and decreased respiratory rate. This respiratory suppression was thought to be because of [MEDICATION NAME]. The patient ' s symptoms seemed to last longer than one would expect, but this was likely due to the fact that she had been given an oral dose and was likely still absorbing from her GI tract. She also had [MEDICAL CONDITION] and as that was acute on admission and as a result, probably could not excrete her [MEDICATION NAME] as effectively. The patient was given multiple doses of [MEDICATION NAME] and then I decided to put her on some scheduled [MEDICATION NAME]. This was to try to counteract the patient's circulating as well as absorbing [MEDICATION NAME] and it did appear that seemed to help with the patient's blood pressure and respiratory rate to some extent." During an interview on 12/3/13 at 4:18 p.m. with ASM # 1 and ASM # 2 in the presence of two medical facilities inspectors this incident was discussed and the possibility of a finding of harm was related. At this time a request for facility policies on medication administration was made. Review of the facility policy General Dose Preparation and Medication Administration" revealed under "Procedure 4.1 Facility staff should: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, ..." During another interview on 12/4/13 at 9:50 a.m. with ASM # 1 and ASM # 2 this concern was again discussed with the possibility of harm and another request for any documentation that they wanted to present was made. According to "Fundamentals of Nursing", Seventh Edition, 2009: by Perry and Potter Chapter 35 "Medication Administration" Chapter 35, pg 707 read: " Professional standards, such as the American Nurses Association's Nursing: Scope and Standards of Nursing Practice (2004), apply to the activity of medication administration. To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication, 2. The right dose, 3. The right client, 4. The right route, 5. The right time, and 6. The right documentation. " Prior to exit no further information was provided. Reference F 281 & F 425 COMPLAINT DEFICIENCY *Lexi-Comp's Drug Information Handbook for Nursing, 2007. ** This information was obtained from the website:http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 2.html