Every finding on record at Fair Park Health & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure that the residents' environment remained free of hazards as was possible for three of eight residents (Residents # 6, #38, #45) and two direct care staff (LVN A and WCN E) reviewed for accident hazard. 1.The facility failed to ensure there was no razor inside Resident #6's room on 07/08/2026. 2.The facility failed to ensure there was no cleaner disinfectant inside Resident #45's room on 07/08/2026. 3.The facility failed to ensure WCN E did not leave her scissors, unattended, inside Resident #38's room on 07/09/2026. 4.The facility failed to ensure there was no germicidal wipes on top of a cart parked in the hallway, unattended, on 07/08/2026. 5.The facility failed to ensure a container of germicidal wipes was not left at the nurse station unattended on 07/09/2026. These failures could place residents at risk of injuries and exposure to toxic chemicals.Findings included: 1.Record review of Resident #6's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old female admitted [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #6's Comprehensive MDS Assessment, dated 05/21/2026, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident required substantial assistance for personal hygiene. Record review of Resident #6's Comprehensive Care Plan, dated 05/28/2026, reflected the resident had an ADL self-care performance deficit and one of the interventions was to assist with personal hygiene as required: e.g. shaving. During an observation and interview on 07/08/2026 at 9:39 a.m. revealed Resident #6 was in her bed, awake. It was observed that an uncovered razor was at the resident's sink. The resident said she did not know who left the razor in her room but the staff would use it to shave the hairs on her chin. 2.Record review of Resident #45's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male, admitted [DATE]. The resident was diagnosed with depression and delusion (brain disorder of an individual who has delusional thoughts). Record review of Resident #45's Comprehensive MDS Assessment, dated 05/22/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was diagnosed with depression and delusion. Record review of Resident #45's Comprehensive Care Plan, dated 06/28/2026, reflected the resident had delirium and one of the interventions was to monitor new onset of signs and symptoms of delirium. During an observation and interview on 07/08/2026 at 9:33 a.m. revealed Resident #45 was in his bed, awake. It was observed that a container of liquid disinfectant (chemical substance used to kill microorganisms) was on top of the resident's side table, in a tray along with the resident's mouthwash. The resident said the solution was used to clean his room and was left by a staff member. He said he could not remember who left the solution inside his room. During an observation and interview on 07/08/2026 at 9:59 a.m., LVN B said there should be no sharp objects or disinfecting solutions inside the rooms of the residents. She went inside Resident #6's room, saw the razor in the resident's sink, and said it should not be left where residents could get it because they might use it to cut themselves. She took the razor and said she would remind the aides not to leave the razors after they were done using it. She then went to Resident #45's room and saw the disinfecting solution on top of the resident's side table. She took the container of solution and said it should not be inside the room because confused residents might consume it. She said the solution had harmful chemicals and had a warning on the back of the container that said, Keep out of reach of children. During an interview on 07/08/2026 at 11:29 a.m., HK F said housekeeping used the disinfecting solution to clean the residents' rooms. She said the solution should not be inside the rooms of the residents because it had chemicals in it that could cause irritation to the skin. She said it would be harmful for the residents if they accidentally drank it. 3.Record review of Resident #38's Face Sheet, dated 07/09/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with cellulitis (bacterial infection of the skin and the tissues beneath it). Record review of Resident #38's Comprehensive MDS Assessment, dated 06/05/2026, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident had arterial ulcers present (wound caused by poor blood circulation). Record review of Resident #38's Comprehensive Care Plan, dated 04/23/2026, reflected the resident had a non-pressure ulcer to the scalp and a venous ulcer to the right leg and the intervention for both was to treat wound as ordered. Record review of Resident #38's Physician Order, dated 06/03/2026, reflected, WOUND: Cleanse scalp with normal saline/wound cleanser, pat dry with 4 x 4 gauze, apply mupirocin ointment, and cover with dry dressing daily and PRN, if soiled or dislodgment, as needed for wound care. Record review of Resident #38's Physician Order, dated 06/24/2026, reflected, WOUND CARE: Cleanse skin tear to right medial ankle with normal saline/wound cleanser, pat dry with 4 x 4 gauze, apply Mupirocin . to open areas and wrap with a kerlix daily and PRN if soiled or dislodged. one time a day for WOUND CARE. During an observation on 07/09/2026 at 8:31 a.m., WCN E was about to clean Resident #38's wounds to his scalp and right leg. She prepared the things needed for wound care, including scissors, and placed them on top of the resident's overbed table. When she was about to start her wound care, another staff member called her for assistance. She left Resident #38's room and assisted the other staff member. She left her scissors on top of the overbed table and within reach of the resident. During an interview on 07/09/2026 at 8:47 a.m., WCN E said she should have taken the scissors when she stepped out of the room or told the other staff to call someone else for assistance because the resident might take the scissors and use them to harm himself. 4.During an observation on 07/08/2026 at 9:26 a.m. revealed a container of germicidal wipes (substance that destroys germs and microorganism) was left on top of a cart, unattended. The lid of the container was open, and a portion of a germicidal wipe was peeping out of the lid. It was observed that several residents were passing the cart. 5.During an observation on 07/09/2026 at 6:38 a.m., LVN A was sitting at the nurses' station. He stood up and left the station leaving a container of germicidal wipes at the edge of the nurses' station, unattended and was within reach of the residents passing the station. On the back of the container was a warning that said, Keep out of reach of children. During an interview on 07/09/2026 at 12:06 p.m., LVN A said the germicidal wipes were used to sanitize the tables, the carts, and the bp cuff. She said the container should be inside the drawers of the cart and not within reach of the residents because they might use it in their face or private area and cause irritations. He said he did not know who left the germicidal wipes on top of the cart. He took the germicidal wipes from the nurses' station and put them inside a cart. During an interview on 07/10/2026 at 9:26 a.m., the ADON said the container of disinfecting wipes, closed or opened, should have been placed inside the cart when staff were leaving their cart unattended. She said residents could get them and use them on their face and body. She said the wipes could cause irritation, that was why the staff used gloves when using them. She said the disinfecting wipes should not be left at the edge of the nurses' station for the same reason. She said the disinfecting solution should not be left in the rooms of the residents because they might mistakenly drink the solution, which had hazardous chemicals in it. She said the razor and the scissors should not be left inside the residents' rooms because they could use it to harm themselves. She said the expectation was for the staff not to leave the germicidal wipes, the razor, and the scissors within reach of the residents. She said would coordinate with the DON regarding the germicidal wipes, razors, and scissors. During an interview on 07/10/2026 at 9:47 a.m., the DON said the germicidal wipes, the disinfecting solution, the razor, and the scissors should not be left unattended because the residents might get them. She said the residents might use the wipes to clean their faces or their private parts and might drink the disinfecting solution. She said the residents might get hold of the razor and scissors and use them to harm themselves. She said the expectation was for all the staff to not leave the germicidal wipes and sharps objects, unattended. She said she would start an in-service about the issues as soon as the interview was over. During an interview on 07/10/2026 at 10:12 a.m., the Administrator said the germicidal wipes, the disinfecting solution, the razor, and the scissors could all cause harm to the residents if used inappropriately. She said the expectation was for the staff to store the germicidal wipes accordingly before walking away from their carts and before leaving the nurses' station to ensure that the residents would not be able to get any wipes. She said another expectation was for the solution; the razor, and the scissors would not be left inside the rooms of the residents because they could also harm the residents if used improperly. She said she would collaborate with the DON about the issue. She said they would in-service the staff about storage of disinfectants and sharp objects and would monitor them closely if the staff understood the in-service. Record review of the facility policy, Medication Storage in the Facility, revised March 2025, reflected, Policy: Medications and biologicals are stored safely, securely, and properly . 8. Potentially harmful substances (e.g. urine test reagent tablets, household poisons, cleaning supplies, and disinfectants) are clearly identified and stored in a locked area. During an interview on 07/10/2026 at 11:05 a.m. via e-mail, the policy about storage of sharp objects was requested from the Administrator. The Administrator said the facility did not have a policy for storage of sharp objects.

Based on observation, interview, and record review, the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for five of eighteen residents (Residents #8, #15, #38, #45, and #47) reviewed for medication storage. 1.The facility failed to ensure that there was no medication for hemorrhoids inside Resident #8's room on 07/08/2026. 2.The facility failed to ensure that there was no laxative solution inside Resident #15's room on 07/08/2026. 3.The facility failed to ensure that there was no nasal spray inside Resident #47's room on 07/08/2026. 4.The facility failed to ensure that there were no eye drops, calcium alginate powder, and wound cleanser inside Resident #45's room on 07/08/2026. 5.The facility failed to ensure WCN E did not leave a cup of topical antibiotic on top of Resident #38's overbed table on 07/09/2026. These failures could place the residents at risk of misuse of medications and possible adverse reactions.Findings included: 1.Record review of Resident #8's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male admitted [DATE]. The resident was diagnosed with a psychotic disorder with delusion (mental health condition with loss of contact to reality, hallucinations, and delusions). Record review of Resident #8's Comprehensive MDS Assessment, dated 04/06/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had a psychotic disorder with delusion. Record review of Resident #8's Comprehensive Care Plan, dated 05/13/2026, reflected the resident required anti-psychotic medications and the intervention for both was to monitor for constipation (problem with passing stool). Record review on 07/08/2026 of Resident #8' list of Physician Orders, reflected the resident did not have an order for hemorrhoids (swollen veins in the anus) medication. Record review on 07/08/2026 of Resident #8's Clinical Assessment List, reflected the resident did not have an assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation on 07/08/2026 at 9:17 a.m., revealed the resident was not inside his room. It was observed that a tube of ointment used for hemorrhoids was on top of the resident's side table and was in plain view. 2.Record review of Resident #15's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male admitted [DATE]. The resident was diagnosed with cognitive impairment and depression. Record review of Resident #15's Comprehensive MDS Assessment, dated 06/02/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had cognitive impairment (decline in mental abilities) and depression. Record review of Resident #15's Comprehensive Care Plan, dated 05/28/2026, reflected the resident required antidepressant and one of the interventions was to administer medications as ordered. Record review on 07/08/2026 of Resident #15' Physician Orders reflected that the resident did not have an order for laxative (substance that loosens the bowels) solution. Record review on 07/08/2026 of Resident #15's Clinical Assessment List, reflected that the resident did not have an assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 07/08/2026 at 9:23 a.m. revealed Resident #15 was sitting in his wheelchair. It was observed that a bottle of laxative was inside the resident's opened drawer. When asked who left the laxative solution, the resident shrugged his shoulder. The laxative solution was in plain view and was within reach. 3.Record review of Resident #47's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with acute upper respiratory infection. Record review of Resident #47's Comprehensive MDS Assessment, dated 06/12/2026, reflected that the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident had acute upper respiratory infection. Record review of Resident #47's Comprehensive Care Plan, dated 06/22/2026, reflected the resident did not have a care plan for acute upper respiratory infection, chronic cough, or SOB. Record review on 07/08/2026 of Resident #47' Physician Orders reflected the resident did not have an order for nasal spray. Record review on 07/08/2026 of Resident #47's Clinical Assessment List, reflected that the resident did not have an assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 07/08/2026 at 9:18 a.m., Resident #47 was sitting in her wheelchair. It was observed that a nasal spray was on top of her side table. The resident said it was her nasal spray, and she would use it sometimes. The nasal spray was in plain view and was within reach. During an observation and interview on 07/08/20206 at 9:56 a.m., LVN A said medications were not supposed to be inside the room of the residents because first, the staff should be the ones administering the medications; second, the staff would not be able to monitor how frequent and how much the residents were administering the medications that could eventually lead to overdosing or underdosing; third, the staff would not know if the medications were needed; fourth, the staff would not know if the resident was allergic to the medications,; and lastly, other residents might get the medications and use them inappropriately. He went inside the rooms of Residents #8, #15, and #47, and removed them. She said she was not aware that there were medications inside the rooms of the residents. 4.Record review of Resident #45's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male admitted [DATE]. The resident was diagnosed with depression and delusion. Record review of Resident #45's Comprehensive MDS Assessment, dated 05/22/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident had depression and delusion. Record review of Resident #45's Comprehensive Care Plan, dated 06/28/2026, reflected that the resident had a non-pressure ulcer to the scalp and a venous ulcer to the right leg and the intervention for both was to treat wounds as ordered. Record review of Resident #45's Physician Order, dated 06/03/2026, reflected, WOUND: Cleanse scalp with normal saline/wound cleanser, pat dry with 4x4 gauze, apply mupirocin ointment, and cover with dry dressing daily and PRN if soiled or dislodgment as needed for wound care. Record review on 07/08/2026 of Resident #45's Clinical Assessment List, reflected that the resident did not have an assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 07/08/2026 at 9:33 a.m., Resident #45 was in his bed, awake. It was observed that containers of wound cleanser and collagen powder were on top of the resident's side table, in a tray along with the resident's mouthwash. The resident said the wound cleanser and the powder were used for his wounds. He said he did not know who left the wound cleanser and powder on his table. During an observation and interview on 07/08/2026 at 9:56 a.m., LVN B said she was not aware there were wound cleaning materials inside Resident #45's room and she did not know who left them. She said those should be inside the treatment cart. She said confused residents might get them and use them inappropriately. She took the containers of wound cleanser and collagen powder and said she would place them inside the treatment cart. 5.Record review of Resident #38's Face Sheet, dated 07/09/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with cellulitis. Record review of Resident #38's Comprehensive MDS Assessment, dated 06/05/2026, reflected that the resident had a moderate impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated that the resident had venous and arterial ulcers present. Record review of Resident #38's Comprehensive Care Plan, dated 04/23/2026, reflected that the resident had a non-pressure ulcer to the scalp and a venous ulcer to the right leg and the intervention for both was to treat wounds as ordered. Record review of Resident #38's Physician Order, dated 06/03/2026, reflected, WOUND: Cleanse scalp with normal saline/wound cleanser, pat dry with 4 x 4 gauze, apply mupirocin ointment (antibiotic used to treat skin infection), and cover with dry dressing daily and PRN if soiled or dislodgment as needed for wound care. Record review of Resident #38's Physician Order, dated 06/24/2026, reflected, WOUND CARE: Cleanse skin tear to right medial ankle with normal saline/wound cleanser, pat dry with 4 x 4 gauze, apply Mupirocin and adaptic (an absorbent dressing) to open areas and wrap with a kerlix daily and PRN if soiled or dislodged one time a day for WOUND CARE. During an observation on 07/09/2026 at 8:31 a.m., WCN E was about to clean Resident #38's wounds to his scalp and right leg. She prepared the things needed for wound care, including the antibiotic ointment, and placed them on top of the resident's overbed table. When she was about to start her wound care, another staff member called her for assistance. She left Resident #38's room and assisted the other staff member. She left her antibiotic ointment, along with the other wound care supplies, on top of the overbed table and within reach of the resident. During an interview on 07/09/2026 at 8:47 a.m., WCN E said she should have told the other staff to call someone else for assistance because she already prepared everything needed for wound care. She said the ointment was a topical medication and should not be left inside the room because confused residents might consume them or put it in their eyes. She said she did not know who left the wound cleanser and the collagen powder inside Resident #45's room should be inside the treatment cart. During an interview on 07/10/2026 at 9:26 a.m., the ADON said there should be no medications inside the rooms of the residents because confused residents might mistakenly consume them or use them inappropriately. She said the antibiotic ointment should not have been left with the resident. She said she was not sure why there were wound cleansers, collagen powder, and laxative solutions inside the rooms but will try to find out who left them, so they would be reminded why they were not supposed to be inside the rooms of the residents. She said the expectation was for the staff to be diligent enough to scan the rooms of the residents for any medication. She said she would also talk to the residents and assess them if they needed the medications so she could request orders for the said medications. She they would include other staff in the in-service so they could notify the nurses if they saw any medications inside the rooms of the residents. During an interview on 07/10/2026 at 9:47 a.m., the DON said medications, whether oral, nasal, optical, or topical, should not be inside the residents' rooms or left inside the rooms because the residents might use them inappropriately and that could result in adverse reactions. She said the expectation was for the staff to be vigilant when they entered the residents' room to check for any medications and for staff not to leave the wound cleanser, collagen powder, the antibiotic ointment, and the laxative solution inside the rooms of the residents. She said she would start an in-service about medications storage. She said she would also remind the residents that they could not keep any medications inside their rooms. During an interview on 07/10/2026 at 10:12 a.m., the Administrator said the expectation was for the staff to make sure there were no medications inside the rooms of the residents because the residents might consume them or use them on their eyes causing irritation. She said she would coordinate with the DON about the issue. She said she would collaborate with the DON about the issue regarding the medications inside the rooms of the residents. She said they would in-service the staff about medications inside the rooms of the residents and monitor closely if the staff understood the in-service. Record review of the facility policy, Medication Storage in the Facility, revised March 2025, reflected, Policy: Medications and biologicals are stored safely, securely, and properly . The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . 2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g. medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's kitchen reviewed for food and nutrition services. The facility failed to ensure all food items in kitchen was dated and discarded prior to their use-by date and were properly sealed. This failure could place residents at risk for food contamination and food-borne illness. During an observation on 07/08/2026 between 9:05 AM and 9:39 AM in the facility's kitchen revealed: One gallon bag containing Cookie pieces dated 05/01/2025 expiration date 09/01/2025.One gallon bag of cake mix dated 04/07/2026 with an expiration date of 05/07/2026.One large plastic bag containing ketchup with no visible dates. One container of all-vegetable shortening 02/14/2022 best buy date of 12/25/2023.One ready pie crust with no visible dates, not properly sealed and exposed to air contaminants. One 6lb 15 oz can Garbanzo beans dated 01/09/2023 with an expiration date of 07/12/2025. One 5lb 13oz can of leaf spinach dated 05/04/2021 with an expiration date of 01/12/2024. One plastic bin containing squash dated 06/22/2026 with no visible expiration date. During an interview on 07/09/26 at 11:14 AM, the DM stated she was the person overall responsible for ensuring the kitchen was meeting guidelines for food storage and kitchen sanitization. DM confirmed the surveyor observations and stated the listed items would be corrected. DM stated once items were opened, they should be properly sealed and dated. DM stated he was responsible for ensuring policy was followed. DM stated the risk to residents if policy was not followed was a health risk to the residents. DM stated the items should be labeled, and the risk of the concerns not being addressed could result in food-borne illnesses. DM stated if food items were not dated when opened, then they would not know how long the item would remain fresh. DM stated the risk of serving foods that were past the use-by date, or serving food that was not labeled or dated, could cause food borne illness. During an interview on 07/10/2026 at 12:55 PM, Admin stated she oversaw all departments, and ensured residents were taken care of. Admin stated the expired items could cause food contamination. She stated if items were expired, they should not serve them to residents. ADMIN stated the risk of all those concerns observed in the kitchen could result in residents getting sick. Admin stated she expected DM to ensure the kitchen staff followed all guidelines, including ensuring the food items were labeled properly in the kitchen. She said the risk to residents if policy was not followed, was residents could get sick from food borne illnesses. Admin stated she expected staff to ensure they were following policies and procedures of the facility kitchen policy, to protect residents and to deliver good care. Record review of the facility's, Food Storage and Supplies Dietary Services Policy & Procedure Manual, dated ??2012, indicated, All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry, and protected from vermin, and insects. Procedure: 6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it, so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four of eighteen residents (Residents #11, #19, #31, and #33) reviewed for infection control. 1.The facility failed to ensure CNA C performed hand hygiene during Resident #31's incontinent care on 07/08/2026. 2.The facility failed to ensure MA G performed hand hygiene when preparing medications for Residents #11, #19, and #33 on 07/09/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings included: 1.Record review of Resident #31's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old female admitted [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #31's Comprehensive MDS Assessment, dated 04/24/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was incontinent (unable to control) for bladder and bowel. Record review of Resident #31's Comprehensive Care Plan, dated 05/03/2026, reflected the resident had an ADL self-care performance deficit and one of the interventions was to assist with toilet use. During an observation on 07/08/2026 at 12:59 p.m., CNA C was about to do Resident #31's incontinent care. She went inside the room, washed her hands, and put on a pair of gloves. It was observed that on top of the resident's overbed table were a box of gloves, wipes, plastic bags, a brief, and a container of hand sanitizer. She pulled the resident's pants down and unfastened her brief. She pulled some wipes and cleaned the sides of the resident's perineal area (area between the legs) using the front to back technique. After cleaning the sides, she took off her gloves and put on a new pair of gloves and cleaned the middle portion of the perineal area. She took off her gloves and put on a new pair of gloves. She assisted the resident to roll towards the wall and started to clean the resident's bottom. After cleaning the resident's bottom, she took off her gloves and put on a new pair of gloves, took the brief from the overbed table, and fixed it under the resident's bottom. She did not perform hand hygiene every time she changed gloves. During an interview on 07/08/2026 at 1:18 p.m., CNA C said she should have sanitized her hands when she changed gloves to prevent contamination. She said there was sanitizer on top of the table, and she also had one in her pocket but forgot to use it. 2.Resident #11 Record review of Resident #11's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male admitted [DATE]. The resident was diagnosed with cerebral infarction (blockage in the blood vessels of the brain), hypertension (high blood pressure), and diabetes mellitus (high blood sugar). Record review of Resident #11's Comprehensive MDS Assessment, dated 06/10/2026, reflected the resident had severe impairment in cognition with a BIMS score of 04. The Comprehensive MDS Assessment indicated the resident had debility (weakness) and cardiorespiratory (relating to the heart and the lungs) conditions. Record review of Resident #11's Comprehensive Care Plan, dated 04/16/2026, reflected that the resident had cerebral infarction, hypertension, and diabetes mellitus, and the intervention for all the above was to administer medications as ordered. Resident #19 Record review of Resident #19's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male admitted [DATE]. The resident was diagnosed with hypertension, diabetes mellitus, chronic pain, and atrioventricular block (disruption of the electrical signals in the heart). Record review of Resident #19's Comprehensive MDS Assessment, dated 06/24/2026, reflected the resident had severe impairment in cognition with a BIMS score of 05. The Comprehensive MDS Assessment indicated the resident had medically complex conditions (multiple health conditions affecting the body. Record review of Resident #19's Comprehensive Care Plan, dated 05/10/2026, reflected that the resident had hypertension, diabetes mellitus, chronic pain, and AV block, and the intervention for all of the above was to administer medications as ordered. Resident #33 Record review of Resident #33's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason) and schizophrenia (a mental condition characterized by abnormal though processes and unstable mood). Record review of Resident #33's Comprehensive MDS Assessment, dated 04/30/2026, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident had medically complex conditions. Record review of Resident #33's Comprehensive Care Plan, dated 05/10/2026, reflected the resident had altered neurological status and impaired cognitive function and the intervention for both was to administer medications as ordered. During an observation on 07/09/2026 starting at 6:29 a.m. revealed MA G was about to prepare Resident #11's medications. He took a small cup and started to place Resident #11's medications. He then went inside Resident #11's room and administered the resident's medications. He did not perform hand hygiene before preparing and after administering Resident #11's medications. He then went to Resident !9's room and started to prepare Resident #19's medication. After preparing Resident #19's medication, he went inside Resident #19's room and administered his medications. MA G did not perform hand hygiene before preparing and after administering Resident #19's medication. He then went to Resident #33's room, prepared his medications, and then administered his medications. He did not perform hand hygiene before he prepared and after he administered Resident #33's medications. During an interview on 07/10/2026 at 9:26 a.m., the ADON said the staff should always perform hand hygiene before, during, and after each care. She said the staff should have sanitized or washed their hands when they changed their gloves and before preparing the residents' medications to prevent cross contamination or spread of infection if there was any. She said the expectation was for the staff to practice what they were taught. She said they would do an in-service again about infection control. During an interview on 07/10/2026 at 9:47 a.m., the DON said hand hygiene was the most effective way to prevent cross contamination and spread of infection. She said staff should perform hand hygiene every time they changed their gloves and before they prepared the medications. She said she just did an in-service about infection control and, not following the policies and procedures of infection control, could contribute to cross contamination, development of infection, and spread of infection. She said the expectation was for the staff to adhere to the policies and procedures of infection control. She said she would start another in-service about infection control. During an interview on 07/10/2026 at 10:12 a.m., the Administrator said the expectation was for the staff to practice the proper procedure for hand hygiene to prevent cross contamination. She said she would collaborate with the DON about the issue regarding not doing hand hygiene. She said they would in-service the staff about infection control and would monitor closely if the staff understood the in-service. She said she would also ensure proper training was done. Record review of the facility's policy, Fundamentals of Infection Control Precautions, undated, reflected, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions . 1. Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene . Before and after direct resident contact . Before and after assisting a resident with personal care . Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident) . After contact with a resident's mucous membranes and body fluids or excretions . After removing gloves.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for four of eighteen residents (Residents #2, #19, #30, and #35) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident Residents #2, #19, #30, and #35's rooms were in a position that was accessible to the residents on 07/08/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Resident #19 Record review of Resident 19's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body), hemiparesis (weakness on one side of the body), and history of falling. Record review of Resident #19's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 06/24/2026, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 05. The Comprehensive MDS Assessment indicated the resident was dependent on staff for transfer, bed mobility, toileting, hygiene, shower, and dressing. Record review of Resident #19's Comprehensive Care Plan, dated 05/10/2026, reflected the resident had a history of having actual falls and interventions included be sure the resident's call light was within reach. During an observation and interview on 07/08/2026 at 9:08 a.m., Resident #19 was in his bed, awake. It was observed that his call light was hanging by the wall and was not within reach. It was also observed that there was a sign inside the room that indicated Call, don't fall. The resident stated his call light was nowhere to be found. Resident #35 Record review of Resident #35's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident diagnoses included muscle weakness, muscle wasting (loss of muscle leading to its shrinking and weakening), and repeated falls. Record review of Resident #35's Comprehensive MDS Assessment, dated 05/31/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was dependent on staff for transfer, bed mobility, toileting, hygiene, shower, and dressing. Record review of Resident #35's Comprehensive Care Plan, dated 05/10/2026, reflected the resident had an actual fall and one of the interventions was to be sure the resident's call light was within reach. During an observation on 07/08/2026 at 9:11 a.m., Resident #35 was on her bed with eyes closed. It was observed that her call light was hanging by the wall and was not within reach. During an interview on 07/08/2026 at 9:56 a.m., LVN A said he did not notice that the Resident #19 and Resident #35's call lights were not withing reach. He said staff should always make sure the call lights were with the residents before leaving the room so that they could call the staff if they needed anything. He said he would check if the call lights on his hall were with the residents. Resident #2 Record review of Resident #2's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident diagnosis included hemiplegia affecting the left side. Record review of Resident #2's Comprehensive MDS Assessment, dated 04/27/2026, reflected that the resident had a moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 09. The Comprehensive MDS Assessment indicated the resident was dependent on staff for transfer, bed mobility, toileting, hygiene, shower, and dressing. Record review of Resident #2's Comprehensive Care Plan, dated 04/07/2026, reflected the resident often yells out at staff for assistance instead of using the call light and interventions included to encourage use of call lights for assistance. During an observation and interview on 07/08/2026 at 9:40 a.m., Resident #2 was in his bed, awake. The resident said he was soiled, and he had no way to reach out to the staff to change him. He said he could not move his left arm because he had a stroke but even with his right hand he could not reach his call light. The call light was observed hanging by the wall and was not within reach of the resident. He said, sometimes, he would just yell to get the attention of the staff. He said the staff should clip his call light where his right hand could reach it if they want him to use his call light. Resident #30 Record review of Resident 30's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident diagnosis included muscle weakness and lack of coordination. Record review of Resident #30's Comprehensive MDS Assessment, dated 04/03/2026, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident needed assistance from staff for transfer, bed mobility, toileting, hygiene, shower, and dressing. Record review of Resident #30's Comprehensive Care Plan, dated 05/10/2026, reflected that the resident had an ADL self-care performance deficit and interventions included to encourage the resident to use the call light to call for assistance. During an observation and interview on 07/08/2026 at 9:26 a.m., Resident #30 was in his bed, awake. The call light was observed hanging by the wall and was not within reach of the resident. The resident said he would use the call light if he could reach it, and if not, he would just wait for someone to come to check on him. During an observation an interview on 07/08/2026 at 9:45 a.m., LVN B said call lights should be with the residents at all times to call the staff if they needed something or assistance. She said if the call lights were not within reach of the residents, their needs would not be known and addressed. During an observation LVN B went into Resident #2's room, and the resident told her he needed to be changed. LVN B told Resident #2 that she would call somebody to change him. She said she would remind the aides to make sure his call light was within his reach after incontinent care. She said she would also check Resident #30's call light. During an interview on 07/09/2026 at 8:12 a.m., CNA D said she would always make sure the resident's call light would be withing their reach so they could call the staff if they needed anything. She said she did not notice that some of the call lights were not within the reach of the residents. She said call lights were important because some residents might fall trying to do things by themselves because they could not call the staff. During an interview on 07/10/2026 at 9:26 a.m., the ADON said call lights should always be with the residents or within reach of the residents in case the residents have questions or if something was happening to them. She said the staff should make sure that the call lights were with the residents before staff left the room. She said the call lights were for all residents, regardless of whether they were dependent or independent. She said all the staff were responsible in making sure the call lights were with the residents. She said even housekeeping staff could call any nursing staff if they saw call lights that were not within reach of the residents. She said the expectation was that all the residents had their call lights. She said she would coordinate with the DON on what to do about the issue regarding the call lights. During an interview on 07/10/2026 at 9:47 a.m., the DON said call lights were for all the residents, and all the staff were responsible in making sure the call lights were within reach of all the residents. She said if the call lights were not within reach, their needs would not be met, and the residents might fall trying to do something on their own. She said the expectation was for the staff to scan the residents' rooms when they did their rounds and ensure the call lights were within reach of the residents before they left the rooms. She said she would start an in-service about call light placement as soon as the interview was over. During an interview on 07/10/2026 at 10:12 a.m., the Administrator said call lights should always be within the reach of all the residents in case they were having emergencies. She said independent residents might be having shortness of breath or chest pain and would not be able to call the staff because they could not reach their call lights. She said some residents needed the call lights for pain medications, a refill for their pitcher, or if they needed to be changed. She said she would collaborate with the DON about the issue regarding call lights. She said they would in-service the staff about call lights and would monitor closely if the staff understood the in-service. Record review of the facility's policy Resident Rights undated, reflected Respect and dignity - The resident has a right to be treated with respect and dignity, including . 3. The right to . receive services in the facility with reasonable accommodation of resident needs. Policy for call lights requested on 07/09/2026 at 1:38 p.m. and 07/10/2026 at 10:58 a.m. via email to the Administrator and verbally requested on 07/10/2026 at 2:05 p.m. was not provided prior to exit.

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during medical treatment and personal care and confidentiality of personal and medical records for five of twenty residents (Residents #2, #6, #12, #21, and #49) reviewed for privacy and confidentiality. 1.The facility failed to ensure Residents #12, #21, and #49's personal medical information was secured on 07/09/2026. 2.The facility failed to ensure LVN B closed the door or pulled the privacy curtain while checking Resident #2's blood sugar and administering his insulin on 07/09/2026. 3.The facility failed to ensure LVN B closed the door or pulled the privacy curtain while checking Resident #6's blood sugar on 07/09/2026. These failures could place the residents at risk of not having their personal privacy maintained while treatments were provided, which could result in the residents feeling uncomfortable during care, and having their personal and medical record exposed to unauthorized individuals.Findings included: 1.Record review of Resident #12's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The Face Sheet indicated the resident's primary payer. Record review of Resident #21's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The Face Sheet indicated the resident's primary payer. Record review of Resident #49's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The Face Sheet indicated the resident's primary payer. During an observation on 07/08/2026 at 9:07 a.m. revealed a piece of paper, titled Midnight Census Report, was on top of the ledge of the nurses' station. On the piece of paper were Residents #12, #21, and #49's names and their respective type of healthcare delivery system that coordinated and managed the healthcare services, the type of insurance plan where healthcare services were prepaid, the Medicare payment used, and the name of the insurance company that provided the health insurance. It was observed that the piece of paper was in plain view and there were no staff in the station. During an interview on 07/08/2026 at 9:56 a.m., LVN A said he did not notice that the paper had PHI on them. He said if he noticed it, he would flip it or secure it somewhere because the information on the paper was confidential. 2.Record review of Resident #2's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar). Record review of Resident #2's Comprehensive MDS Assessment, dated 04/27/2026, reflected the resident had a moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin. Record review of Resident #2's Comprehensive Care Plan, dated 04/07/2026, reflected the resident had diabetes mellitus and the interventions included to check the blood sugar and administer insulin as ordered. Record review of Resident #2's Physician Order, dated 07/02/2026, reflected Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject subcutaneously (administer under the skin) before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (high blood sugar in the blood stream) . BEFORE MEALS NOTIFY FOR BLOOD SUGARS > 400. During an observation on 07/09/2026 at 10:37 a.m., LVN B prepared to check Resident #2's blood sugar. She sanitized her hands, put on a pair of gloves, and prepared her glucometer, test strips, alcohol wipes, and a push button safety lancet. She went inside the resident's room and positioned herself at the side of the resident, who was sitting in his wheelchair in front of his door, and checked the resident's blood sugar. She told the resident that he needed some insulin. She went back to her cart and prepared the resident's insulin. She then lifted the resident's shirt and administered the insulin to the resident's right upper abdomen. She did not close the door while she was checking the resident's blood sugar and when she administered the resident's insulin. The treatment could be seen from the hallway. 3.Record review of Resident #6's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus. Record review of Resident #6's Comprehensive MDS Assessment, dated 05/21/2026, reflected that the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin. Record review of Resident #6's Comprehensive Care Plan, dated 05/28/2026, reflected that the resident had diabetes mellitus and one of the interventions was to administer diabetes medication as ordered. Record review of Resident #6's Physician Order, dated 05/11/2026, reflected NovoLog Solution 100 UNIT/ML (Insulin Aspart) Inject subcutaneously threetimes a day for DIABETES. During an observation on 07/09/2026 at 11:15 a.m., LVN B prepared to check Resident #6's blood sugar. She sanitized her hands, put on a pair of gloves, and prepared her glucometer, test strips, alcohol wipes, and a push button safety lancet. She went inside the resident's room and positioned herself at the side of the resident, who was lying in her bed, and checked the resident's blood sugar. She told the resident that she did not need any insulin. She did not close the door while she was checking the resident's blood sugar, and the treatment could be seen from the hallway. During an interview on 07/09/2026 at 11:32 a.m., LVN B said she forgot to close the door when she checked Resident #2 and Resident #6's blood sugars and when she administered resident #2's insulin. She said the door should be closed, or the privacy curtain should have been pulled to provide privacy during treatment or care. She said the resident might get embarrassed that other people could see what their treatments were. She said it did not matter if the resident minded it or not, but the staff had the responsibility to provide privacy. During an interview on 07/10/2026 at 9:26 a.m., the ADON said staff should close the door or pull the privacy curtain when they were providing treatments to the residents. She said the staff needed to get used to providing privacy during treatment so that individuals that did not have anything to do with the residents' care would not see it. She said it did not matter if the residents minded or not, but the expectation was the staff should be sensible enough that if they were in the residents' position, they might want their door closed during treatment. She said the piece of paper had some personal medical information that was supposed to be confidential. She said the paper should not have been left unattended in the nurses' station or should have flipped over. She said the expectation was that information that was confidential was secured, and residents were provided with privacy during treatment. She said she would coordinate with the DON to do an in-service about privacy and confidentiality. During an interview on 07/10/2026 at 9:47 a.m., the DON said the door should be closed every time the staff provided treatment to give privacy and prevent improper exposure of any body part. She said privacy should be given so others, like non-clinical personnel, visitors, and other residents, would not see the treatments being done. She said the door should be closed, or the privacy curtain pulled to avoid embarrassment and so that the residents would be more comfortable during treatment. She said the paper should have been turned over. She said she did not know why the census report was on the ledge of the nurses' station. She said the resident's insurance was PHI and could be a HIPAA (law protecting health information aimed to ensure confidentiality) violation. She said she would start an in-service about privacy and confidentiality as soon as the interview was over. During an interview on 07/10/2026 at 10:12 a.m., the Administrator said the piece of paper that had the resident's name, and their insurances should have been turned over or was placed in a folder because it could be a HIPAA violation. She said the staff must make sure that the residents were provided privacy when treatment was being done so they would be comfortable and would not be embarrassed. She said the expectation was for the staff to be mindful about providing privacy and securing confidential records. She said she would collaborate with the DON about the issue. She said they would in-service the staff about privacy and confidentiality and would monitor closely if the staff understood the in-service. Record review of the facility's policy Resident Rights undated, reflected Privacy and confidentiality . The resident has a right to personal privacy and confidentiality of his or her personal and medical records . 1. Personal privacy includes . medical treatment . 3. The resident has a right to secure and confidential personal and medical records.

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care to one of eight residents (Resident #47) reviewed for baseline care plan. The facility failed to ensure Resident #47 had a baseline care plan for atelectasis after admission to the facility on [DATE]. This failure could place the resident at risk of not receiving necessary care, treatment, and services upon admission that could result in worsening conditions.Findings included: Record review of Resident #47's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Upon admission, the resident diagnosis included atelectasis (collapse of the lungs that could result in SOB and coughing). Record review of Resident #47's Comprehensive MDS Assessment, dated 05/09/2026, reflected that the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated that the resident had atelectasis. Record review of Resident #47's Baseline Care Plan, dated 05/11/2026, reflected that the resident did not have a care plan for atelectasis, cough, or shortness of breath. Record review of Resident #47's Physician Order, dated 05/10/2026, reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5(3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 4 hours as needed for SOB OR WHEEZING. Record review of Resident #47's admission Note, dated 05/09/2026, reflected Cough: Occasional, non-productive cough (dry cough). During an observation and interview on 07/08/2026 at 9:19 a.m., Resident #47 was observed with occasional coughing. The resident said her cough was on and off, but she had medications for her cough. During an observation and interview on 07/08/2026 at 9:56 a.m., LVN A said Resident #47 had a chronic cough but was non-compliant with her treatment. He said the resident had respiratory issues when she was admitted to the facility. During an observation and interview on 07/10/2026 at 8:59 a.m., the RRM said if a resident had a pertinent condition when admitted to the facility, then there should be a baseline care plan for that condition. The RRM logged on to a computer, reviewed Resident #47's profile, and saw the resident did not have a care plan for a cough when she was admitted . She said there should have been a care plan for her cough or any respiratory issues. She said she would let the MDS Coordinator know about the issue so she could audit the care plans accordingly. During an interview on 07/10/2026 at 9:26 a.m., the ADON said if a resident was admitted to the facility with respiratory issues, it should have been included in the baseline care plan to plan for the immediate treatment of the issues. During an interview on 07/10/2026 at 9:47 a.m., the DON said the baseline care plans were important because it would give the providers the minimum healthcare information about the resident that needed to be addressed immediately or upon admission. She said without the baseline care plan, the immediate needs of the resident would not be met. She said she would start an in-service about baseline care plan as soon as the interview was over.During an interview on 07/10/2026 at 10:12 a.m., the Administrator said all the residents must have a baseline care so that the care staff would know how to take care of the residents. She said the expectation was for the staff to initiate the baseline care plan immediately after admission. She said she would collaborate with the DON about the issue would monitor closely if the staff understood the in-service. Policy for baseline care plan requested on 07/10/2026 at 11:00 a.m. but was not provided prior to exit. Record review of the facility's policy Comprehensive Care Planning Nursing Policy & Procedure Manual, undated reflected The facility will develop and implement a comprehensive person-centered care plan for each resident . The resident's care plan will be reviewed after each Admission.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of eight residents (Resident #47) reviewed for care plans. The facility failed to ensure that Resident #47 had a care plan for her acute upper respiratory infection on 07/09/2026. This failure could place the residents at risk of not receiving the necessary care and services.Findings included: Record review of Resident #47's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with acute upper respiratory infection (infection that could affect the nose, throat, and voice box) eleven days after admission. Record review of Resident #47's Comprehensive MDS Assessment, dated 06/12/2026, reflected that the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated that the resident acute upper respiratory infection. Record review of Resident #47's Comprehensive Care Plan, dated 06/22/2026, reflected that the resident did not have a care plan for acute upper respiratory infection, chronic cough, or SOB. Record review of Resident #47's Physician Order, dated 05/10/2026, reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5(3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 4 hours as needed for SOB OR WHEEZING.Record review of Resident #47's Physician Order, dated 05/20/2026, reflected AZITHROMYCIN 500 mg 1 tab PO QD x 3 days for URI. Record review of Resident #47's Progress Note, dated 05/20/2026, reflected resident is being treated for URI . Negative Findings: Nasal Congestion, Productive cough. Sputum is Clear . Respirations: SOB on Exertion, Observed SOB While Lying . Interventions: Antibiotic treatment: AZITHROMYCIN 500 mg 1 tab PO QD x 3 days.Record review of Resident #47's Progress Note, dated 05/28/2026, reflected N/O received from . NP of Medrol dose pak and Tessalon for cough RT residual cough/ congestion . Treatment Plan: Nebulizer treatments according to physician orders delivered by handheld device. Record review on Resident #47's Progress Note, dated 05/30/2026, reflected resident is being treated for URI . Negative Findings: Productive cough . Antibiotic treatment: LEVAQUIN 500 MG QD X 7 DAYS.Record review on Resident #47's Progress Note, dated 06/03/2026, reflected This resident is being treated for URI. Record review on Resident #47's Progress Note, dated 06/05/2026, reflected This resident is being treated for Pneumonia . Productive cough.Record review on Resident #47's Progress Note, dated 06/09/2026, reflected NP contacted nurse to give the following orders . 1. DuoNeb 3 ml via neb QD Dx: SOB/Cough.Record review on Resident #47's Progress Note, dated 06/26/2026, reflected NP notified nurse of the following orders . 1. Guaifenesin 600 mg 1 tab PO BID x 7days Dx: Cough. Record review on Resident #47's Progress Note, dated 06/27/2026, reflected Note Text: XRAY RESULTS SENT TO . FOR REVIEW. NEW ORDER PREDNISONE 20 MG 1 TAB PO DAILY X 3 DAYS, REPEAT CHEST XRAY ON 7/1/26. ENCOURAGE USE OF INCENTIVE SPIROMETER, N/O IS Q 2 HRS WHILE AWAKE X 72 HRS.During an observation and interview on 07/08/2026 at 9:19 a.m., Resident #47 was in her wheelchair and was observed with occasional coughing. The resident said her cough was on and off, but she had medications for her cough. She said she also had an infection last month, and she was given antibiotics for it. During an observation and interview on 07/08/2026 at 9:56 a.m., LVN A said Resident #47 had a chronic cough but was non-compliant to her treatment. He said the resident had on and off respiratory issues like the respiratory infection and cough. During an observation and interview on 07/10/2026 at 8:59 a.m., the RRM said if a resident had a change in condition like respiratory infection, then it should be reflected on her care plan. The RRM logged on to a computer, reviewed Resident #47's profile, and saw the resident was diagnosed with upper respiratory infection. She then checked the resident's current and discontinued physician orders and saw the resident had orders, during her stay, for breathing treatment, cough syrup, prednisone, and antibiotics for respiratory issues. She said there should be a care plan for her respiratory issues, especially if she was prone to have one. She said the care plans should be in place so that everybody taking care of the resident would be aware of how to manage it. She said the care plan should reflect the potential issues of the residents and provide interventions for such issues. She said she should let the MDS Coordinator know about the issue so she could make a care plan for the resident's respiratory issues. During an interview on 07/10/2026 at 9:26 a.m., the ADON said care plans should reflect the needs of the residents that needed to be addressed. She said the care plan served as the facility's agreement with the resident in terms of the care and services that the facility would be providing. She said another purpose of the care plan was that the individuals taking care of the residents would be on the same page. During an interview on 07/10/2026 at 9:47 a.m., the DON said the MDS Nurse was responsible for making the care plans of the residents. She said care plans should be in place to reflect the realistic goals, reflect the needed interventions, to gauge if the expectations were being met, so that the staff could provide the best care needed. She said the expectation was for all the issues of the residents were care planned appropriately. She said the change in the resident's condition should be planned. She said she would coordinate with the MDS Coordinator with regards to Resident #47's care plan for respiratory issues. During an interview on 07/10/2026 at 10:12 a.m., the Administrator said the expectation was that all the residents were care planned specific to their needs so the staff taking care of the residents could provide the care and services needed. She said care plans should be in place so that the individuals providing care for the residents would be on the same page. She said she would coordinate with the MDS Nurse and the DON regarding the care plans of the residents. Record review of the facility's policy Comprehensive Care Planning Nursing Policy & Procedure Manual, undated reflected The facility will develop and implement a comprehensive person-centered care plan for each resident . Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs . The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change.

Based on observations, interviews and record reviews, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for two of twelve residents (Residents #12 and Resident #29) reviewed for care plans revision. The facility failed to ensure the care plans for Residents #12 and Resident #29 were reviewed and revised after each comprehensive and quarterly assessment. This failure could place the residents at risk of care and needs not being met. Findings included: Resident #12 Record review of Resident #12's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #12's Quarterly MDS Assessment reflected that the last MDS completed for the residents was on 06/09/2026. Record review of Resident #12's Quarterly Care Plan reflected the last care plan completed for the resident on 03/24/2026. Resident #29 Record review of Resident #29's Face Sheet, dated 07/09/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #29's Comprehensive MDS Assessment reflected that the last MDS completed was on 06/24/2026. Record review of Resident #29's Comprehensive Care Plan reflected the last care plan completed for the resident was 03/06/2026. During an observation and interview on 07/09/2026 at 1:39 PM, the MDS Coordinator said care plans were updated or revised quarterly or if there was a change in condition. She said she was responsible for updating the care plans of the residents. She said the care plan should be updated quarterly or if the resident had a change in condition, had a fall, or had an infection. She logged onto her computer and checked the residents in question and saw that the residents' care plans were not updated. She said the residents had their quarterly assessments, and the quarterly care plans should have followed. She said both Resident #12 and Resident #29's last care plans were both done last March 2026, and the next care plans should have been done last June and not July. During an interview on 07/10/2026 at 9:26 a.m., the ADON said care plans were done during admission and updated quarterly. She said care plans were also updated if there was a change in condition like the resident had a new wound or had a fall. She said care plans should be updated so the staff would know if there were new interventions that needed to be done and to monitor the resident's response to the new interventions. During an interview on 07/10/2026 at 9:47 a.m., the DON said every resident needed a detailed care plan to ensure the residents received the care they needed. She said the care plans should be updated because the resident might have new issues that needed attention or previous issues that needed more extensive interventions. She said the care plan should be done quarterly or if there was a change in condition. She said the expectation was for the care plans to be updated. She said she would coordinate with MDS Nurses to audit the care plans of the residents. During an interview on 07/10/2026 at 10:12 a.m., the Administrator said care plans were supposed to be updated quarterly to make sure that the care being given was still appropriate. She said the expectation was for all the residents to be care planned and that the care plans were updated quarterly and when needed. She said she would coordinate with the MDS Nurse and the DON regarding the care plans of the residents. Record review of the facility's policy Comprehensive Care Planning Nursing Policy & Procedure Manual, undated reflected The facility will develop and implement a comprehensive person-centered care plan for each resident . Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs . The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change . and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of five residents (Resident #45) reviewed for catheter care. The facility failed to ensure Resident #45's catheter bag was off the floor on 07/08/2026. This failure could place the residents at risk of urinary tract infection.Findings included: Record review of Resident #45's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old male admitted [DATE]. The resident was diagnosed with neuromuscular dysfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness). Record review of Resident #45's Comprehensive MDS Assessment, dated 05/22/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter (a thin, flexible tube inserted in the bladder to allow the urine to flow in the catheter bag). Record review of Resident #45's Comprehensive Care Plan, dated 06/28/2026, reflected the resident had a suprapubic catheter (device inserted into the stomach to the bladder to drain urine) and one of the interventions was to maintain the drainage bag (catheter bag: (collects urine from the urinary bladder) off the floor. Record review of Resident #45's Physician Order, dated 03/28/2026, reflected MAY HAVE SUPRAPUBIC INDWELLING CATHETER: 22-24 F (French: unit of measurement for catheter sizes) WITH 30 ML BULB (a soft tube with a balloon at the tip). CHANGE FOR OCCLUSION, LEAKING, CLOSED SYSTEM WAS COMPROMISED. every shift related to NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED . AND as needed for CATHETER CHANGE INDICATED. During an observation and interview on 07/08/2026 at 9:33 a.m., Resident #45 was in his bed, awake. It was observed that the resident had a catheter bag hanging at the side of his bed. The resident said he had the catheter for almost ten years. During an observation on 07/08/2026 at 11:53 a.m., Resident #45's catheter bag was touching the floor. During an observation and interview on 07/08/2026 at 11:56 a.m., LVN B said the catheter bag should be off the floor because it could result in urinary tract infection (infection in any part of the urinary system). She went inside Resident #45's room and saw that the resident's catheter bag was touching the floor. She said, maybe, somebody changed the resident and put the bed in the lowest position but did not notice that the bag was touching the floor. She raised the resident's bed until the catheter bag was off the floor. She said she would remind the CNAs that catheter bags should not be touching the floor. She said she would also change the resident's catheter bag. During an interview on 07/10/2026 at 9:26 a.m., the ADON said catheter bags should always be off the floor because it could cause UTI. She said the expectation was catheter bags would always be off the floor. She said she would coordinate with the DON on what to do about the issue regarding the catheter. During an interview on 07/10/2026 at 9:47 a.m., the DON said the catheter bags should not be touching the floor to keep it clean and prevent UTI. She said she would start an in-service about catheter carer. During an interview on 07/10/2026 at 10:12 a.m., the Administrator said the expectation was that the catheter bag would be off the floor to prevent infection. She said she would collaborate with the DON about the issue regarding the catheter. She said they would in-service the staff about catheter care and would monitor closely if the staff understood the in-service. Record review of the facility's policy, Catheter Care Nursing Policy and Procedure Manual, undated reflected General Guidelines . 10. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of ten residents (Residents #47) reviewed for respiratory care. The facility failed to ensure Resident #47's breathing mask was properly stored when not in use on 07/08/2026. This failure could place residents at risk of respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #47's Face Sheet, dated 07/09/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with acute upper respiratory infection. Record review of Resident #47's Comprehensive MDS Assessment, dated 06/12/2026, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident had acute upper respiratory infection. Record review of Resident #47's Comprehensive Care Plan, dated 06/22/2026, reflected the resident did not have a care plan for acute upper respiratory infection, chronic cough, or SOB. Record review of Resident #47's Physician's Order, dated 05/10/2026, reflected, Ipratropium-Albuterol Inhalation Solution 0.5-2.5(3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 4 hours as needed for SOB OR WHEEZING. Record review of Resident #47's eMAR, dated July 2026, reflected the last time the resident used her breathing mask (a medical device used to deliver medication in the form of mist directly to the lungs) was 07/06/2026. During an observation and interview on 07/08/2026 at 9:19 a.m., Resident #47 was in her wheelchair, awake. It was observed that the resident's breathing mask was on top of the resident's side table and was unbagged. She said the staff would put her mask on and would take it off when the treatment was done. During an observation and interview on 07/08/2026 at 9:56 a.m., LVN A said the breathing mask should be inside a plastic bag when not in use to keep it clean and prevent any respiratory infection. He said he had already placed the breathing mask inside a bag. During an interview on 07/10/2026 at 9:26 a.m., the ADON said the breathing mask should be inside a plastic bag when not in use to maintain its cleanliness as well as its patency (opened, unobstructed, or unblocked). She said bagging the mask was important to prevent cross contamination and development of any respiratory infections. She said the staff administering the breathing treatment was responsible for bagging the breathing mask once the treatment was done. She said she would coordinate with the DON about the issue. During an interview on 07/10/2026 at 9:47 a.m., the DON said the staff were responsible in bagging the breathing mask to prevent any respiratory infection. She said she would start an in-service about respiratory care. During an interview on 07/10/2026 at 10:12 a.m., the Administrator said the expectation was all the masks be bagged when the residents were not using them to keep them clean. She said the resident already had respiratory issues and using dirty masks, nasal cannula, and suction tip could add to their medical issues. She said she would collaborate with the DON about the issue regarding the breathing mask. She said they would in-service the staff about respiratory care and would monitor closely if the staff understood the in-service. Record review of the facility's policy, Respiratory Muscle Trainer (RMT) Respiratory Policies and Procedures, revised June 01, 2006, reflected, POLICY: Respiratory muscle training is performed by a respiratory therapist with a physician's order . Process . 8. If using a nebulizer . 18 . Store in treatment bag labeled with patient's name.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident was free from abuse, neglect and corporal punishment of any type by anyone one of four residents (Resident #1) reviewed for abuse. PTA M reported and observed Resident #2 hitting Resident #1 while in the smoking area on 04/09/26. This failure could place residents at risk of sustaining serious harm and not being free from abuse.Findings included:Record review of Resident #1's Face Sheet, dated 05/06/26, reflected a [AGE] year-old female admitted [DATE]. Resident #1 had a diagnosis of COPD (obstructed airflow).Record review of Resident #1's Quarterly MDS Assessment, dated 03/20/26, reflected BIMS score of 12 indicating moderate cognitive impairment. The MDS assessment reflected the resident had active diagnoses of COPD and bi-polar.Record review of Resident #2's Face Sheet, dated 05/07/26, reflected a [AGE] year-old male admitted [DATE]. Resident #2 had a diagnosis of schizophrenia (severe brain disorder).Record review of Resident #2's Quarterly MDS Assessment, dated 03/01/26, reflected a BIMS score of 4, indicating severe cognitive impairment. The MDS assessment reflected the resident had an active diagnoses of schizophrenia. Record review of the facility's incident logs on 05/06/26 for the past four months reflected no incidents between the two residents. During an interview on 05/06/25 at 10:35 a.m., Resident #2 stated he was trying to get to a wedding today. He stated he did not know if he was involved in an incident with another resident. Resident #2 did not respond when asked if he hit another resident. During an interview on 05/06/25 at 10:50 a.m., Resident #1 stated she felt safe at the facility. She stated Resident #2 was talking trash to her and she told him to do something and Resident #2 punched her in the heart twice. She stated it did not bruise her, but it did hurt at the time. She stated there was no other incident since then. She stated she had a pacemaker, but records and DON confirmed she did not have one. She stated the Physical Therapist was present during the incident and separated them. During an interview on 05/06/25 at 12:15 p.m., the DON stated she was notified by PT M that Resident #2 hit Resident #1 twice in the chest area. She stated she immediately assessed Resident #2 at the time of the incident. She stated she completed a head-to-toe assessment, and she observed no marks or bruises. She stated the incident was observed by PT M. She stated they placed Resident #2 on 1:1 monitoring, completed a urinalysis test to check for any infections, and contacted psych services. She stated the resident had a history of being aggressive with staff and this was the first time he was aggressive with another resident. During an interview on 05/06/25 at 12:30 p.m., PTA M stated he was supervising residents in the smoking area and witnessed the incident between Resident 1 and #2. He stated Resident #2 stated Resident #1 had bumped his foot. He stated they started arguing and Resident #2 struck Resident #1 in the chest when he was sitting in his wheelchair and then Resident #2 stood up and struck her again in the chest. He stated Resident #2 struck Resident #1 quite hard. He stated he separated the residents. He stated he was not sure if the resident had a history of hitting other residents. He stated he notified the Administrator and DON, and they arrived within minutes. During an interview on 05/06/26 at 12:45 p.m., the Administrator stated he was informed by staff of Resident #2 striking Resident #1. He stated Resident #2 was placed on 1:1 monitoring, he was referred to psychiatric services, and they completed a urinalysis test to check for an infection, but it was negative. He stated the resident sees a therapist from Psych services weekly to address his behaviors. He stated he completed a safe survey with all residents in the facility and there were no concerns. He stated he in-serviced the staff on reporting abuse and neglect on 04/09/26.Record review of the facility's policy titled, Abuse and Neglect, dated 3/29/18, revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.Definitions1. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systemically organized in accordance with accepted professional standards for 2 of 3 residents (Residents #1 and #2) reviewed for clinical records regarding wound care.1. The facility failed to ensure nursing staff documented that physician ordered wound care was provided to Resident #1 for a skin tear on her left buttocks on 03/06/26, 03/07/26, 03/08/26, 03/14/26, and 03/15/26 and for a post-surgical wound on her abdomen on 03/06/26, 03/07/26, 03/08/26, 03/14/26, 03/15/26, 03/20/26, 03/21/26, 03/28/26 and 03/30/26. 2. The facility failed to ensure nursing staff documented that physician ordered wound care was provided to Resident #2 on 03/10/26, 03/20/26, 03/27/26, 03/28/26, 03/29/26. This failure could place residents at risk for incomplete and inaccurately documented medical records that included their progress treatment, services, and interventions. Findings included: 1.Record review of Resident #1's Comprehensive MDS dated [DATE] reflected that the resident was a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included unspecified intestinal obstruction, unspecified as to partial versus complete obstruction (a partial or complete blockage of the small or large intestine that prevents food, fluids, and gas from moving through the digestive tract). The resident #1's BIMS score was 15, indicating her cognition was intact. The MDS reflected that the resident had recent surgery requiring active Skilled Nursing Facility Care and was at risk of developing pressure ulcers/injuries.Record review of Resident #1's care plan dated 02/20/26 reflected the following:* resident had the potential for pressure ulcers (injuries to the skin and underlying tissue caused by prolonged pressure on the skin) development related to decreased mobility and urinary incontinence. Resident #1 had a wound on her sacral area (the triangular bone at the base of the spine). The care plan interventions included following the facility policies and protocols for the prevention and treatment of skin breakdown. * Resident #1 had post-surgical site to abdomen. Goal: - Resident #1 surgical sites will show signs of improving and remain free from signs and symptoms of infection with treatment as ordered over the next 90 days. Interventions Observed for sign and symptoms of pain during treatment and medicate as needed per physician orders.Record review of Resident #1's physician orders for dated 02/27/2026 reflected the following: skin tear of the left buttock: cleanse wound with normal saline/woundCleanser [an isotonic solution that does not interfere with normal wound repair], pat dry with gauze, apply hydrogel w/silver [an antimicrobial silver compound], cover with bordered gauze [an absorptive dressing consisting of three layers: a low-adherent layer protects the wound surface, an absorbent gauze layer absorbs exudate, and a non-woven adhesive tape holds the dressing in place and maintains a moist wound environment]. Daily and as needed .post-surgical wound of the abdomen: cleanse with normal saline/wound cleanser, pat dry with gauze, apply xeroform [a medicated gauze dressing that keeps the wound moist and helps prevent infection] to wound bed, cover with bordered gauze. Daily and as needed. Record review of Resident #1's March 2026 Wound Administration Record reflected that:- there was no documentation showing that the resident was provided with wound care for the skin tear on her left buttocks on 03/06/26, 03/07/26, 03/08/26, 03/14/26, and 03/15/26; and - there was no documentation showing that the resident was provided with wound care for the post-surgical wound on her abdomen on 03/06/26, 03/07/26, 03/08/26, 03/14/26, 03/15/26, 03/20/26, 03/21/26, 03/28/26 and 03/30/26.Record review of Resident 1's wound care report by the Wound Care Physician for March 2026 reflected the resident was being seen and treated weekly and there was no evidence the wound deteriorated and all wounds were healed.Interview with resident#1 on 04/02/26 at 9:25AM revealed she was receiving wound care, and she stated all the wounds are healed. She denied skin assessment.During an interview on 04/02/26 at 1:35 PM, the Wound Care Nurse revealed she was responsible for Resident #1's wound care Tuesday through Thursday and on the other days, it was done by the charge nurses. The Wound Care Nurse said she was not aware Resident #1's wound care treatment record was being left blank on (03/06/26, 03/07/26, 03/08/26, 03/20/26,03/21/26, 03/28/26 and 03/30/26). She said when she reported on Tuesdays for wound care the dressing were dated with a previous day date and wounds were not getting worse. She stated it would be unknown if the resident had been provided with the wound care or if the charge nurse failed to document the wound care. She stated the wound care report not being completed would indicate the wound care was not done and it would put the wound at risk of becoming infected and taking longer to heal. During an interview on 04/02/26 at 3:05 PM with LVN K, she stated she provided wound care to Resident #1 on the weekends. LVN K said if there were dates that were blank (03/06/26, 03/07/26, 03/08/26, 03/20/26, 03/21/26, and 03/28/26) that probably meant she performed the resident wound care, but she probably forgot to check the box. She stated there were some weekends she performed wound care, and she did not know where to document it. She stated later she was notified to document the wound care on the residents' wound care treatment records. She said she did not go back and document the care she forgot to document, and she did not notify the DON. She stated failure to document care could affect wound management and healing. Attempts to contact LVN F via phone on 04/02/26 at 3:50PM who worked with Resident #1 was unsuccessful. 2. Record review of Resident #2's quarterly MDS assessment, dated 02/06/26, reflected that the resident was a [AGE] year-old male who was admitted on [DATE]. His diagnoses included paraplegia (partial or complete paralysis of the lower half of the body), chronic pain syndrome, muscle weakness, and orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down). Resident #2's BIMS score was 12 which indicated moderate cognitive impairment. The MDS further reflected that Resident #2 had other open lesions on the foot and skin tears. Record review of Resident #2's care plan, revised 02/27/26, reflected * Focus: [Resident #2] has a non- pressure wound to the left ankle. Non pressure wound to left ankle: cleanse with normal saline, pat dry with gauze, apply betadine to the area, [leave open to air] QD and PRN. Goal: [Resident #2] will be free from non-pressure wound to the left ankle through the review date. Interventions: Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry. Use lotion on dry scaly skin. * Focus: [Resident #2] has a non- pressure wound to the right ankle. Trauma Injury to right ankle cleanse area with normal saline/wound cleanser, pat dry with gauze, apply collagen powder, secondary dressing: continue gauze island dressing with bdr [an absorbent pad surrounded by a sticky frame]. Record review of Resident #2's physician orders, dated 03/04/25, reflected the following orders: * Non-Pressure trauma injury to right lateral shin: cleanse area with normal saline/wound cleanser, pat dry with gauze, apply collagen powder to wound bed, cover with non-adherent pad, secure with bordered gause QD and PRN one time a day for wound care.* Trauma injury to right ankle: cleanse area with normal saline/wound cleanser, pat dry with gauze, apply collagen powder; cover with bordered gauze one time a day for wound care if saturated, soiled or dislodged.Record review of Resident #2's physician orders, dated 03/18/25, reflected the following orders:* Skin tear wound to right lateral foot: cleanse area with normal saline/wound cleanser, pat dry with gauze, apply collagen powder and cover with gauze island w/bdr; once daily and as needed: if saturated, soiled or dislodged one time a day. * Non pressure wound injury to right distal lateral shin: cleanse area with normal saline; wound cleanser, pat dry with cause, apply skin prep to wound bed, cover with non-adherent pad, secure with bordered gauze; once daily and PRN if saturated<soiled or dislodged, one time a day for wound careRecord review of Resident #2's March 2026 Wound Administration Record reflected there was no documentation showing that wound care was provided on 03/10/26, 03/20/26, 3/27/26, 03/28/26, 03/29/26 to the right distal lateral shin, right ankle and left ankle.During an interview and observation on 04/02/26 at 9:55 AM, Resident #2 revealed he had wounds on his feet. He stated he received wound care but was not sure if it was all the time. He stated he was not sure if he required wound care everyday or every other day. Observed Resident #2's dressings, it was dated 03/31/26, resident stated he did not receive wound care on 04/01/26 because he was out on pass on 04/01/26. Observation on 04/02/26 at 2:12 PM, wound care was provided to Resident #2 by the Wound Care Nurse. Observed Resident #2's wounds located on his right ankle and left ankle appeared to be healing, no foul odor detected and no signs of infection noted. During an interview on 04/02/26 at 3:31 PM, the Wound Care Nurse stated she provided Resident #2's wound care Tuesday through Thursday. She stated wound care on the other days was done by the assigned charge nurses. Wound Care Nurse stated Resident #2 was out on pass on 04/01/26. The Wound Care Nurse stated she was not aware that Resident #2's Wound Administration Record was being left blank. The Wound Care Nurse reviewed Resident #2's Wound Administration Record, and she stated there were blanks on the record. She stated it would be unknown if the resident had been provided with the wound care or if the charge nurse failed to document the wound care. The Wound Administration Record not being completed would indicate the wound care was not done, and it would put the resident at risk of his wound getting infected.During an interview on 04/02/26 at 4:09 PM, RN H revealed she was the assigned nurse for Resident #2 Monday through Friday. She stated she would provide Resident #2 with wound care until the facility hired a new Wound Care Nurse. She stated the last time she provided wound care to Resident #2 was about two weeks. She stated she would document wound care in the resident's clinical records. She stated if the TAR (Wound Administration Record) had blanks on it then it meant that the wound care was not provided or the nurse failed to chart the wound care. She stated it might have been her because she was bad at charting. She stated the potential risk of not documenting would be the staff not knowing if wound care was being provided. During an interview on 04/02/26 at 4:14 PM, RN I revealed she was the nurse assigned to Resident #2 on Saturdays and Sundays. She stated she provided wound care to Resident #2 and would document in the resident TAR (Wound Administration Record). She stated she was not aware of the TAR (Wound Administration Record) being blank and was not sure what it meant if there were blanks. She stated if it was blank it probably meant wound care was not provided or the nurse failed to chart the wound care. During an interview on 04/2/26 at 4:21 PM, the DON revealed the expectation was that the charge nurses provided wound care when the treatments nurse was not in the facility. She said nurses were supposed to document wound care on the Wound Administration Record. She said she was responsible for monitoring resident wound care to ensure the wound care was being provided and documented by the nurse. She said she checked treatment records every day, and she did not realize wound care treatment record was being left blank in March 2026. The DON stated if ,the wound report was being left blank that could indicate that wound care was not given to the residents including Resident #1 and Resident #2. Failure to document there was potential of missed care and wounds getting worse.Record review of the facility's current, undated Documentation policy reflected the following: .Documentation is the recording of all information, both objective and subjective, int eh clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments.9. Document or check information on flow sheets each shift or as appropriate for the care or treatment being monitored.Record review of the facility's current, undated Dressing Change Checklist policy reflected the following: Verifies Treatment: Verifies orders for wound treatment form TARS and chart. Documents procedure per facility policy.Record review of the facility's current, undated Wound Treatment Management policy reflected the following:Policy - To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.7. Treatments will be documented on the Treatment Administration Record

Based on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 Residents (Resident #1, and Resident #2) observed for infection control. 1.The facility failed to ensure CNA D and RN A utilized Enhanced Barrier Precautions and performed hand hygiene during wound care for Resident #1 on 02/21/26. 2. The facility failed to ensure RN A handled Resident #1's wound care supplies appropriately to prevent cross contamination during wound care on 02/21/26. 3.The facility failed to ensure LVN B performed hand hygiene during wound care for Resident # 2 and failed to prevent cross contamination of wound care supplies on 02/21/26. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. Record Review of Resident #1's Face Sheet dated 02/21/26 reflected a [AGE] year-old male with an admission date of 11/11/25. His diagnoses included quadriplegic (partial or total loss of sensation and motor function in all four limbs) and protein malnutrition (deficiency resulting in inadequate intake of protein/and or calories leading to weight loss and muscle wasting). Record review of Resident #1's care plan initiated on 11/13/2 reflected, [Resident #1] is on Enhanced Barrier Precautions.Interventions included. Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care.high-contact activity. Posting at the residents room entrance indicating the resident is on enhanced barrier precautions. In an interview and observation on 02/21/26 at 8:25 a.m. with Resident #1 in his room, resident was observed on a low air loss mattress and pressure relieving boots on both feet. Resident #1 stated he had been in the facility before and had moved closer to his family to another facility but stated it was terrible and came back here November 2025. He stated the wound care doctor comes to see him once a week. He stated they had his wounds closed up but they had opened back up. He stated he had requested his wound care be done only three times a week on Monday, Wednesday, and Friday. He stated he did decline wound yesterday (02/202/26) and stated he would let the nurse do his wound care today. An observation on 02/21/2026 at 8:55 a.m. revealed RN A outside of Resident #1's room preparing his wound care supplies. An EBP sign was posted on the door. RN A pulled several packages of boarder dressings, stack of 4x4 gauze, syringes of normal saline, squeezed some hydrogel into a medication cup and poured collagen powder in another medication cup. RN A and CNA D entered the room and RN A placed the wound care supplies on the resident's bedside without cleaning the table or placing the supplies on a barrier. Both staff then washed their hands and put on gloves, but no gowns. RN A removed the old dressing from Resident #1's left inner knee and discarded the dressing. With the same gloves she picked up a syringe of normal saline and picked up a few 4xr4's from the stack and cleaned with wound. RN A then took her gloved finger and dipped it into the cup containing the hydrogel and rubbed it onto the wound with her finger and did the same with the collagen powder and then covered the wound with a boarder dressing. RN A then removed her gloves and put on clean gloves without performing hand hygiene and removed the outer dressing from the resident's right outer ankle and picked up a syringe of a saline to help remove the old calcium alginate dressing which had stuck to the wound bed. RN A removed the dressing and continued to clean the wound bed with normal saline. RN A then laid the syringe which still had some normal saline on the bedside table with the other wound care supplies and with the same soiled gloves she opened a package of calcium alginate and pulled a piece sized for the wound and placed it on the wound and then covered it with a boarder gauze dressing. RN A then removed her gloves and put on clean gloves without performing hand hygiene and then with the assistance of CNA D they rolled the resident onto his side for her to perform the sacral wound care. RN A removed the old dressing and picked up the previously used syringe of normal saline and some 4x4 gauze and cleaned the wound bed. With the same gloves RN A then used her finger to apply the collagen powder to the wound and then covered the wound with calcium alginate and covered with a border gauze dressing. RN A gathered the trash, removed her gloves, performed hand hygiene, and left the room. CNA D repositioned the resident and offloaded his feet and knees with pillows, removed her gloves, performed hand hygiene, and left the room. In an interview on 02/21/26 at 9:25 a.m. RN A stated any resident who had a wound required EBP and she stated, Oh my goodness, I did not wear a gown. She stated she just simply forgot. She stated the reason for EBP was to prevent the spread of drug-resistant organisms from patient to patient. She stated she works double weekends and stated they were responsible for the wound care on the weekends but had a treatment nurse during the week. She stated she did not have very many treatments scheduled on the weekend. She stated she was not aware she had to set up her wound care supplies on a clean field and thought she only had to change her gloves when going from one wound to the next wound. She stated she really wanted to learn to do the correct way. She stated she could see how easily you could cross contaminate a wound. In an interview with CNA D on 02/21/26 at 9:30 a.m. she stated she had received training on Enhanced Barrier precautions and any resident with a foley or wound they were required to wear a gown and gloves when they provided care. She stated since she was just helping turn the resident, she just forgot to put on gown. She stated the risk of not following the correct precautions was the spread of infection. 2. Record review of Resident #2's Face Sheet dated 2/21/26, reflected a [AGE] year-old male with an admission date of 04/15/24. His diagnoses included metabolic encephalopathy (acute brain dysfunction caused by systemic illnesses that disrupt metabolic process) and diabetes. In an observation on 2/21/26 at 11:15 a.m. revealed LVN B at the treatment cart pulling wound care supplies to provide wound care for Resident #2. LVN B grabbed a large package of 4x4 gauze, a tube of hydrogel ointment, tubes of normal saline and a border gauze and entered the resident's room. LVN B placed the wound care supplies on the resident's bedside table without cleaning the table and placing the supplies on a clean field. LVN B washed her hands, put on gloves and gown, and then removed the old dressing from Resident #2's right upper thigh wound. LVN B then removed her gloves and re-gloved without performing hand hygiene pulled some 4x4 gauze and opened a tube of normal saline and cleaned the wound. LVN B then removed her gloves and re-gloved without performing hand hygiene and called out to the DON to bring her a smaller boarder dressing than the large dressing she had brought into the room. The DON entered the room and handed LVN B a smaller boarder dressing. LVN B opened the package of boarder dressing and then opened the tube of hydrogel ointment and squeezed a small amount onto the dressing. LVN B then laid the tube of hydrogel ointment on the bedside table without closing the lid and covered the wound with the boarder dressing. LVN B then removed her gown and gloves and washed her hands and gathered the package of 4 x 4 gauze, the tube of hydrogel and the large boarder dressing and returned them to the treatment cart. In an interview with LVN B on 2/21/26 at 11:35 a.m. she stated they usually do not have a lot of wound care treatments to do. She stated she knew she was supposed to change her gloves when she went from cleaning the wound before treating the wound and should have performed hand hygiene. She stated she was not aware she had to set her wound care supplies on a clean field and did not know she could not bring out unused supplies. In an interview with the DON on 2/21/26 at 1:03 p.m. she stated staff were to change their gloves and perform hand hygiene before going form dirty to clean, before entering a resident's room and before leaving a resident's room. She stated all residents who were in Enhanced Barrier Precautions had signs posted on their doors and the staff was expected to follow those protocols. She stated they train and do in-services constantly on infection control. She stated that failing to follow those protocol places residents at a higher risk of infections. She stated annual skills checks on the nurse's which included wound care. She stated they were to set up their supplies on a clean field and most definitely were not to apply any wound treatment with their gloved hand. She stated the staff was only to carry in the supplies they needed and anything not used needed to be discarded. She stated she would discard the tube of hydrogel, gauze, and dressing that was brought out of Resident #2's room. She stated they had a treatment nurse during the week but stated the weekend nurses were to be doing the wound care on the weekends. She stated she would be doing skills checks and re-education with the nurses. She stated she and her ADON do spot checks with nurses on their skills. Record review of the facility's policy titled, Enhanced Barrier Precautions, dated on April 2024, reflected, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities.Wounds generally include chronic wounds.pressure ulcers.unhealed surgical wounds.venous stasis ulcers. Record review of the facility undated policy titled, Fundamentals of infection control, reflected, .Hand Hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene.When hands are visibly soiled.before and after direct contact resident contact.Before and after isolation precautions.Before and after changing a dressing.after removing gloves. Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections.

Based on observation, interview and record review the facility failed to provide a safe, easy to use, clean and comfortable environment for 4 of 10 resident rooms on the 100 - hall (Resident rooms #1, #2, #3, and #4). The facility failed to ensure Resident rooms #1, #2, #3, and #4, were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.Findings include: An observation on 9/23/25 at 8:26 AM of resident room [ROOM NUMBER] reflected trash on the floor and white milk spilled on the floor, near the resident's bed. An observation on 9/23/25 at 8:27 AM of resident room [ROOM NUMBER] reflected large patches of brown and black stains on the floor, under the resident's bed. An observation on 9/23/25 at 8:28 AM of resident room [ROOM NUMBER] reflected large brownish stains on the floor, under the resident's bed. An observation on 9/23/25 at 8:28 AM of resident room [ROOM NUMBER] reflected large brownish dirt stains on the floor, under the resident's bed. Near the resident's bed was a large reddish fluid stain. The bedside table in the room was heavily stained on the bottom portion of the frame. In an interview on 09/23/25 at 01:38 PM, the Housekeeping Assistant Supervisor stated she had been at the facility for 7 seven years. She stated she cleaned the rooms on the 100-hall daily. She stated she cleaned the entire room, which included the bathrooms, under the beds, floors, and bedside tables. She stated she had not been at the facility for two days and someone else was responsible for cleaning the rooms. She stated all the concerns observed in Resident #1, #2, #3, and #4 rooms should have been cleaned. She stated the resident's family could have seen the dirty rooms and someone could have fallen from the spilled milk. In an interview on 09/23/25 at 01:49 PM, the Housekeeping Supervisor stated he had been at the facility for 20 years. He stated staff was to clean the entire rooms. He was advised and shown pictures of Resident room [ROOM NUMBER], #2, #3, and #4. He stated his cleaning staff was responsible for cleaning the areas observed. He stated the areas were unsanitary and not a good living environment for the residents. He stated he was responsible for checking to ensure the rooms were thoroughly cleaned but had not been checking them like he should have. In an interview on 09/23/25 at 2:16 PM, the Administrator was advised and shown pictures of concerns observed in Resident room [ROOM NUMBER], #2, #3, and #4. He stated he expected his housekeeping staff to thoroughly clean the resident rooms daily. He stated it was a sanitary and resident rights concern. Record review of the facility's policy on For Housekeeping Cleaning & Disinfecting, 2021, reflected In a quality program, its essential for all employees doing the same type of work to perform procedures in the same manner. To keep facilities clean and odor free, while providing the residents, their families, and staff with the safest environment possible and projecting a positive image.

Based on observations, interviews, and record reviews, the facility failed to ensure each resident is being watched and has assistance devices, when needed, to prevent accidents for six of nine residents (Resident #4, #5, #6, #7, #8, and #9) reviewed for accident hazards. The facility failed to ensure Resident #4, #5, #6, #7, #8, and #9 were properly supervised while smoking in the smoking area of the facility. This failure could place the residents at risk of harm and serious injuries. Findings include: 1 Record review of Resident #4's Face Sheet, dated 09/23/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Asthma (inflamed airways) and COPD (lung disease). Record review of Resident #4's Quarterly MDS assessment, dated 8/22/25, reflected she had a BIMS score of 15 (intact cognitive response). For active diagnosis it reflected a stroke. Record review of Resident #4's Comprehensive Care Plan, dated 9/23/25, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety. Record review of Resident #4's Smoking assessment, dated 8/18/25, reflected the resident required supervision while smoking. 2. Record review of Resident #5's Face Sheet, dated 09/23/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included stroke syndrome (neurological disorder) and lack of coordination. Record review of Resident #5's Quarterly MDS assessment, dated 6/25/25, reflected she had a BIMS score of 9 (moderate cognitive impairment). For active diagnosis it reflected contracted hand (tightening of tendons). Record review of Resident #5's Comprehensive Care Plan, dated 9/05/25, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety. Record review of Resident #5's Smoking assessment, dated 9/15/25, reflected the resident required supervision while smoking. 3. Record review of Resident #6's Face Sheet, dated 09/23/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination. Record review of Resident #6's Quarterly MDS assessment, dated 9/05/25, reflected she had a BIMS score of 1 (severe cognitive impairment). For active diagnosis it reflected a stroke. Record review of Resident #6's Comprehensive Care Plan, dated 9/05/25, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety. Record review of Resident #6's Smoking assessment, dated 8/23/25, reflected the resident required supervision while smoking. 4. Record review of Resident #7's Face Sheet, dated 09/23/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and COPD (lung disease). Record review of Resident #7's Quarterly MDS assessment, dated 9/01/25, reflected he had a BIMS score of 11 (moderate cognitive impairment). For active diagnosis it reflected COPD and tremors. Record review of Resident #7's Comprehensive Care Plan, dated 9/23/25, reflected the resident was a smoker, and an intervention was for the resident to be supervised while smoking for safety. Record review of Resident #7's Smoking assessment, reflected the resident did not have a smoking assessment completed. 5. Record review of Resident #8's Face Sheet, dated 09/23/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included schizoaffective disorder (mood disorder) and lack of coordination. Record review of Resident #8's Quarterly MDS assessment, dated 7/01/25, reflected she had a BIMS score of 10 (moderate cognitive impairment). For active diagnosis it reflected schizophrenia and muscle weakness. Record review of Resident #8's Comprehensive Care Plan, dated 8/22/25, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety. Record review of Resident #8's Smoking assessment, dated 8/23/25, reflected the resident required supervision while smoking. 6. Record review of Resident #9's Face Sheet, dated 09/11/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included stroke syndrome and lack of coordination. Record review of Resident #9's Quarterly MDS assessment, dated 8/15/25, reflected he had a BIMS score of 6 (severe cognitive impairment). For active diagnosis it reflected lack of coordination. Record review of Resident #9's Comprehensive Care Plan, dated 9/05/25, reflected no care plan for the resident being a smoker. Record review of Resident #9's Smoking assessment, reflected the resident did not have a smoking assessment completed. In an observation on 09/23/25 from 9:30 AM to 9:35 AM, Resident #4, #5, #6, #7, #8, and #9 were observed outside smoking in the smoking area. CNA G was observed sitting down and looking down at her phone and not observing the residents. In an interview on 09/23/25 at 10:52 AM, CNA G, stated she was responsible for monitoring Resident #4, #5, #6, #7, #8, and #9 when they were outside smoking. She stated she passed out the cigarettes and lit them. She stated she placed smoking apron on the residents who required them to prevent them from causing a fire on themselves. She stated she should be constantly monitoring them and should not be on her phone. She stated the resident could get hurt if she was distracted. She stated she had no excuse for being on her phone. In an interview on 09/23/25 at 1:16 PM, the DON stated she had been at the facility for 8 years. She was advised of, Resident #4, #5, #6, #7, #8, and #9 observed smoking in the smoking area, and CNA G being observed looking at her phone for at least five minutes. She stated staff should be keeping watch of the residents when they were smoking to ensure they did not have any accidents. She stated staff should not be on their phone and paying attention to the residents. In an interview on 09/23/25 at 2:16 PM, the Administrator was advised of, Resident #4, #5, #6, #7, #8, and #9 observed smoking in the smoking area, and CNA G being observed looking at her phone for at least the five minutes she was observed[KS1] . He stated he expected staff to keep watch of the residents when they were smoking to ensure they did not have any accidents. He stated he would in-service staff of this expectation. Review of the facility's policy SMOKING POLICY, undated, reflected Smoking policies must be formulated and adopted by the facility. The policies must comply with all applicable codes, regulations and standards, including local ordinances. The facility is responsible for informing residents, staff, visitors, and other affected parties of smoking policies through distribution and/or posting. The facility is responsible for enforcement of smoking policies which must include at least the following provisions: 2. A safe smoking assessment will be done regularly for each resident who smokes. Smoking by residents classified as unsafe will be prohibited except when the resident will be directly supervised by facility personnel or visitors who are aware of the resident's limitations with smoking. The resident must be within direct view of the smoking supervisor, in reasonably close proximity of the supervisor, and the supervisor must be able to quickly respond in the event of an emergency. Additionally, the supervisor, whether staff or visitor must be aware of these responsibilities.

Based on observations, interviews, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one of three residents (Resident #2) reviewed for respiratory care. The facility failed to ensure Resident #2's nasal canula was properly stored in a bag when not in use on 09/23/25. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings include: Record review of Resident #2's Face Sheet, dated 09/23/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Chronic Respiratory Failure (lack of oxygen) and Chronic Obstructive Pulmonary Disease (lung disease). Record review of Resident #2's Quarterly MDS assessment, dated 8/08/25, reflected he had a BIMS score of 15 (intact cognitive response). For ADL care, it reflected the resident required total assistance and it reflected an active diagnosis of cardiorespiratory failure and COPD. Record review of Resident #2's Comprehensive Care Plan, dated 9/05/25, reflected the resident requiring oxygen therapy and one of the interventions was to provide oxygen therapy through a moveable oxygen apparatus. Record Review of Resident #2's Physician Orders, dated 9/23/25, reflected Oxygen LPM 2-5 Via nasal canula In an observation on 09/23/25 at 08:29 AM, Resident #2 was not seen in his room. The resident had an oxygen tank connected to his wheelchair and his nasal canula was observed under a pile of clothes on his wheelchair. In an interview on 09/23/25 at 11:23 AM, LVN S was advised of Resident #2 not having his nasal canula bagged on his oxygen device attached to his wheelchair. She stated the resident usually removes the bag off his nasal canula. She was advised to observe the nasal canula on top of his wheelchair, under a pile of clothes. She started her shift at 6:00 AM but did not check to ensure the nasal canula was bagged when she checked on him this morning. She stated CNAs were responsible for checking to ensure the nasal cannulas were bagged. She stated it could cause an infection if the nasal canula was not bagged when not in use. In an interview on 09/23/25 at 1:16 PM, the DON was advised of Resident #2 nasal canula being observed on top of his wheelchair, under a pile of clothes, and unbagged. She stated nasal cannulas should be bagged when not in use to avoid transmission of germs. She stated primarily the nurses check for this when they make their rounds. Review of the facility's policy Oxygen Administration, 02/07/21, reflected Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. The nasal cannula delivers 22-40 % oxygen and is the most common, inexpensive, and easiest device to use. Common oxygen sources for long-term administration include cylinder (portable or stationary) or wall system near the resident's bed or concentrator. All sources require humidification to prevent drying of mucous membranes and thickening of respiratory secretions if used routinely. Goals 1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. 2. The residents will maintain an effective breathing pattern with administration of oxygen. 3. The resident will be free from infection.

Based on observation, interview and record review the facility failed to ensure the call system was accessible to residents while in their bed or other sleeping accommodations within the resident's room for two of five residents (Resident #1, and #3) reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light system in Resident #1, and #3's room was in a position that was accessible to the residents on 09/23/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: 1. Record review of Resident #1's Face Sheet, dated 09/23/25, reflected he was an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included stroke and lack of coordination. Record review of Resident #1's Quarterly MDS assessment, dated 9/05/25, reflected he had a BIMS score of 9 (moderate cognitive impairment). For ADL care, it reflected the resident required total assistance. Record review of Resident #1's Comprehensive Care Plan, dated 9/05/2025, reflected no care plan involving the resident's use of the call light. In an observation and interview on 09/23/25 at 08:25 AM Resident #1 was observed lying in bed. His call light pull cord was hanging from the wall behind him and out of reach. He was asked if he could reach his call light and he stated he did not know where it was at. 2. Record review of Resident #3's Face Sheet, dated 09/23/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and unsteadiness on feet. Record review of Resident #3's Quarterly MDS assessment, dated 8/21/25, reflected he had a BIMS score of 12 (moderate cognitive impairment). For ADL care, it reflected the resident required extensive assistance. Record review of Resident #3's Comprehensive Care Plan, dated 09/05/25, reflected the resident was a fall risk and one of the interventions was to ensure call light was within reach of the resident and to encourage the resident to use it. In an observation on 09/23/25 at 8:31 AM, Resident #3 was observed lying in bed and his call light was located approximately 3 feet away from his bed, out of reach from the resident. In an observation and interview on 09/23/25 at 08:35 AM Resident #3 was observed lying in bed. His call light pull cord was hanging from the wall behind him and out of reach. He was asked if he could reach his call light and he stated he did not know where it was and asked the surveyor to pull it for him because he needed assistance. In an interview on 09/23/25 at 8:35 AM, LVN C was advised of the call lights for Resident #1 and Resident #3 not being within reach of the residents. She stated staff checked the resident rooms at least every 2 hours to ensure call lights were within reach of the resident. She stated if the resident's call light were not within reach, they could not contact anyone if they needed help. She stated Resident #1 and Resident #3 were fall risk. In an interview on 09/23/25 at 11:06 AM, LVN P stated she had been at the facility for 15 years. She stated call lights should be close to the residents, and within their reach so they could call for assistance when they need it. She was shown pictures of the call light pull cord for Resident #1 and Resident #3 and where the cords were positioned. She stated it was the responsibility of all staff to ensure the call light was within the resident's reach. She stated they did have clips on them to ensure they stayed in place, but sometimes the clips fall off. In an interview on 09/23/25 at 11:23 AM, LVN S stated she had been at the facility since May 2025. She stated call lights should generally be within reach of the residents so they could notify staff if they need something. She stated they checked for this at least two times during her shift. She stated the call lights had a clip on them, but it may have fallen off. She was shown pictures of the call light pull cord for Resident #1 and Resident #3 and where the cords were positioned. She stated staff may have moved the call light when they brought in the residents' breakfast. She stated the risk of the call light not being within reach would be the resident would not be able to notify anyone if anything happened. In an interview on 09/23/25 at 11:51 AM, CNA L stated the call lights were to be clipped to the resident's bed and within reach. She was advised of Resident #1 and Resident #3 call light not being within reach. She stated she normally checked for this at the start of the shift, but it slipped her mind this morning. She stated the residents would not be able to contact anyone if they were in distress if the call lights were not within reach. In an interview on 09/23/25 at 1:16 PM, the DON was shown pictures of the call light pull cord for Resident #1 and Resident #3 and where the cords were positioned. She stated her expectation was for call lights to be in the resident's reach. She stated staff should check to ensure that they observe for call lights being within reach of the residents when making their rounds. She stated they need the call light within reach in case they need anything. Record review of the facility's policy on Resident Rights (11/28/16), revealed The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents.

Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two (Resident #1 and Resident #2) of two reviewed for abuse and neglect.The facility failed to ensure Resident #2 was free from abuse, on 6/27/25, when Resident #1 struck her in the forehead with a cane, which resulted in a laceration.This failure could place residents at risk of abuse and emotional stress. Findings include: 1. Record review of Resident #1's face sheet dated 02/26/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dementia of unspecified severity without behavioral disturbance (a decline in memory or other cognitive function not accompanied by aggression), psychotic disturbance (delusions or hallucinations), delirium due to psychological condition (acute confusion linked to psychiatric causes), cognitive communication deficit (difficulty understanding or using language), unsteadiness on feet, gait abnormalities, muscle weakness, and a history of lack of coordination.Record review of Resident #1's Quarterly MDS dated [DATE] , reflected a BIMS score of 10, which indicated she was moderately cognitively impaired. Resident #1 used a cane when off the facility premises but did not typically use it inside the facility.Record review of Resident #1's June 27, 2025 care plan reflected interventions related to behavioral health and safety, including redirection, increased monitoring, and staff awareness of behaviors that could place others at risk. The care plan specifically indicated that the resident had exhibited physical behaviors toward others and outlined interventions such as staff immediately intervening to protect involved residents, calling for assistance, and attempting to de-escalate situations by removing the resident from the source of distress and engaging them calmly. If the resident's response was aggressive, staff were directed to calmly walk away. These interventions reflected a history of agitation and physical aggression toward others.Record review of progress notes dated 06/26/25, entered at 11:50 p.m. indicated Resident #1 had returned to the facility and was involved in an altercation with Resident #2. The progress note did not include a detailed or verbatim account of the incident, but did outline the facility's response following the event. According to the documentation, the residents were separated, first aid was provided to both individuals, and both a skin assessment and pain assessment were completed. Urinalysis samples were obtained from both residents, the abuse coordinator was notified, and the facility's abuse protocol was followed. The progress note also stated that one-on-one supervision was initiated for Resident #1 and that the facility would continue to monitor the situation.2. Record review of Resident #2's face sheet dated 10/02/ 24 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: spinal stenosis (narrowing of the spine that can cause pain or mobility issues), muscle weakness, chronic low back pain, major depressive disorder (recurrent, severe feelings of sadness and loss of interest ), generalized anxiety disorder(intense , excessive or persistent worry or fear ), and essential hypertension(high blood pressure ).Record review of Resident #2's Quarterly MDS dated [DATE] , reflected a BIMS score of 13, which indicated she was cognitively intact.Record review of Resident #2's June 27, 2025 care plan reflected interventions addressing safety, mood, and behavior. The care plan noted Resident #2 preferred to eat in her room and had minimal peer interaction. No history of aggressive behaviors was documented. Record review of progress notes dated 06/26/25 relevant to the incident were reviewed. The progress notes reflected that Resident #2 was involved in an altercation with another resident. Resident #2 was assessed both physically and emotionally afterward. The progress notes reflect that first aid was administered, a skin assessment and pain assessment were completed, and that Resident #2 received support following the incident. The progress notes reflected appropriate post-incident procedures were followed, but did not include an in-depth description of the resident's behavior or emotional state beyond confirming that interventions were provided.Record review of Resident #2's progress notes 06/26/25 reflected law enforcement was dispatched to the facility following the altercation. Resident #2 initially requested to be sent to the hospital when officers arrived but later refused treatment upon ambulance arrival, and stated she felt fine. A small laceration approximately 2 cm in length was noted on her forehead. The wound did not require stitches or advanced intervention. Record review treatment orders for Resident #2's forehead laceration were discontinued on , 07/08/25 which indicated the wound had resolve. Record review of documentation by social services dated 06/27/25 reflected Resident #2 was alert, oriented, and stated she was feeling better. She accepted supportive counseling and was encouraged to avoid contact with Resident #1 and to report any further concerns. Resident #2 consented to a referral for psychological services. Documentation reflected plans for continued monitoring and supportive interventions due to the incident . Interview on 7/8/25 at 12:38 p.m. with Resident #2 During the interview with Resident #2 the resident appeared visibly irritated and used profanity multiple times. However, her irritation did not appear to be related to the altercation that occurred with Resident #1. Resident #2 expressed frustration that her handwritten Do Not Disturb sign, which was posted on her door, was not being respected by staff or others entering her room. She specifically stated that staff continued to knock on her door to deliver meals and medications, which she felt disregarded her request to not be disturbed.Before initiating the interview, surveyor made an attempt was made to contact the resident using the phone number listed in the system; however, the number was not in service. As the resident remained in the building and the sign on the door had not been removed during the time the surveyor was on site, surveyor knocked on her door to attempt the interview before leaving the facility. Resident #2 acknowledged during the interview that she was not mad at the surveyor directly, but also emphasized, You saw the sign on the door and still knocked and bothered me anyway. Based on her comments and demeanor, it appeared that she remained frustrated with the interruption despite stating it was not personal. Resident # 2's irritation during the interaction appeared to be tied to the presence of the Do Not Disturb sign being ignored, rather than to the prior incident with Resident #1. Interview on 7/8/25 at 12:45 p.m. with the Assistant Director of Nursing revealed she was working on the backside of the unit at the time of the incident and reported hearing raised voices, though she was unable to make out what was being said or which residents were involved. She stated that shortly afterward, staff came to notify her that assistance was needed. She secured her medication cart and responded to the location of the incident. Upon arrival, she observed that the two residents. Resident #1 and Resident #2 had already been separated. The ADON stated she observed blood coming from a laceration on Resident #2's forehead and immediately began assessing the resident, initiated the abuse protocol, and contacted law enforcement. She confirmed that 911 was called and that Resident #2 initially agreed to be transported to the hospital for further evaluation, but later refused treatment upon arrival. The ADON described the injury as minor. She added that Resident #1 had just returned to the facility prior to the incident and was later transported to the hospital for psychiatric evaluation in accordance with facility protocol.Interview on 7/8/25 at 1:32 p.m. with the Director of Nursing revealed that the facility was aware that both residents displayed behaviors such as verbal agitation, including the use of profane language and raised voices. One resident was described as feisty, a term often used informally to indicate someone who is spirited, outspoken, or easily upset. In this context, it reflects the resident's tendency to become verbally agitated or assertive, including using strong language or raising their voice. This description did not imply physical aggression or violence but highlighted that the resident may express frustration or disagreement loudly or passionately.Interview on 7/8/25 at approximately 2:00 p.m. with the facility Administrator revealed he considered the incident an isolated event which involved two residents with a known history of behavioral concerns at previous facilities. He stated neither resident had exhibited physically aggressive behavior while at the current facility. The Administrator reported both residents declined to provide written statements. He responded to the facility 30-45 minutes after being notified and expressed confidence that the facility responded appropriately by separating the residents and contacting emergency service. According to facility records and staff interviews, neither of the two residents had any history of physical or verbal altercations with each other while residing at the current facility. Both residents were known to display verbal agitation and use profane language individually, but there were no documented incidents of conflict or behavioral issues between them prior to the reported incident.Interview conducted on 7/8/25 at approximately 2:30 p.m. with the LVN A revealed that she assessed Resident #2's wound the day after the incident occurred. The LVN A explained that the incident took place late at night, near midnight, and by the time of documentation and follow-up, it was already considered the next calendar day. She further clarified that although she personally evaluated the wound the following day during her scheduled shift, other nursing staff had already responded to and assessed the resident at the time of the incident. The LVN A stated that Resident #2 was selective about who she allowed to examine her, and she did not permit paramedics or certain staff to view or treat the area. The LVN A described the wound as minor, resembling a scratch, and noted that it was already beginning to heal by the time she observed it. She also mentioned that the resident had removed the initial bandage herself prior to the LVN A's assessment.Interview on 7/8/25 at 1:46 p.m. with CNA A revealed she was present the day of the incident and had prior familiarity with both residents. CNA A stated Resident #1 typically left the facility during the day and returned in the evening, while Resident #2 usually stayed in her room and did not participate in group dining. CNA A reported the residents had never bumped heads before meaning they had never had a disagreement, argument, or conflict and typically stayed to themselves. She stated, They would speak to each other and go about their day. I've never known either of them to be physical with anyone. CNA A stated since the incident occurred, the residents were separated and there had been no further incidents between the two residents. Additional interviews conducted with staff on 7/8/25 from 12:45 PM to 2:45 PM revealed consistent knowledge of the facility's abuse and neglect policies, including guidelines related to resident-to-resident aggression. Interviews were conducted with the Assistant Director of Nursing, Director of Nursing, Licensed Vocational Nurse, Certified Nursing Assistant, and the Administrator. Staff members stated they received in-service training covering abuse prevention, behavioral interventions, resident rights, and reporting requirements. Staff were able to describe the process for managing residents with behavioral concerns. Attempted interview on 7/8/25 at 2:10 p.m. with Family Member #1 (associated with Resident #1): A voicemail was left; no return call was received.Attempted interview on 7/8/25 at 2:11 p.m. with Family Member #2 (associated with Resident #2): A voicemail was left; no return call was received.Attempted interview on 7/8/25 at 2:05 p.m. with the facility Social Worker: The Social Worker was not on site at the time of the visit. A phone interview was attempted using the number provided by facility staff. A voicemail was left; no return call was received.Record review of the facility's, undated, Abuse/Neglect policy reflected all residents had the right to be free from all forms of abuse, including abuse by other residents. The policy directed that the facility must investigate all allegations of abuse, report findings, and implement measures to ensure resident safety when abuse is suspected or confirmed.

Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #4) of 5W residents reviewed for PASARR. The facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal 02/20/2025 as required within 20 business days after the date of the Interdisciplinary Team meeting . The NFSS Request submittal by the NF was denied on 02/10/2025, and there was no evidence of facility follow up. to ensure the request was approved to provide specialized services for PASARR for the resident. These failures could place the resident at risk of not receiving necessary care and/or services. Findings Included: Record review of the NFSS submission for Resident #4 on 02/10/2025 revealed the submission was completed electronically, and not via SIMPLELTC web portal, as required on 02/10/2025. Record review of Resident #4's admission record dated 06/10/2025 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, Acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), major depressive disorder recurrent severe (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), brief psychotic disorder (a temporary psychiatric condition characterized by sudden onset of psychotic symptoms, such as delusions and hallucinations, lasting less than one month), and generalized anxiety disorder (inability to control constant worrying). Record review of Resident #4's Comprehensive MDS assessment dated [DATE] indicated Resident #4 understood others and was understood. The MDS assessment indicated Resident #4 was considered by the state level II PASARR process to have serious mental illness. The MDS assessment indicated Resident #4 had a BIMS score of 15, which indicated her cognition was intact. Record review of Resident #4's order summary report dated 06/10/2025 revealed the following orders: Dapagliflozin Propanediol Oral Tablet 5MG (Dapagliflozin Propanediol) Give 1 tablet by mouth one time a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. Buspirone HCl Tablet 5 MG Give 1 tablet by mouth three times a day related to ANXIETY DISORDER, UNSPECIFIED Benztropine Mesylate Oral Tablet 2 MG (Benztropine Mesylate) Give 1 tablet by mouth two times a day related to NEUROLEPTIC INDUCED PARKINSONISM Record review of Resident#4's care plan reviewed on 06/10/2025 indicated, she had mental illness, Mental Disability and was PASARR positive. Resident #4's goal indicated she would have the specialized services recommended by the local authority per PASARR specialized services program as needed. Resident #4's interventions indicated the local authority would be invited annually to the care plan meeting for review of specialized services. Record review of Resident #4's most recent PASARR Level 1 Screening completed 01/03/2025 indicated she was positive for a primary diagnosis of Mental Illness and positive for Intellectual Disability. During an interview on 06/10/2025 at 11:20 AM the DON stated the MDS nurse was responsible for making sure PASARRs were done. The DON stated if they were not completed accurately, it could prevent residents from receiving services. During an interview on 06/10/2025 at 4:05 PM the MDS Coordinator said she had been the MDS coordinator for about a month. She stated she was responsible to complete the PASARRs. It is responsibility to enter the resident into SimpleLTC program for the state to where it is sent. Also, to where it is sent to the local authorities if it comes up positive. When it was positive someone usually came in and then assessed them for services. She stated if a PASARR screening was not completed correctly, residents may not receive the services to which they were entitled. She said there was a risk that the resident could miss services she was entitled to if the PASARR forms were not filled out correctly. The MDS coordinator stated, it went automatically if the PASARR unit did not contact her or the SW She stated the only communication she received was confirmation, that they received the orders. She stated someone would come in locally after they received an order to assess a resident. She stated, she does not receive any type of electronic notification of submitting, whether it was submitted properly. She stated she had not been notified by anyone from the state PASARR unit that it was not received. She said it could affect residents negatively if they do not receive the services for which they are slated. Both mentally and even physically. The MDS Coordinator stated even if they do not get the services some of the service department lend some assistance and help till, they do get those services. She stated they do not receive confirmation electronically and they usually just monitor it and go from there. During an interview on 06/10/2025 at 4:20 PM the ADMIN said the responsibility would fall on the MDS Coordinator to take care of the NFSS submission and follow up to ensure acceptance. it. The MDS Coordinator would be responsible for ensuring PASARR assessments were correct. ADMIN stated in the past we(staff) usually would be the backup. ADMIN stated in the past he would reach out to the appropriate dept and find out why it was not submitted. He stated he would follow up with MDS Coordinator to see if it were overlooked and not submitted. He was not aware of the facility receiving a denial. The usual protocol was if it were denied then an email would correspond to advise as such. He stated in this instance they did not receive an email. The ADMIN stated he was familiar with the incident and recalled receiving an email from the PASARR unit regarding resident #4. The ADMIN stated the facility submitted the NFSS electronically. He stated he did not recall the person at the PASARR unit. He stated they could not view it in the portal, so it appeared is the NFSS was not submitted. The ADMIN stated Resident#4 did not receive PT services. He stated it was the ADMIN responsibility to make sure this process was completed properly and in accordance with procedure for electronic submission in the SIMPLELTC portal. The ADMIN stated in the future he would ensure NFSS are submitted properly in the portal to prevent this from happening again. During an interview on 06/16/2025 at 3:10 PM Complainant advised it is the responsibility of the facility to monitor the submission of the NFSS into SIMPLELTC portal to ensure if it is accepted. If it is denied, the facility is responsible for making the necessary corrections and resubmit NFSS. The material that is submitted is time sensitive in regard to making sure everything is completed and necessary for the resident in question to get the proper care and services. There is only one method for submission of the documents and that is through the SIMPLE LTC portal, there is no other means to submit this information. Record review of the facility policy, dated Revised 03/16/2019, titled PASARR Nursing Facility Specialized Services Policy and Procedure reflected It is the policy of facility facilities to ensure NFSS Forms are submitted timely and accurately. 7. The IDT may recommend NFSS services for ID/DD and dual MI + ID/DD Residents. 8. Therapy, CMWC DME or DME is notified ASAP after the IDT meeting. (You only have 3 days to enter the PCSP Form after the PCSP meeting). 9. The facility only has 20 business days from the Date of the PCSP meeting to submit a completed and accurate NFSS Form. 10. NFSS will be inputted in SIMPLELTC within 24 hours of receipt of the Assessment/Service from therapy and the Alert section of SIMPLELTC will be monitored daily for approval/denial.

Based on interviews and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status; a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility for one (Resident #1) of one resident reviewed for Notification of Changes. The facility failed to immediately notify the physician of Resident #1's change of condition to his lower extremity ulcers. The resident's ulcers had malodorous odor, slough (dead tissue, usually cream or yellow in color), and live maggots (appear like pale worms - a young form of the fly evolved from eggs laid by flies) embedded in the wound and had no wound dressing. An Immediate Jeopardy (IJ) was identified on 06/28/23 at 2:58 PM. While the IJ was removed on 06/29/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. This deficient practice placed residents at high risk of, or the likelihood of, serious injury, harm, impairment, or death by not receiving treatment, developing complications, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: A record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old male admitted on [DATE]. Resident #1 had medically complex conditions and active diagnoses of anemia; HTN (when the pressure in the blood vessels is too high - 140/90 mmHg or higher); Cerebral infarction (also called a stroke, occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it); COPD (a group of diseases that cause airflow blockage and breathing-related problems); incomplete quadriplegia (paralysis of all four limbs) with contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to impairment and inability to bend joints) of left upper limb; atherosclerosis (thickening or hardening of the arteries) of left leg with ulceration (the formation of a break on the skin) of other part of foot; and cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of left lower limb. Resident #1's BIMS score was 11, which indicated moderately impaired cognitive impairment. The Quarterly MDS reflected Resident #1 required one-person physical assist with ADLs. The Quarterly MDS did not indicate Resident #1 had any behavioral symptoms or rejection of care during the MDS review period. Section M, Skin Conditions, of the Quarterly MDS reflected Resident #1 had two venous and arterial ulcers present. No other ulcers, wounds and skin problems were identified. The Quarterly MDS reflected a pressure reducing device for chair, a pressure reducing device for bed, and application of dressings to feet as skin and ulcer/injury treatments. Resident #1's clinical physician orders reflected: - Start date 05/21/23 [D/C date: 06/06/23]: Santyl External Ointment 250 unit/Gm (Collagenase). Apply to dorsal lateral left foot topically one time a day for wound care cleanse left foot with normal saline apply Santyl with calcium alginate with gauze with border dressing daily and prn soilage/dislodgment of dressing - Start date 05/21/23 [D/C date: 06/06/23]: Santyl External Ointment 250 unit/Gm (Collagenase). Apply to left leg topically one time a day for wound care cleanse left leg with normal saline apply Santyl/Calcium Alginate with gauze with border dressing daily and prn soilage/dislodgment of dressing - Start date 06/06/23: Cleanse dorsal left foot with normal saline apply Honey Gauze Dressing (a sterile non-adhering & breathable mesh sheet gauze dressing soaked or saturated with a medical grade honey substance) with Kling [a flexible rolled gauze dressing] daily & prn soilage/dislodgment of dressing - Start date 06/06/23: Cleanse left lower leg with normal saline apply Honey Gauze Dressing (a sterile non-adhering & breathable mesh sheet gauze dressing soaked or saturated with a medical grade honey substance) with Kling [a flexible rolled gauze dressing] daily & prn soilage/dislodgment of dressing - Start date 06/19/23 [Revision date 06/14/23; End date 06/26/23]: Weekly skin evaluation/ Monday/ 6A - 2P. One time a day every Monday until 06/26/23 A review of Resident #1's comprehensive care plan indicated: FOCUS: - The resident has a wound or skin abnormality arterial wound to left shin - Arterial wound dorsal left foot [Initiated: 02/21/23; Revision on 04/14/23] GOAL: - Resident's skin abnormality or wound will remain stable or improve [Initiated: 02/21/23; Target: 09/05/23] INTERVENTIONS: - 03/24/23 Vascular Surgeon consult [Initiated: 03/24/23; Revision: 04/19/23] - Call the doctor or NP if needed for any signs of infection or worsening of the skin - Provide treatments as ordered by physician. See medication and/or treatment administration record Review of Resident #1's June 2023 TAR reflected blank spaces in the columns that represented the day(s)/date(s) in June and treatment time, Day [6 AM - 2 PM]. There were no nurse initials or a chart code with reason/comment that the treatment was or was not provided for the following order(s): - Saturday 3rd and Sunday 4th: Santyl External Ointment 250 unit/Gm (Collagenase). Apply to dorsal lateral left foot topically one time a day for wound care cleanse left foot with normal saline apply Santyl with calcium alginate with gauze with border dressing - Saturday 3rd and Sunday 4th: Santyl External Ointment 250 unit/Gm (Collagenase). Apply to left leg topically one time a day for wound care cleanse left leg with normal saline apply Santyl/Calcium Alginate with gauze with border dressing - Sunday 18th: Cleanse dorsal left foot with normal saline apply Honey Gauze Dressing with Kling daily & prn soilage/dislodgment of dressing - Sunday 18th: Cleanse left lower leg with normal saline apply Honey Gauze Dressing with Kling daily & prn soilage/dislodgment of dressing Review of Resident #1's June 2023 TAR reflected initials and Chart Codes/Follow-Up Codes in the columns that represented the day(s)/date(s) in June and treatment time, Day [6 AM - 2 PM] for the following order(s): Cleanse dorsal left foot with normal saline apply Honey Gauze Dressing with Kling daily & prn soilage/dislodgment of dressing Cleanse left lower leg with normal saline apply Honey Gauze Dressing with Kling daily & prn soilage/dislodgment of dressing - On Wednesday, 06/07/23 the TAR reflected a chart code, 2 = Drug Refused. LVN E initialed, linked and entered a progress note (06/07/23 at 2:23 PM), Resident refused to allow this writer [LVN E] to complete wound care to left leg and left foot per orders, only allowed areas to be cleansed with normal saline and dressing applied, [NP] notified of resident's refusal of complete wound care. - On Sunday, 06/11/23 the TAR reflected a chart code - 9 = Other/See Nurse Notes. RN A initialed the TAR but did not enter a progress note. - On Saturday, 06/17/23 the TAR reflected a chart code - 5 = Hold/See Nurse Notes. RN C initialed, linked and entered a progress note (06/17/23 at 1:31 PM), Not in facility. - On Sunday, 06/25/23 the TAR reflected a chart code, 2 = Drug Refused. LVN D initialed, linked and entered a progress note (06/25/23 at 9:50 PM), [Resident #1] Refused dressing change. A review of the WMD Wound Evaluation and Management Summary dated 02/20/23 reflected, At the request of the referring provider, [PCP], a thorough wound care assessment and evaluation was performed today [02/20/23]. The Focused Wound Exam revealed an arterial wound of the left, dorsal, lateral foot that measured (L x W x D): 3.5 x 12.5 x 0.1 cm; moderate serous exudate; 100% slough (dead tissue, usually cream or yellow in color); and wound progress deteriorated. Further review of the Focused Wound Exam revealed an arterial wound of the left leg that measured (L x W x D): 13 x 10.5 x 0.1 cm; moderate serous exudate; 100% slough; and wound progress improved. A dressing treatment plan recommended for both wounds included Primary dressing(s) - Alginate calcium apply once daily for 30 days; Santyl apply once daily for 30 days; and Secondary dressing(s) - Gauze Island with border apply once daily for 30 days. The WMD performed a clean surgical excision debridement procedure to each wound to remove necrotic tissue and establish the margins of viable tissue. The WMD documented factors that complicated wound healing were [Resident #1] was a daily smoker and Anemia diagnosis. Review of the subsequent weekly WMD progress notes dated 02/27/23, indicated Resident #1 refused visit. The next available WMD progress note in Resident #1 digital chart was dated 03/20/2023, that also indicated Resident #1 refused visit. The last WMD progress note uploaded to Resident #1's chart was dated 06/19/23, that indicated Resident #1 was inactive - initial 90 days cut off related to refused WMD visits. An interview and observation on 06/27/23 at 2:01 PM revealed Resident #1 up to wheelchair, able to self-propel, entering the facility from the smoking area. Resident #1 was alert and oriented to self, surroundings, time of day, and situation. Resident #1 asked to speak with the investigator in private. During the interview, Resident #1 informed the investigator that he had not received wound care since Friday (06/23/23). A foul smell was noted coming from the resident. Resident #1 said that the nurses always say they could not find me . only go to smoke break and in my room . they [nurses] wait until gone outside for smoke break to say they were ready to perform wound care, then return from smoke break the nurse would say their shift ended. Resident #1 said that he would not receive wound care and the nurses would say that he refused. When asked was there a treatment nurse who usually performed wound care, Resident #1 stated he did not want her [LVN E] to do his wound care because she did not know what she was doing. Resident #1 said that he allowed RN A to do the wound care, but she gets busy and does not do the wound care every day. When Resident #1 was asked if the WMD visited, Resident #1 said that the WMD visit every Monday and was seen a couple of times, but whatever he told [LVN E] to put on my legs made them worse . now the wound is coming all up my leg, so he refused to see the WMD anymore. During the interview and observation on 06/27/23 at 2:01 PM with Resident #1, RN A was observed in the hallway pushing a medication cart towards Resident #1's room. RN A approached the investigator and stated that she was about to perform wound care but would wait until the investigator was done speaking with Resident #1. The investigator suggested RN A follow through with wound care and informed [RN A] that the investigator would observe. Resident #1 consented to the investigator observing wound care. On 06/27/23 at 2:23 PM, RN A was observed performing wound care to Resident #1's left lower leg and foot. When RN A pulled Resident #1's sock down, a non-pressure- related skin ulcer/wound(s) was noted at the left distal front portion of the lower leg (greater than 13 x 10.5 cm by visual inspection). The wound was malodorous (smelled very unpleasant), moist, covered in slough (dead tissue, usually cream or yellow in color), and approximately eight maggots were observed on the front left leg, about 2 - 3 maggots were embedded in the wound bed, and approximately 10 maggots had fallen off the leg onto the barrier placed on the bed when the sock was pulled down from over the wound. The surrounding skin was a dark red discoloration with some chaffing noted. The wound was not covered with any type of dry dressing. When RN A pulled the sock all the way off Resident #1's left foot, a non-pressure- related skin ulcer/wound (greater than 3.5 x 12.5 cm) was observed to the left top lateral foot. No maggots were noted on the foot. 1 - 2 maggots were observed in the crease of the sock. The wound was moist, some slough, no drainage. The surrounding skin had a dark red discoloration with some chaffing noted. The wound was not covered with any type of dressing. During an interview on 06/27/23 at 2:41 PM, RN A said that she was the charge nurse for the hall that Resident #1 resided Monday - Friday, 6A - 2P. RN A stated that LVN E was the treatment nurse who was responsible for performing wound care for Resident #1. RN A said that Resident #1 refused [LVN E- treatment nurse] to perform wound care and preferred [RN A] to do wound care. RN A said that she tried to perform wound care daily when she could or write on the 24-hr report to notify the on-coming nurse if she [RN A] did not get a chance to perform Resident #1's wound care. RN A stated that although she tried to perform wound care for Resident #1, LVN E is responsible when on duty Monday through Friday. When asked if RN A performed wound care the day before (Monday, 06/26/23), RN A said that she was very busy on that day and Resident #1 went outside to smoke when she made time to do the wound care around 1:00 PM, but she did not get around to doing it before her shift ended at 2:00 PM. RN A said that one of the smoke breaks was sometime between 1:00 PM and 1:30 PM. RN A said that the MD/NP should be immediately notified about a resident condition change immediately. RN A said that she told LVN E [treatment nurse] about the maggots to follow up and notify the doctor. RN A said that she should have called the MD since she discovered the maggots during wound care. When RN A was asked if she followed the wound care order as written, RN A replied Yes. When RN A asked to state in her own words the supplies needed for Resident #1's wound care, RN A stated, normal saline to clean the wound, Medihoney or Therahoney to apply to the wound, ABD pads to cover the wound and roll gauze to wrap and secure the wound. The investigator reviewed Resident #1 wound order with RN A and asked if Medihoney/Therahoney gel and honey gauze dressing were the same, RN A replied, yes, but the treatment nurse [LVN E] orders the supplies . and [RN A] used the supplies available when required to perform wound care. RN A was asked if supplies were interchangeable if the physician order reflect a specific or brand name supply, RN A said yes. During an interview on 06/27/23 at 3:58 PM, LVN E said that her roles were treatment nurse and MDS nurse. LVN E said that Resident #1 admitted with arterial/vascular wounds to his left lower extremity and the WMD was consulted. When asked who was responsible for providing wound care, LVN E said that she was responsible Monday - Friday, 8A - 4:30 PM; and the floor nurses were responsible over the weekend and whenever the treatment nurse was not at the facility. LVN E said that she did not work 06/19/23 - 06/26/23 and the floor nurses were responsible for resident wound care. LVN E said that Resident #1 had an order for daily wound care but often refused wound care. LVN E said that she was unaware that Resident #1 had maggots in his leg wound because [Resident #1] refused [LVN E] to perform wound care and would ask for RN A to perform the wound care. LVN E described a significant change to a wound would include an adverse reaction to a treatment, no improvement, or worsening of a wound with the current prescribed treatment. LVN E said that the MD/NP should be notified if a resident refused wound care, if there were significant changes to a wound, it should be care planned. LVN E did not confirm or deny if she called the MD/NP when RN A notified her [LVN E] that Resident #1 had maggots in his leg wound on 06/27/23. In a continued interview on 06/27/23 at 3:58 PM, LVN E said that Resident #1 was not followed by the WMD because he refused the visits. LVN E said that she notified the NP around the end of May or beginning of June (2023) that Resident #1 refused the WMD visits. LVN E said that the NP's recommendation was to locate another wound care provider or clinic to send Resident #1 for wound care treatments. When asked if the MD/NP was responsible to give treatment orders if Resident #1 refused visits by the WMD, LVN E said that care was coordinated with the MD/NP to obtain orders for medications/treatments. Review of Resident #1's nurse progress notes on 06/28/23 indicated: - 06/27/23 at 2:29 PM, the LVN E entered: Resident has refused wound care this shift. Prefers wound care to be done at his discretion and when he wants it done. - 06/27/23 at 2:47 PM, RN A entered: . performed wound tx today . there are worms on the leg and under his pants leg. It was under his moist pant leg that is very odorous . Will notify wound nurse of my findings. - 06/28/23 at 6:34 AM, RN A entered: [Resident #1] will not let me use Therahoney, only Medihoney he states. Wound care still completed. No worms noted in wound site today. During record review, there was no documentation that indicated the facility notified the MD/NP about a change in condition of Resident #1's wound on or before 06/27/23. During an interview on 06/28/23 at 8:00 AM, LVN E said that she was not the treatment nurse for the day [06/28/23] because she had to work as the floor nurse, therefore, the investigator could not observe her perform wound care. When LVN E was asked if she would still be responsible to perform wound care even as a floor nurse in the absence of the treatment nurse, LVN E replied that RN A had already performed wound care this morning [06/28/23] and to talk to [NFA] to ask who is responsible if wound care is not done. LVN E was asked how she ensured the wound care orders were followed and supplies were available over the weekend or when she does not work. LVN E stated that she inventoried wound care supplies and notified central supply staff to order what is needed. LVN E said that central supply staff were responsible for ordering supplies as needed when running low or a new medication/treatment is ordered. LVN E said that the treatment supplies are ordered as outlined in the physician order. LVN E said if the order reflected a brand name it still meant to use a certain product and not specifically the brand and that is what she [LVN E] informed central supply staff to order. LVN E stated that Medihoney and Therahoney are interchangeable, they are just brand names of a honey treatment. The investigator reviewed Resident #1 wound order with LVN E and asked if Medihoney/Therahoney gel and honey gauze dressing were the same, LVN E replied, the order said to use honey and gauze dressing. LVN E said that the MD should be notified if supplies are not available to obtain an order for an alternative medication/treatment. During an interview on 06/28/23 at 8:27 AM, RN A said that she worked overnight (10P - 6A) and was not working her regular 6A - 2P shift. When asked if RN A performed wound care to Resident #1 this morning (06/28/23) she stated that she did. RN A said that she brought TheraHoney (a brand name) Wound Gel to apply to Resident #1's wound because she could not find any MediHoney (a brand name) Wound Gel. RN A said that she only cleaned the wound with NS and wrapped with rolled gauze because Resident #1 refused TheraHoney Wound Gel to be applied to his wound, only the MediHoney. RN A said that she tried to explain [to Resident #1] that the two wound gels were the same just different names. RN A said that the wound was not as smelly and still had slough. RN A denied observing any maggots when wound care was performed. When RN A was asked if the MD/NP was notified about the maggots or that the MediHoney was unavailable to get an order for an alternative treatment, RN A denied. During a phone interview on 06/28/23 at 12:56 PM, the NP denied that she received a call from the facility about maggots in Resident #1's wound. The NP stated that had she informed she would have likely given an order to send [Resident #1] to the hospital for evaluation and treatment. During a phone interview on 06/28/23 at 1:08 PM, the MD indicated that she did not receive a call about Resident #1 or informed about maggots observed in [Resident #1's] wound. The MD stated that her expectation is to be updated about changes in condition as soon as possible to ensure resident care needs are med and to make changes in treatment as necessary. During an interview on 06/28/23 at 1:56 PM, the NFA stated that his expectation was for nurses to document and notify the doctor about any change in a resident condition immediately. The NFA stated that he currently did not have a DON, but had an RN scheduled to work 8 hours per day 7 days per week and the RNC is a resource in place of the DON until the position is filled. Record review of the facility's Change in a Resident's Condition or Status policy, revised February 2021, reflected the policy statement to notify the resident, attending physician, and resident representative of changes in the resident's medical/mental condition and/or status. Record review of the facility's Wound Care policy, revised December 2020, reflected, Reporting - Notify the supervisor if the resident refuses the wound care . Report other information in accordance with facility policy and professional standards of practice The NFA was notified of an Immediate Jeopardy (IJ) on 06/28/23 at 2:58 PM due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 06/29/23 at 3:58 PM and included: On 6/28/23, the ADON under the guidance of the Regional Nurse Consultant (RNC) initiated an in-service and training with all licensed nurse staff on duty and newly hired staff to cover the topics of the following: - The expectation and practice of immediately consulting with the resident's physician of a significant change in any resident's physical status that requires a need to alter treatment - Changes of condition to be reported to the attending physician immediately as dictated by the care attention warranted by the resident's physical condition - Standard Operating Procedure if unable to contact physician and/or specialist regarding a significant change of condition. Each attempt will be documented in the medial record. After the 3rd attempt the DON/designee will be notified and will then notify the Medical Director for further guidance. - The DON and designees audited the last 72 hours (about 3 days) of documentation in progress notes, or possible other missed opportunities - All licensed nurse staff will acknowledge and demonstrate understanding - The DON/ADON Designee will contact all licensed nurse staff and get a verbal acknowledgement as a return demonstration of understanding that a Physician must be notified immediately of changes of condition - On 06/28/23, the NFA, ADON, and RNC held an ad hoc QAPI meeting with the Medical Director via phone to discuss the IJ cited on 06/28/23. - Effective 06/28/23, the DON/ADON/Designee will conduct random audits of 24-hour Summary in PCC to include review of all progress notes with emphasis on validating that all changes in condition have been identified and physician has been notified of all pertinent information - The DON/ADON/designee will conduct random audits with all licensed staff to validate the understanding that they are to notify the physician of a significant change in any resident's physical status; nursing staff were contacted in person or by phone and verbally in-serviced; all in-services will be completed by 2:00 PM 06/29/23. - Results of all audits will be reviewed by the IDT to ensure proper adherence to this process is met. Any deviations or omissions will be addressed immediately with staff member. - This will be reviewed monthly in QAPI until compliance is met. On 06/29/23 the surveyor began monitoring if the facility implemented their plan or removal sufficiently to remove the IJ by: Staff interviews were conducted with nurses on the 6A-2P [RN A and LVN B] and 2P-10P shifts on 06/29/23 [LVN F and LVN G] indicated they participated in an in-service training about physician notification of a resident change in condition and documentation. The nurses summarized the topic of discussion - physician notification protocol. The nurses stated in their own words the procedure was to notify physicians immediately of resident change in condition and verbalized steps on how to notify attending physician/NP/physician designee or the wound physician, including what actions to take if unable to contact a physician. Record review of the POR education bundle was conducted to determine which staff participated in the immediate in-service training as part of the POR indicated: An in-service conducted 06/28/23 by the RNC on the subject: Physician is to be notified by the charge nurse immediately of changes of condition and this notification is to be documented in the resident's Progress Notes in PCC to include *abnormal skin issues that deviate from the resident's baseline reflected the ADON and NFA signatures. An in-service conducted 06/28/23 by the RNC on the subject: The expectation of and practice of immediately consulting with the resident's physician when there is a significant change in the resident's physical status and a need to alter treatment significantly and to ensure that all pertinent information is reported. Physician is to be notified by the charge nurse immediately of changes of condition and this notification is to be documented in the resident's Progress Notes in PCC to include *abnormal skin issues that deviate from the resident's baseline reflected LVN F, CNA I, CNA J, CNA K, LVN G, CNA L, CNA M, LVN H, RN A, LVN B, CNA N, CNA O, and CNA P signatures. An in-service beginning 06/28/23 by the ADON about the facility's expectation that all changes in a resident's condition are immediately discussed with the resident's physician reflected a signed attestation of in-service participation by LVN H, LVN F, LVN G, LVN B, RN C and RN A. On 06/29/23 at 3:58 PM, the NFA was notified the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one (Resident #1) of four residents reviewed for wounds. 1. The facility failed to ensure Resident #1 with diagnoses including atherosclerosis (thickening or hardening of the arteries) and cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) to his left leg received scheduled daily wound care to his ulcers (wound on the leg or ankle caused by abnormal or damaged veins) according to physician orders on 06/03/2023, 06/04/2023 and 06/18/2023 causing the resident's wounds to worsen. 2. The facility failed to immediately notify the physician of Resident #1's change of condition to his lower extremity ulcers. The resident's ulcers had malodorous (smelling very unpleasant) odor, slough (dead tissue, usually cream or yellow in color), and live maggots (appear like pale worms - a young form of the fly evolved from eggs laid by flies) embedded in the wound with had no wound dressing. An Immediate Jeopardy (IJ) was identified on 06/28/23 at 2:58 PM. While the IJ was removed on 06/29/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. This deficient practice placed residents at high risk of, or the likelihood of, serious injury, harm, impairment, or death by not receiving care, services, or treatment, developing complications, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: A record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old male admitted on [DATE]. Resident #1 had medically complex conditions and active diagnoses of anemia; HTN (when the pressure in the blood vessels is too high - 140/90 mmHg or higher); Cerebral infarction (also called a stroke, occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it); COPD (a group of diseases that cause airflow blockage and breathing-related problems); incomplete quadriplegia (paralysis of all four limbs) with contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to impairment and inability to bend joints) of left upper limb; atherosclerosis (thickening or hardening of the arteries) of left leg with ulceration (the formation of a break on the skin) of other part of foot; and cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of left lower limb. Resident #1's BIMS score was 11, which indicated moderately impaired cognitive impairment. The Quarterly MDS reflected Resident #1 required one-person physical assist with ADLs. The Quarterly MDS did not indicate Resident #1 had any behavioral symptoms or rejection of care during the MDS review period. Section M, Skin Conditions, of the Quarterly MDS reflected Resident #1 had two venous and arterial ulcers present. No other ulcers, wounds and skin problems were identified. The Quarterly MDS reflected a pressure reducing device for chair, a pressure reducing device for bed, and application of dressings to feet as skin and ulcer/injury treatments. Resident #1's clinical physician orders reflected: - Start date 05/21/23 [D/C date: 06/06/23]: Santyl External Ointment 250 unit/Gm (Collagenase). Apply to dorsal lateral left foot topically one time a day for wound care cleanse left foot with normal saline apply Santyl with calcium alginate with gauze with border dressing daily and prn soilage/dislodgment of dressing - Start date 05/21/23 [D/C date: 06/06/23]: Santyl External Ointment 250 unit/Gm (Collagenase). Apply to left leg topically one time a day for wound care cleanse left leg with normal saline apply Santyl/Calcium Alginate with gauze with border dressing daily and prn soilage/dislodgment of dressing - Start date 06/06/23: Cleanse dorsal left foot with normal saline apply Honey Gauze Dressing (a sterile non-adhering & breathable mesh sheet gauze dressing soaked or saturated with a medical grade honey substance) with Kling [a flexible rolled gauze dressing] daily & prn soilage/dislodgment of dressing - Start date 06/06/23: Cleanse left lower leg with normal saline apply Honey Gauze Dressing (a sterile non-adhering & breathable mesh sheet gauze dressing soaked or saturated with a medical grade honey substance) with Kling [a flexible rolled gauze dressing] daily & prn soilage/dislodgment of dressing - Start date 06/19/23 [Revision date 06/14/23; End date 06/26/23]: Weekly skin evaluation/ Monday/ 6-2. One time a day every Monday until 06/26/23 A review of Resident #1's comprehensive care plan indicated: FOCUS: - The resident has a wound or skin abnormality arterial wound to left shin - Arterial wound dorsal left foot [Initiated: 02/21/23; Revision on 04/14/23] GOAL: - Resident's skin abnormality or wound will remain stable or improve [Initiated: 02/21/23; Target: 09/05/23] INTERVENTIONS: - 03/24/23 Vascular Surgeon consult [Initiated: 03/24/23; Revision: 04/19/23] - Call the doctor or NP if needed for any signs of infection or worsening of the skin - Provide treatments as ordered by physician. See medication and/or treatment administration record Review of Resident #1's June 2023 Nursing MAR reflected a blank space in the column that represented the day(s)/date(s) in June and treatment time, 9:00 AM. There were no nurse initials or a chart code with reason/comment that the treatment was or was not provided for the following order(s): - Monday 19th: Weekly skin evaluation/ Monday/ 6-2. One time a day every Monday until 06/26/23 Review of Resident #1's June 2023 TAR reflected blank spaces in the columns that represented the day(s)/date(s) in June and treatment time, Day [6 AM - 2 PM]. There were no nurse initials or a chart code with reason/comment that the treatment was or was not provided for the following order(s): - Saturday 3rd and Sunday 4th: Santyl External Ointment 250 unit/Gm (Collagenase). Apply to dorsal lateral left foot topically one time a day for wound care cleanse left foot with normal saline apply Santyl with calcium alginate with gauze with border dressing - Saturday 3rd and Sunday 4th: Santyl External Ointment 250 unit/Gm (Collagenase). Apply to left leg topically one time a day for wound care cleanse left leg with normal saline apply Santyl/Calcium Alginate with gauze with border dressing - Sunday 18th: Cleanse dorsal left foot with normal saline apply Honey Gauze Dressing with Kling daily & prn soilage/dislodgment of dressing - Sunday 18th: Cleanse left lower leg with normal saline apply Honey Gauze Dressing with Kling daily & prn soilage/dislodgment of dressing Review of Resident #1's June 2023 TAR reflected initials and Chart Codes/Follow-Up Codes in the columns that represented the day(s)/date(s) in June and treatment time, Day [6 AM - 2 PM] for the following order(s): Cleanse dorsal left foot with normal saline apply Honey Gauze Dressing with Kling daily & prn soilage/dislodgment of dressing Cleanse left lower leg with normal saline apply Honey Gauze Dressing with Kling daily & prn soilage/dislodgment of dressing - On Wednesday, 06/07/23 the TAR reflected a chart code, 2 = Drug Refused. LVN E initialed, linked and entered a progress note (06/07/23 at 2:23 PM), Resident refused to allow this writer [LVN E] to complete wound care to left leg and left foot per orders, only allowed areas to be cleansed with normal saline and dressing applied, [NP] notified of resident's refusal of complete wound care. - On Sunday, 06/11/23 the TAR reflected a chart code - 9 = Other/See Nurse Notes. RN A initialed the TAR but did not enter a progress note. - On Saturday, 06/17/23 the TAR reflected a chart code - 5 = Hold/See Nurse Notes. RN C initialed, linked and entered a progress note (06/17/23 at 1:31 PM), Not in facility. - On Sunday, 06/25/23 the TAR reflected a chart code, 2 = Drug Refused. LVN D initialed, linked and entered a progress note (06/25/23 at 9:50 PM), [Resident #1] Refused dressing change. Record review revealed facility staff documented in the TAR that the resident refused wound treatments when the resident attended pre-scheduled facility activities and not immediately available. The documented refusal by staff did not alert the next shift nurse(s) as a past due task that Resident #1's wound care needed to be followed up resulting in the resident not receiving wound treatment for that day. A review of the WMD Wound Evaluation and Management Summary dated 02/20/23 reflected, At the request of the referring provider, [PCP], a thorough wound care assessment and evaluation was performed today [02/20/23]. The Focused Wound Exam revealed an arterial wound of the left, dorsal, lateral foot that measured (L x W x D): 3.5 x 12.5 x 0.1 cm; moderate serous exudate; 100% slough (dead tissue, usually cream or yellow in color); and wound progress deteriorated. Further review of the Focused Wound Exam revealed an arterial wound of the left leg that measured (L x W x D): 13 x 10.5 x 0.1 cm; moderate serous exudate; 100% slough; and wound progress improved. A dressing treatment plan recommended for both wounds included Primary dressing(s) - Alginate calcium apply once daily for 30 days; Santyl apply once daily for 30 days; and Secondary dressing(s) - Gauze Island with border apply once daily for 30 days. The WMD performed a clean surgical excision debridement procedure to each wound to remove necrotic tissue and establish the margins of viable tissue. The WMD documented factors that complicated wound healing were [Resident #1] was a daily smoker and Anemia diagnosis. Review of the subsequent weekly WMD progress notes dated 02/27/23, indicated Resident #1 refused visit. The next available WMD progress note in Resident #1 digital chart was dated 03/20/2023, that also indicated Resident #1 refused visit. The last WMD progress note uploaded to Resident #1's chart was dated 06/19/23, that indicated Resident #1 was inactive - initial 90 days cut off related to refused WMD visits. Review of the weekly non-pressure logs dated 06/01/23, 06/08/23, and 06/15/23 provided by LVN E, reflected Resident #1with an arterial wound to the front left leg that measured 13 x 10.5 x 0.1 (L x W x D), with serous drainage, no odor, treated with Medihoney; and an arterial wound to left dorsal foot that measured 3.5 x 12.5 x 0.1 (L x W x D), with serous drainage, no odor, treated with Medihoney. The measurements, drainage, odor, and treatment remained the same on each weekly log; as well as on the weekly non-pressure logs dated 05/04/23, 05/18/23, and 05/22/23. Review of the eight weekly wound progress notes for Resident #1, the most recent weekly wound progress note had an effective date 06/12/23 at 11:35 AM, signed and locked by LVN E on 06/27/23 at 2:39 PM. The weekly wound progress note dated 06/12/23 indicated [Resident #1] had two wounds, previously documented on last wound progress record [previous wound progress record dated 06/05/23]. Wound #1: Wound Site: other - lower left leg Wound Type: Arterial Wound Status: Ongoing Length (in cm): 13 cm Width (in cm): 10.5 cm Depth (in cm): 0.1 cm Wound Characteristics: Slough, firmly adherent, no undermining, no tunneling, undefined wound edges, light serous (thin, watery, clear) drainage, odor absent after cleansing Surrounding tissue normal and intact [Resident #1] had pain [pain level 3] associated with wound. Additional wound factors to consider: non-adherent with treatment plan related to provision of treatment or care Wound #2: Wound Site: other - dorsal left foot Wound Type: Arterial Wound Status: Ongoing Length (in cm): 3.5 cm Width (in cm): 12.5 cm Depth (in cm): 0.1 cm Wound Characteristics: Slough, firmly adherent, no undermining, no tunneling, undefined wound edges, light serous (thin, watery, clear) drainage, odor absent after cleansing Surrounding tissue normal and intact [Resident #1] had pain [pain level 3] associated with wound. Additional wound factors to consider: non-adherent with treatment plan related to provision of treatment or care Notifications for change in condition related to wound: Resident (Responsible party or Physician was not checked off as notified) Notification for treatment and plan of care changes: Resident A Braden Scale - For Predicting Pressure Sore Risk was completed at the end of the weekly wound progress note. The scores from the six categories were added, and the total score was 16, which indicated a mild risk for developing a pressure injury. Review of the TAR for 06/12/23 reflected a checkmark that indicated RN A performed wound care. Review of Resident #1 progress notes dated 06/12/23 indicated: - an eMar - General Note from eRecord effective date: 06/12/23 at 8:08 AM for the order: Cleanse dorsal left foot with normal saline apply honey gauze dressing with Kling daily & prn Soilage/dislodgment of dressing one time a day for WOUND CARE, RN A entered: [Resident #1] would not stay inside to have dressing changes - an eMar - General Note from eRecord effective date: 06/12/23 at 8:08 AM for the order: Cleanse left lower leg with normal saline apply honey gauze dressing with Kling daily & prn Soilage/dislodgment of dressing one time a day for WOUND CARE, RN A entered: [Resident #1] would not stay inside to have dressing changed - A Health Status Note dated 06/12/23 at 9:36 AM, LVN E entered: Resident Refused wound assessment by wound care MD. Review of the previous weekly wound progress note dated 06/05/23 at 12:27 PM indicated [Resident #1] had two wounds, previously documented on last wound progress record [previous wound progress record dated 05/31/23]. Wound #1: Wound Site: Left lower leg front Wound Type: Arterial Wound Status: Ongoing Length (in cm): 13 cm Width (in cm): 10.5 cm Depth (in cm): 0.1 cm Wound Characteristics: Slough, firmly adherent, no undermining, no tunneling, attached undefined wound edges, moderate serous (thin, watery, clear) drainage. Surrounding tissue normal and intact [Resident #1] had pain [pain level 3] associated with wound. Wound #2: Wound Site: other - dorsal left foot Wound Type: Arterial Wound Status: Ongoing Length (in cm): 3.5 cm Width (in cm): 12.5 cm Depth (in cm): 0.1 cm Wound Characteristics: Slough, firmly adherent, no undermining, no tunneling, attached undefined wound edges, light serous (thin, watery, clear) drainage, odor absent after cleansing Surrounding tissue normal and intact [Resident #1] had pain [pain level 3] associated with wound. Notifications for change in condition related to wound: Resident (Responsible party or Physician was not checked off as notified) Notification for treatment and plan of care changes: Resident A Braden Scale - For Predicting Pressure Sore Risk was completed at the end of the weekly wound progress note. The scores from the six categories were added, and the total score was 17, which indicated a mild risk for developing a pressure injury. The weekly wound progress note dated 05/31/23 indicated Resident #1 had two wounds: Wound #1 had Eschar (dead tissue that sheds or falls off from the skin commonly seen in advanced ulcer wounds) with moderate serous drainage and moderate odor. Wound #1 measured 13 x 10.5 x 0.1 (L x W x D). [Resident #1] reported pain level was 4. Wound #2 had Eschar with moderate serous drainage. Wound #2 measured 3.5 x 12.5 x 0.1 (L x W x D). [Resident #1] reported pain level was 4. Notifications for change in condition related to wound: Resident (Responsible party or Physician was not checked off as notified) Notification for treatment and plan of care changes: Resident A Braden Scale - For Predicting Pressure Sore Risk was completed at the end of the weekly wound progress note. The scores from the six categories were added, and the total score was 16, which indicated a mild risk for developing a pressure injury. An interview and observation on 06/27/23 at 2:01 PM revealed Resident #1 up to wheelchair, able to self-propel, entering the facility from the smoking area. Resident #1 was alert and oriented to self, surroundings, time of day, and situation. Resident #1 asked to speak with the investigator in private. During the interview, Resident #1 informed the investigator that he had not received wound care since Friday (06/23/23). A foul smell was noted coming from the resident. Resident #1 said that the nurses always say they could not find me . only go to smoke break and in my room . they [nurses] wait until gone outside for smoke break to say they were ready to perform wound care, then return from smoke break the nurse would say their shift ended. Resident #1 said that he would not receive wound care and the nurses would say that he refused. When asked was there a treatment nurse who usually performed wound care, Resident #1 stated he did not want her [LVN E] to do his wound care because she did not know what she was doing. Resident #1 said that he allowed RN A to do the wound care, but she gets busy and does not do the wound care every day. When Resident #1 was asked if the WMD visited, Resident #1 said that the WMD visit every Monday and was seen a couple of times. Resident #1 stated he refused some wound treatments by staff because they did not follow the physician orders for wound treatment . the leg wound worsened . now the wound is coming all up my leg. Resident #1 said that is why he refused to see the WMD anymore. During the interview and observation on 06/27/23 at 2:01 PM with Resident #1, RN A was observed in the hallway pushing a medication cart towards Resident #1's room. RN A approached the investigator and stated that she was about to perform wound care but would wait until the investigator was done speaking with Resident #1. The investigator suggested RN A follow through with wound care and informed [RN A] that the investigator would observe. Resident #1 consent to the investigator observed wound care. On 06/27/23 at 2:23 PM, RN A was observed performing wound care to Resident #1's left lower leg and foot. RN A removed supplies from a dresser drawer at the foot of Resident #1's bed. The supplies included a 120 ml normal saline cup, a pack of 4 x 4 gauze pads, gloves, two 0.5 oz tubes of wound gels - Medihoney and Therahoney, 3-ABD gauze pads, 1 pack sealed rolled gauze, bio bag, and an absorbent disposable pad. Resident #1 self-transferred from wheelchair to side of bed and raised his left leg up to the bed and onto the barrier RN A placed on the bed. RN A pulled Resident #1's sock down, a non-pressure- related skin ulcer/wound(s) was noted at the left distal front portion of the lower leg (greater than 13 x 10.5 cm by visual inspection). The wound was malodorous (smelled very unpleasant), moist, covered in slough (dead tissue, usually cream or yellow in color), and approximately eight maggots (appear like pale worms - a young form of the fly evolved from eggs laid by flies) were observed on the front left leg, about 2 - 3 maggots were embedded in the wound bed, and approximately 10 maggots had fallen off the leg onto the barrier placed on the bed when the sock was pulled down from over the wound. The surrounding skin was a dark red discoloration with some chaffing noted. The wound was not covered with any type of dry dressing. When RN A pulled the sock all the way off Resident #1's left foot, a non-pressure- related skin ulcer/wound (greater than 3.5 x 12.5 cm) was observed to the left top lateral foot. No maggots were noted on the foot. 1 - 2 maggots were observed in the crease of the sock. The wound was moist, some slough, no drainage. The surrounding skin had a dark red discoloration with some chaffing noted. The wound was not covered with any type of dressing. During a continued observation of wound care on 06/27/23 at 2:23 PM, RN A cleaned the wound with NS. Resident #1 verbalized discomfort and grimaced when the wound was being cleaned. RN A started to open a black tube of wound gel with gold lettering [TheraHoney Wound Gel] to apply to the wound. Resident #1 told RN A not to put that [TheraHoney Wound Gel] on his leg because that is not what the doctor ordered and why my leg is getting worse! RN A picked up the white tube of wound gel with yellow lettering [Medihoney Wound Gel] and showed it to Resident #1. Resident #1 said that the Medihoney tube was what the doctor used, but it was in a little jar. Resident #1 agreed that RN A could use the Medihoney wound gel and RNA applied the gel to the wound with a tongue depressor, covered the wound(s) with ABD (abdominal) gauze pads, wrapped with a rolled gauze dressing, and secured with tape. During an interview on 06/27/23 at 2:35 PM, CNA D stated that he assisted residents with ADLs. CNA D stated if he discovered an open area, redness, or a rash on a resident, he would notify the nurse. CNA D said that Resident #1 preferred to wash up on his own and was unaware if he [Resident #1] had skin issues. CNA D stated that the nurses provided wound care by changing the dressing but did not know what type of treatment was done to the wound(s). CNA D stated that he would notify the charge nurse if he discovered the wound dressing came off or was soiled. During an interview on 06/27/23 at 2:41 PM, RN A said that she was the charge nurse for the hall that Resident #1 resided Monday - Friday, 6A - 2P. RN A stated that LVN E was the treatment nurse, but Resident #1 refused for her [LVN E] to perform wound care. RN A said that she tried to perform wound care when she could or write on the 24-hr report to notify the on-coming nurse if she [RN A] did not get a chance to perform Resident #1's wound care. When asked if RN A performed wound care the day before (Monday, 06/26/23), RN A said that she was very busy on that day and Resident #1 went outside to smoke when she made time to do the wound care around 1:00 PM, but she did not get around to doing it before her shift ended at 2:00 PM. RN A said that one of the smoke breaks was sometime between 1:00 PM and 1:30 PM. RN A said that the MD/NP should be immediately notified about a resident condition change immediately. RN A said that she told LVN E [treatment nurse] about the maggots to follow up and notify the doctor. RN A said that she should have called the MD since she discovered the maggots during wound care. When RN A was asked if she followed the wound care order as written, RN A replied Yes. When RN A asked to state in her own words the supplies needed for Resident #1's wound care, RN A stated, normal saline to clean the wound, Medihoney or Therahoney to apply to the wound, ABD pads to cover the wound and roll gauze to wrap and secure the wound. The investigator reviewed Resident #1 wound order with RN A and asked if Medihoney/Therahoney gel and honey gauze dressing were the same, RN A replied, yes, but the treatment nurse [LVN E] orders the supplies . and [RN A] used the supplies available when required to perform wound care. RN A was asked if supplies were interchangeable if the physician order reflect a specific or brand name supply, RN A said yes. RN A stated that weekly skin assessments automatically appear on the MAR/TAR on the date and time/shift it is scheduled. RN A stated she did a skin assessment on 06/26/23, the skin assessment form was completed in PCC. [A weekly skin assessment form was not completed in PCC for 06/26/23]. RN A said that the nurse that performed the skin assessment should immediately notify the MD if the nurse discovered changes or new skin issues. RN A denied any skin issues identified on 06/26/23. RN A stated that weekly skin assessments are not the same as wound assessments. RN A stated LVN E was responsible for completing weekly wound monitoring in addition to the weekly skin assessments. During an interview on 06/27/23 at 3:58 PM, LVN E said that her roles were treatment nurse and MDS nurse. LVN E said that there were four residents that received non-pressure wound care in the facility. LVN E said that she generated a wound report by Wednesday every week to present to Corporate on Thursdays. LVN E said that she received wound care orders from the WMD that followed the resident or coordinated care with the MD/NP if the WMD did not follow a resident's wound. LVN E said that the WMD or MD/NP gave orders for medications/treatments and central supply was responsible for ordering supplies as needed when running low or a new medication/treatment is ordered. When asked who was responsible for providing wound care, LVN E said that she was responsible as the treatment nurse Monday - Friday, 8A - 4:30 PM; and the floor nurses were responsible over the weekend and whenever the treatment nurse [LVN E] was not at the facility. LVN E said that she did not work 06/19/23 - 06/26/23 and the floor nurses were responsible for providing resident wound care. LVN E said if a resident refused wound care, she would acknowledge, then follow up with the resident to get the wound care done. LVN E said that she would try at least three times, then document that the resident refused treatment. LVN E said that documenting resident refusal of care is noted on the TAR and in a progress note. LVN E said that she would write on the 24-hr report if wound care was not performed to communicate with the nurse on the next shift. LVN E said the risks of not performing wound care as ordered or notifying the MD/NP of changes include a resident getting a severe infection of the wound or other complications. When asked who was responsible for weekly skin assessments, LVN E said that the floor nurses were responsible for skin assessments. In a continued interview on 06/27/23 at 3:58 PM, LVN E said that Resident #1 admitted with arterial/vascular wounds to his left lower extremity and the WMD was consulted. LVN E said that Resident #1 had an order for daily wound care but often refused wound care. LVN E said that she was unaware that Resident #1 had maggots in his leg wound because [Resident #1] refused [LVN E] to perform wound care and would ask for RN A to perform the wound care. LVN E did not confirm or deny if she called the MD/NP when RN A notified her [LVN E] that Resident #1 had maggots in his leg wound on 06/27/23. LVN E said that Resident #1 was not followed by the WMD because he refused the visits. When asked if the MD/NP was responsible to give treatment orders if Resident #1 refused visits by the WMD, LVN E said that she notified the NP around the end of May or beginning of June (2023) that Resident #1 refused the WMD visits. LVN E said that the NP's recommendation was to locate another wound care provider or clinic to send Resident #1 for wound care treatments. LVN E stated that she communicated with three wound care clinics that denied Resident #1 due to being a LTC resident or did not accept his insurance. When asked if the SW assisted with resources, LVN E stated that she was trying to make the arrangements herself and would ask the SW to assist with finding a wound care clinic. LVN E said that weekly skin assessments are performed by the floor nurses. LVN E stated that weekly skin assessments are not the same as wound assessments. LVN E said that she completed weekly wound progress notes in PCC for residents with wounds. LVN E stated Resident #1's current treatment order was Medihoney and cover with a dry dressing, the last orders provided by the WMD. Review of Resident #1's nurse progress notes on 06/28/23 indicated: - 06/27/23 at 2:29 PM, the LVN E entered: Resident has refused wound care this shift. Prefers wound care to be done at his discretion and when he wants it done. - 06/27/23 at 2:47 PM, RN A entered: . performed wound tx today . there are worms on the leg and under his pants leg. It was under his moist pant leg that is very odorous . Will notify wound nurse of my findings. During record review, there was no documentation that indicated the facility notified the MD/NP about a change in condition of Resident #1's wound on or before 06/27/23. During an interview on 06/28/23 at 8:00 AM, LVN E said that she was not the treatment nurse because she had to work as the floor nurse, therefore, the investigator could not observe her perform wound care. When LVN E was asked if she was responsible to perform wound care as a floor nurse in the absence of the treatment nurse, LVN E replied that RN A had already performed wound care this morning (06/28/23). During an interview on 06/28/23 at 8:27 AM, RN A said that she worked overnight (10P - 6A) and was not working her regular 6A - 2P shift. When asked if RN A performed wound care to Resident #1 this morning (06/28/23) she stated that she did. RN A said that she brought TheraHoney (a brand name) Wound Gel to apply to Resident #1's wound because she could not find any MediHoney. RN A said that she only cleaned the wound with NS and wrapped with rolled gauze because Resident #1 refused TheraHoney (a brand name) Wound Gel to be applied to his wound, only the MediHoney. RN A said that she tried to explain [to Resident #1] that the two wound gels were the same just different names. RN A said that the wound was not as smelly and still had slough. RN A denied observing any maggots when wound care was performed. When RN A was asked if the MD/NP was notified about the maggots or that the MediHoney was unavailable to get an order for an alternative treatment, RN A denied. During an interview on 06/28/23 at 9:00 AM, Resident #1 stated that RN A performed wound care earlier that morning (06/28/23) but did not have the Medihoney wound gel, so she just cleaned and wrapped my leg (and foot). Resident #1 denied observing any maggots during wound care. During staff interviews, no one indicated a specific conversation with Resident #1 about consequences of refusing any wound care or refusing Wound Doctor visits. During a phone interview on 06/28/23 at 12:56 PM, the NP denied that she received a call from the facility about maggots in Resident #1's wound. The NP stated had she been informed about maggots; she would have likely given an order to send [Resident #1] to the hospital for evaluation and treatment. The NP stated that during her last visit (05/28/23), Resident #1 dressing was intact to his left leg/foot and was aware that Resident #1 refused care at times. During a phone interview on 06/28/23 at 1:08 PM, the MD indicated that she did not receive a call about Resident #1 or informed about maggots observed in [Resident #1's] wound. The MD indicated that she was aware that Resident #1 was noncompliant with care at times. The MD stated if Resident #1 continued to refuse care by the WMD, he [Resident #1] would need to see an outside wound care physician. The MD stated that her expectation is to be updated about changes in condition as soon as possible to ensure resident care needs are met and to make changes in treatment as necessary. During an interview on 06/28/23 at 1:31 PM, the SW indicated that she was currently assisting LVN E with locating a wound care clinic that would accept Resident #1. The SW stated that [Resident #1] was denied by one clinic and received a referral for another wound care provider that she would try to call this afternoon (06/28/23). During an interview on 06/28/23 at 1:56 PM, the NFA stated that his expectation was for the treatment nurse and floor nurses, when applicable, to provide wound care as ordered. The NFA also stated if any changes in the wound, the nurses should notify the doctor about any change in a resident condition and

Based on observation, interview, record review, policy review and review of Centers for Disease Control (CDC) guidelines, the facility failed to ensure two new admission residents (Resident (R)21 and R22) were placed in quarantine isolation for 14 days to monitor for COVID-19 symptoms. Additionally, on 08/14/21 a staff member was confirmed as positive with COVID-19 and the facility began outbreak procedures as recommended by the Centers for Disease Control (CDC). The facility failed to ensure residents were kept safe during the outbreak by social distancing, residents wearing masks when in the hallway, staying in their rooms, stopping communal meals, and staff wearing full Personal Protective Equipment (PPE) to include N95 masks, gowns, gloves, and eye protection when providing direct resident care. As a result of this deficient practice not placing new admission residents in 14-day quarantine isolation and not following the CDC guidelines for a COVID outbreak, there is a potential for all 47 residents in the facility to be at risk for exposure to COVID-19. On 08/17/21 at 7:00 PM, the Administrator and the Director of Nursing (DON) were notified that the facility failed to place in quarantine isolation two new residents admitted to the facility that were not fully vaccinated for COVID. The facility also failed to ensure the residents were kept safe when the facility began outbreak procedures, due to a positive staff member confirmed on 08/14/21, by stopping communal meals, have residents' social distance, encourage residents to stay in their rooms and wear a mask, and for staff to wear full PPE when providing resident in room care. This constituted an immediate jeopardy at F880. The facility presented an acceptable removal plan for the immediate jeopardy at F880 on 08/19/21 at 3:28 PM. The removal plan indicated the two new admission residents, R21 and R22, were placed on quarantine isolation with signs on the door, PPE supplies outside the room and residents encouraged to stay in their rooms, wear masks, social distance and eat meals in their rooms. Staff were to wear full PPE (N95 mask, eye protection, gown, and gloves) when providing care for the residents. The plan also included training of the staff about new admission residents being on quarantine isolation for 14 days. Staff and resident testing and staff to wear full PPE for resident care to continue until there have been no new positives for 14 days placing the facility in a 'warm' status. The removal plan was validated through observation and interview of staff. Observations verified that the new admission residents were placed on quarantine isolation with signs on the door and PPE supplies outside the room. Staff were observed donning PPE prior to entering resident rooms delivering meal trays. Interviews with staff confirm training about admission of residents being on quarantine isolation and placing the facility in warm status, using full PPE when providing direct resident care. The survey team notified the Administrator and DON the immediate jeopardy at F880 was removed on 08/19/21 at 5:30 PM. After removal of the Immediate Jeopardy, the deficiency remained at an F scope and severity for a pattern of potential harm. Findings include: 1. On 08/16/21 at 9:10 AM, the Administrator verbalized the facility had no residents on isolation and that the surgical mask was the PPE the surveyors needed to wear. The Administrator stated that one staff member, Receptionist 4, had just tested positive for COVID-19 on 08/14/21. On 08/17/21 the facility provided the list of residents admitted in the past 30 days. The list included R11, who was readmitted on [DATE]; R21 was admitted on [DATE]; and R22 was admitted on [DATE], all within the prior 14 days. During an interview on 08/17/21 at 10:04 AM, the DON verbalized the new admission residents from the acute care setting (R21 and R22) had a negative COVID test or were fully vaccinated for COVID and therefore were not placed on quarantine isolation. a. Review of the Admission Record in the Electronic Medical Record (EMR) under the Profile tab revealed R11 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Immunization tab in the EMR revealed R11 was fully vaccinated for COVID on 02/01/21. b. Review of the Admission Record in the EMR under the Profile tab revealed R21 was admitted to the facility on [DATE]. Review of the Immunization tab in the EMR revealed R21 has not been vaccinated for COVID-19. Review of the Misc tab in the EMR for R21 lacked documented evidence of a negative COVID test prior to admission. c. Review of the Admission Record in the EMR under the Profile tab revealed R22 was admitted to the facility on [DATE]. Review of the Misc tab in the EMR for R22 revealed documentation of a negative COVID test dated 08/04/21, eight days prior to admission. During an interview on 08/17/21 at 11:50 the Infection Preventionist, Licensed Vocational Nurse (LVN)13 confirmed R22 was a new admission and not on isolation since there was no isolation supplies outside the door and no sign on the door. LVN13 did not know why the R22 was not on isolation. During the interview on 08/17/21 at 5:25 PM, Registered Nurse (RN)9 verbalized new admission residents are placed on 14-day quarantine isolation for 14-days and R22 should be on isolation but was not on isolation and RN9 did not know why R22 was not on isolation. During an interview on 08/17/21 at 12:02 PM, the DON verbalized new and re-admission residents are placed in a private room and on quarantine isolation for 14 days unless they were fully vaccinated for COVID. The DON confirmed the facility follows CDC guidelines. Review of the facility's policy titled Coronavirus Emergency Pandemic Policy Addendum, dated 07/02/21, revealed Unvaccinated New admission/readmission(s) will be quarantined for 14 days in the designated area of the center. 2. Observation of the dining room on 08/16/21 at 11:30 AM, 10 residents were eating lunch in the dining room. Observation on 08/17/21 at 11:45 AM, Certified Nurse Aides (CNAs) were wearing N95 masks and going in and out of resident rooms on both hallways with no additional PPE. Observation on 08/18/21 at 9:35 AM, residents were not being instructed to stay in their rooms, residents were in the dining room participating in an activity and were not social distancing, residents were not being encouraged to social distance or wear masks in the hallways. CNAs and licensed nursing staff were entering rooms to provide care with N95 mask and no additional PPE. During an interview on 08/17/21 at 12:02 PM, the DON verbalized the facility followed the CDC guidelines. The DON confirmed an employee (Receptionist 4) had a positive COVID test and was confirmed with a second Polymerase Chain Reaction (PCR) test. The DON verbalized a second employee (Dietary Cook 17) had tested positive during routine twice a week staff testing and was awaiting verification of a PCR test and the facility was in a COVID outbreak and would test staff and residents until they went 14-days without any new positive tests. During an interview on 08/17/21 at 5:25 PM, RN9 confirmed an employee, Receptionist 4, had tested positive for COVID during the routine staff twice a week testing. When there was a positive COVID test for an employee then the facility has all the staff wear an N95 mask (no other precautions were required for staff), monitor residents for COVID signs or symptoms and everyone gets tested . During an interview on 08/17/21 at 5:52 PM, the Certified Medication Aide (CMA)7 confirmed an employee tested positive and all the residents are being tested as well. Precautions staff were to wear was N95 masks while providing care, no other precautions were needed. During an interview on 08/19/21 at 10:13 AM, the Medical Director verbalized the expectation new admission or readmission residents who were not fully vaccinated were to be placed on 14-day quarantine isolation. The Medical Director was aware an employee tested positive for COVID and the facility was in an outbreak scenario which meant staff were to wear N95 masks, residents were to not eat in the dining room, wear masks when out of their room, social distance and staff were to wear additional PPE (eye protection, gowns, and gloves) when providing direct care to the residents. During an interview on 08/19/21 at 4:05 PM, the Medical Director verbalized agreeing with the removal plan to ensure staff wear full PPE when providing care and confirmed the facility will be warm facility wide with all residents on isolation until 14 days of no new positive COVID tests among staff or residents. Review of the facility's policy titled Coronavirus Emergency Pandemic Policy Addendum, dated 07/02/21, revealed Probable case(s) of COVID in the center-A probable or confirmed case of COVID is considered an outbreak in a resident or employee. Review of the CDC guidelines for New Infection in Healthcare Personnel or Resident, updated 03/29/21, revealed to implement facility wide testing and healthcare personnel should care for residents using an N95 or higher respirator, eye protection, gloves, and gown. Residents should generally be restricted to their rooms and halting social activities and communal dining. Recommend precautions should be continued until no new cases have been identified for at least 14 days. Deficiency cited based on complaint # TX 360

Based on observations, record review, review of facility policy and staff and resident interviews, the facility failed to ensure six residents (Resident (R) 2, R3, R10, R18, R19, and R20) of 23 sampled residents were free from physical abuse by R8. Due to the vulnerable nature of the nursing home population, a potential for serious injury or serious physical or psychosocial impairment from being hit by R8 existed, and the likeliness of R8 hitting another resident in the facility was high and required immediate action in order to prevent further events of physical abuse by R8. The facility's Administrator and Director of Nursing (DON) were informed on 08/17/21 at 7:00 PM that Immediate Jeopardy existed related to the failure to ensure R2, R3, R10, R18, R19, and R20 were free from abuse by R8. The Immediate Jeopardy began on 12/10/20, the date of the first incident of resident abuse by R8. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 08/19/21 at 3:28 PM. The survey team validated implementation of the removal plan through observations, staff interviews, and review of resident records and facility training records and the Immediate Jeopardy was removed on 08/19/21 at 3:45 PM. After removal of the Immediate Jeopardy, the deficiency remained at an E scope and severity for a pattern of potential harm. Also, the facility failed to prevent additional resident to resident physical abuse for eight residents (R1, R4, R7, R9, R11, R14, and R15) of the sample of 23 residents. This failure had the potential to cause physical injury or psychosocial distress for the eight residents involved. Findings include: 1. Per the electronic medical record (EMR) Profile tab, R8 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R8's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 05/27/21, located in the MDS tab of the EMR, documented R8 scored six out of 15 on the Brief Interview for Mental Status (BIMS), indicating he had moderately impaired cognition. R8 exhibited verbal behavioral symptoms directed toward others, behavioral symptoms not directed toward others, and wandering behaviors one to three days of the previous seven days. R8 required limited assistance with transfers and walking; he used a walker for assistance with ambulation. Review of R8's Care Plan, located under the Care Plan tab of the EMR and initiated on 11/25/20, revealed R8 had a potential to demonstrate physical behaviors due to [CONDITION(S)], [CONDITION(S)] disorder, and [CONDITION(S)] disorder. The approaches on 11/25/20 included: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; and follow facility protocol . Monitor/document/report to [physician] of danger to self and others . [and] Psychiatric/psychogeriatric consult as indicated. The Care Plan reflected the following dates of physical aggression initiated: 12/10/20, 01/07/21, 02/06/21, 03/03/21, 03/12/21, 05/04/21, and 06/08/21. In an interview with R8 on 08/16/21 at 3:45 PM, R8 stated I have made a few mistakes and fought with people. He went on to explain he was sent to jail because he was hurting people, but he is learning how to act better in the facility. On 08/16/21 at 11:00 AM, R8 was observed in the dining room during an activity program. There were several other residents in the dining room as well. The Activity Director was in the dining room providing supervision. On 08/16/21 at 11:15 AM, R8 was observed out in the courtyard smoking with other facility residents. The receptionist and Activity Director were out in the courtyard providing supervision. On 08/16/21 at 11:49 AM, R8 was observed eating his lunch in the dining room with several other residents also in the dining room. Several Certified Nurse Aides (CNAs) and nurses were also in and out of the dining room providing supervision. On 08/16/21 at 12:22 PM, R8 was observed inside R10's room talking with her while she ate her lunch. There were no staff supervising the resident-to-resident interaction in R10's room. On 08/16/21 at 3:22 PM, R8 was observed playing Bingo in the dining room with several other residents in attendance. The Activity Director was in the dining room leading the activity. On 08/16/21 at 3:30 PM, R8 again was observed in the courtyard smoking with other facility residents. The Receptionist and Activity Director were also in the courtyard. Review of R8's Progress Notes, located in the Progress Notes tab of the EMR, and the facility's Incident Reports and/or Provider Investigation Reports, both kept in files in the Administrator's office, revealed 10 instances of physical abuse by R8: A. Per the EMR Profile tab, R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R2's quarterly MDS assessment, with an ARD of 07/10/21, revealed R2 was unable to complete the Brief Interview of Mental Status (BIMS). The staff determined he had severely impaired cognition. R2 exhibited physical and verbal behavior symptoms directed toward others, behaviors not directed toward others, rejection of care, and wandering. R2 used a wheelchair for locomotion with extensive assistance. Review of R2's Care Plan, initiated on 11/07/19 and reviewed on 03/11/21, revealed, 11/07/19: [R2] initialed [sic] physical aggression towards another resident, hit a male on the arm, with no injury noted. 12/07/20: Physical Aggression. 12/10/20: Physical Aggression. 12/10/20: Verbal Aggression. 12/22/20: Physical Aggression Received. 02/05/21: Verbal Aggression Received. 05/04/21: Physical Aggression Received. 06/08/21: Verbal Aggression Received. Review of R8's Nurse's Note dated 12/10/20 documented R8 was overheard yelling and cursing at [R2]. The note documented, Resident hit the other resident multiple times before staff could intervene. [R8] stated the other resident was verbally aggressive toward him and hit him so he hit the other resident back. Resident encouraged to go to his room and stay away from the other resident. The Provider Investigation Report dated 12/17/20 revealed, On 12/10/20, LVN [Licensed Vocational Nurse (LVN) 14] notified the Administrator that resident [R8] hit resident [R2] on the forehead . [LVN14] completed head to toe skin assessment and pain assessment on resident [R2[ with a small scratch of 1.5 cm [centimeter] noted to his forehead. Resident denied having pain. R8 was also assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The Provider Response included, Will continue to monitor both residents and will continue plan of care on both of them. In-service on abuse to begin. The Investigation Summary documented, On 12/10/20, [LVN14] notified the Administrator that resident [R8] hit resident [R2] on the forehead . The staff separated them and assisted [R8] to his room. Resident [R2] was assisted back to his room. [R8] went to visit [another] resident . in her room and resident [R2] wandered into the same room too. When [R8] was was [sic] interviewed, he stated that he thought that [R2] was going to hit him so he hit him first. [R8] said it was misunderstanding [sic] and that he was sorry that it happened. [R2] stated I went to the room to see what was going on and he hit me. [R8] reacted and did not premeditate, willfully or recklessly hit resident [R2]. The Investigation Findings were Inconclusive. Review of R8's Care Plan in the EMR under the Care Plan tab revealed the following approaches were added in response to this incident: 12/10/20: Actual physical aggression initiated; psych. [psychiatric] eval. [evaluation] completed and 12/14/20: Resident has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no interventions added to address ways to prevent recurrence of the physical abuse. Review of R8's Psychiatric Evaluation and Subsequent Review, dated 12/11/20 located in the Miscellaneous tab of the EMR, revealed, This [patient and] another resident started arguing [and] this escalated to punching each other [and] this [patient] hit the other in the head. The [patient] acknowledges the incident and takes some responsibility for his part. He shows no signs of physical trauma nor psychological sequelae. He agrees to avoid the other [patient] and recognizes the other resident's limitation (like a child). He denies any grudge, denies any intent to carry on this 'rivalry.' The form documented R8 did not appear to be an imminent danger to self or others and was safe in the nursing home. There were no new interventions documented on the form. On 12/10/20, the intervention, Psych [antipsychotic] medication increased [related to] behaviors was added to R2's Care Plan. However, R2's Care Plan did not identify ways to protect him from further abuse by R8. In an interview on 08/17/21 at 2:07 PM, R2 stated he had never been hit, pushed, kicked, or punched in the facility. He stated he had no problems with other residents and was not afraid of anyone in the facility. B. Per the EMR Profile tab, R10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R10's quarterly MDS assessment, with an ARD of 08/09/21, revealed she scored a seven out of 15 on the BIMS, indicating moderate cognitive impairment. R10 exhibited rejection of care behaviors. R10 used a wheelchair for locomotion with limited assistance. R10's Care Plan, in the EMR under the Care Plan tab initiated on 03/23/18, documented she had the potential to be physically aggressive and included the approaches: provide choices about care and activities, monitor behaviors and document observed behaviors and attempted interventions, notify the physician of behaviors, and provide a psychiatric consult as needed. An update to the Care Plan documented 01/07/21: Resident got into physical altercation with another resident. However, there were no new interventions added to prevent recurrence of the abusive behavior. R8's Nurse's Note dated 01/07/20 documented, The receptionist reported to this nurse that she overheard this [sic] two resident yelling at each other in front of the smoke room. On getting there, [R8] has already left and went to his room. [R10] stated he was talking 'naught' [sic] and pointing to my face, I slapped him on the face, kicked him on the leg, and he slapped me on the back of my head. [R8] stated, 'she said something out of line,' but refused to say exactly what it was. He initially said [R10] did not kick or slap him, but later stated, 'she slapped me, and I slapped her.' [R10] stated, 'am good, am good.' Denies any pain or injury. Head to toe assessment completed, no bruise, swelling, redness or area of tenderness noted. Review of the Provider Investigation Report 01/14/21 revealed, On 01/07/21 at 8:39 PM, RN [Registered Nurse (RN) 9] notified the Administrator that [R10] told the receptionist . that she slapped [R8] on the face and [R8] slapped her back at the back of her neck. Both residents were assessed for injury or pain and monitored for emotional distress with none noted. The Provider Response included, Will continue to monitor both residents and will continue the plan of care on both of them. In-service on abuse to begin. The Investigation Summary documented, The staff separated them and [R10] was assisted back to her room. [R8] rolled himself back to his room. When [R8] was interviewed by the Administrator, he stated that, 'I don't want to discuss about it, it was a misunderstanding between two friends, and we have settled it. When [R10] was interviewed by the Administrator, she said, 'I don't want to talk about it . [R10] reacted and did not premeditate, willfully or recklessly slapped [sic] resident [R8]. Review of R8's Care Plan dated 11/25/20 revealed the statement, 01/07/21: Resident got into physical altercation with another resident was added. However, no additional approaches were included to prevent recurrence of the abusive behavior. R8's Psychiatric Evaluation and Subsequent Review dated 01/13/21 did not reflect the episode of physical aggression on 01/07/21. The form documented R8 did not appear to be an imminent danger to self or others and was safe in the nursing home. There were no new interventions documented on the form. Interview with R10 on 08/16/21 at 12:22 PM revealed she was not afraid of R8 and welcomed his company. She stated they were good friends, and though they fought sometimes, they always forgave each other. C. R8's Nurse's Note dated 02/03/21 documented, Was notified by the receptionist that [R8] hit [R2] on his right upper arm with his fist. On getting to the scene, [R8] was on the phone with somebody. The resident that received the hit was instructed to leave the scene and go to his nurse for assessment. His nurse and the administrator were notified. When [R8] got off the phone, he said 'he had to hit him because he was disrespectful while he was on the phone.' [R8] was instructed not to take laws into his hands anymore but to report to the nurse or the management. He was also instructed to stay away from the other resident, he verbalized understanding. No sign of anger or emotional distress noted. Review of the Provider Investigation Report dated 02/03/21 revealed, On 02/03/21, [the receptionist] notified the Administrator that [R8] punch [sic] [R2] on his right arm because [R2] bumped into [R8's] wheelchair with his wheelchair. Both R2 and R8 were assessed for injury or emotional distress with none noted. The Investigation Summary documented, The staff separated them and helped [R8] to his room. [R2] was assisted back to his room. When [R8] was interviewed, he stated that [R2] 'ran into my wheelchair with his wheelchair' and then he punched [R2]. When [R2] was interviewed, he could not recollect what happened. All he said was I don't know and rolled his wheelchair away. [R8] reacted and did not premeditate, willfully, or recklessly punch [R8]. [R2] did not recall the incident. The Investigation Findings were Inconclusive. R8's Care Plan was updated on 02/06/21 with, Physical Aggression Initiated. However, there were no new interventions added at this time to address R8's repeated physical abuse or his tendency to target R2. On 02/05/21, the intervention, [Physician] medication review for behaviors was added to R2's Care Plan; however, the incident of Physical Aggression Received on 02/03/21 was not reflected. R2's Care Plan did not identify ways to protect him from further abuse by R8. D. Per the EMR Profile tab, R18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R18's annual MDS assessment, with an ARD of 06/18/21, revealed he scored ten out of 15 on the BIMS, indicating he had moderately impaired cognition. R18experienced delusions. He walked with supervision from staff. R18's Care Plan, initiated 12/08/20, documented, The resident is/has potential to be physically aggressive [due to] anger. The interventions included: continue psychologist visits, administer medications as ordered, provide physical and verbal cues to alleviate anxiety, modify environment for comfort, monitor and document any behaviors, and provide psychiatric consult as indicated. R8's Nurse's Note dated 02/06/21ocumented, I the nurse overheard the receptionist yelling stop! stop! by the time l got there, the fight was over. Per the receptionist, a female resident who was among them in front of the smoke room waiting for time to go in and smoke said they were fighting because of her. That she said she is no longer going to marry [R8] but the other one and [R8] started punching the other one on the face. When [R8] was asked what the problem was, he responded nothing and proceeded to his room. Resident assessed, he denied being beaten or punched by the other resident. Denied pain or injury and non [sic] noted on assessment, rather resident frowned his face looking sad. The administrator was notified who said to call police. Police came, after all investigations took this resident to jail, that he will see the judge tomorrow. According to the police, they are sending him to jail because two of them live in the same room even though the fight did not take place in their room. Review of the Provider Investigation Report dated 02/08/21 revealed, On 02/06/21 at 6:12 PM, [RN9] notified the Administrator that [R8] punched [R18] on his face. Both R8 and R18 were assessed for pain or injury and monitored for emotional distress with none noted. The Provider Response included, Will continue to monitor and will continue plan of care for both residents. In-service on abuse to begin. The Investigation Summary documented, The staff separated them and moved [R8] from [old room] to [new room]. [R18] was assisted back to his room . [R8] was taken to jail due to the abuse. [R8] was bailed out by the facility. When [R8] was interviewed by the Administrator, he stated, 'I know I was too pushy, I will not do it again and I will let you know next time.' When [R18] was interviewed, he said that [R8] was trying to kill him and that he is no longer his friend. [R8] reacted and did not premeditate, willfully, or recklessly punched [sic] resident [R18]. Review of R8's Care Plan revealed, 02/06/21: Physical Aggression Initiated was added; however, there were no interventions at this time to address the continued abusive behaviors. Review of R8's Psychiatric Evaluation and Subsequent Review dated 02/11/21 revealed, This [patient] became angry [with] another male resident over a female resident [and] this resident punched the other resident [and] was taken to jail by the police. Upon returning he expressed remorse to the Administrator [and] to me today. He denies thoughts of harming himself or others. He shows no signs of psychological sequelae nor physical injury from this altercation. The form documented R8 did not appear to be an imminent danger to self or others and was safe in the nursing home. There were no new interventions documented on the form other than adding a new medication to R8's regimen. Though on 02/06/21, Physical Aggression Received was added to R18's Care Plan; it was not updated with new interventions. In an interview with R18 on 08/17/21 at 2:16 PM, he denied ever having been physically abused while in the facility and stated he was not afraid of any other facility residents. E. Per the EMR Profile tab, R19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R19's admission MDS assessment, with an ARD of 01/26/21, revealed she scored 15 out of 15 on the BIMS, indicating she had no cognitive impairment. R19 did not exhibit any behavioral symptoms. She used a wheelchair with limited assistance for locomotion. Review of R19's Care Plan dated 02/04/21 revealed it did not address risk for inappropriate behaviors or abuse. A Nurse's Note dated 03/03/21 documented, [R8] seen hitting [R19] in the face multiple times in hallway, coming from outside smoking area, by receptionist, after both parties were separated, receptionist notified charge nurse. Head to toe assessment complete, skin intact no open areas, [R8] assist back to residents [sic] room, when asked resident states, 'she stole $5 out of my room so I hit her in the face.' Prior to incident, [R19] was seen by multiple staff/residents coming from [R8's] room and he accused her of stealing his money. Charge nurse notified resident that their [sic] will be an investigation and resident would surely get the $5 back, resident voiced understanding, then minutes later proceeded to confront the accuser of stealing residents [sic] money while hitting the accuser multiple times. [One to one] education on safety awareness, and ways of communicating without using physical action. Review of the Provider Investigation Report dated 03/08/21revealed, On 03/03/21 at 7:27 PM, [RN9] notified the Administrator that [receptionist] told her that [R8] hit [R19] on the face because [R19] went to his room while he was sleeping and took his $5.00. Both R8 and R19 were assessed for pain or injury and monitored for emotional distress with none noted. The Provider Response included, Will continue to monitor both residents and will continue plan of care on both of them. In-service on abuse to begin. The Investigation Summary documented, The staff separated them and [R19] rolled herself back to her room. [R8] rolled himself back to his room. When [R8] was interviewed by the Administrator, he stated, '[R19] came to my room and stole my $5.00.' When [R19] was interviewed by the Administrator, she said, 'you know I am in his room, and you know that right? Bye, I don't know what you are talking about.' [R8] did not premeditate, willfully, or recklessly hit [R19]. The Investigation Findings were Inconclusive. Review of R8's Psychological Services Progress Note dated 03/03/21 revealed the incident was not addressed, and no new interventions were provided. Though on 03/03/21, Physical Aggression was added to R8's Care Plan; it was not updated with new interventions. R19's Care Plan was not updated after this incident. F. R8's Social Services Note dated 03/12/21 documented, While [administrative] staff attended morning standup [meeting], [R8's nurse] entered [meeting] to verbalize [R8] physically punched [R18 at] least once before being assisted away from [R18]. R18's Nurse's Note dated 03/12/21 documented, [R18] was hit by [R8] for being in his room. [RN15] did not observe the altercation but was told by housekeeping and two other residents. [R18] was told to remain inside his room until either the DON or Administrator arrived to talk to him. Again, he does not follow instructions when given. [R18] has no physical injuries and no delayed visible injuries noted this shift. [RN15] will make all attempt to keep the two apart. Though on 03/12/21, Physical Aggression Initiated was added to R8's Care Plan; it was not updated with new interventions. Though on 03/12/21, Physical Aggression Received was added to R18's Care Plan; it was not updated with new interventions. Review of the 05/04/21 Provider Investigation Report revealed R8 hit R18 on his face. There were no injuries or emotional distress noted for either R8 or R18. R8 stated he saw R18 coming out of his room, and since he should not be in others' rooms, he hit him. The residents were separated and the facility continued to monitor. R8's 03/30/21 and 05/16/21 Psychiatric Evaluation and Subsequent Reviews did not reflect the episode of physical aggression on 03/12/21. The form documented R8 did not appear to be an imminent danger to self or others and was safe in the nursing home. There were no new interventions documented on the form. In an interview with R18 on 08/17/21 at 2:16 PM, he denied ever having been physically abused while in the facility and stated he was not afraid of any other facility residents. G. Per the EMR Profile tab, R20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R20's quarterly MDS assessment, with an ARD of 07/13/21, revealed R20 was unable to complete the BIMS. The staff determined he had moderately impaired cognition. He had highly impaired hearing and had no speech. R20 did not exhibit behavioral symptoms and used a walker with limited assistance for locomotion. R8's Nurse's Note dated 05/02/21 documented, Nursing called to the dinning [sic] room to find [R8] standing at the table upset and arguing with another resident. Nursing staff removed resident from altercation to find out what happened. Resident told writer that the other resident coughed over his food, so he became angry and attempted to strike the other resident. [R8] easily redirected back to his room to cool off . Resident instructed to stay away from the other resident and verbalization was voiced. Resident remained in his room for the rest of the night with no further altercations noted. ADON [Assistant Director of Nursing] was notified. R20's 05/02/21 Nurse's Note documented, Writers [sic] attention was called to the dinning [sic] room. Upon entry writer noted this resident standing at the table in an altercation with another resident. Nursing immediately separated the residents to assist in diffusing the situation. When asked by this writer what happened [R20] gestured that he was coughing at the table when the resident sitting across from him attempted to lunge at him. [R20] denied that the other resident actually hit him. He was visibly upset however he was redirected to his room to cool off. [R20] remained in his room for the rest of the shift with no further complaints. Nursing to continue to monitor. ADON was notified. On 08/17/21 at 1:00 PM, the Administrator stated there was no internal incident report or investigation completed, because the agency nurse who was working had not reported the incident. The Administrator and DON were unaware of this incident. The Administrator stated it was not reportable to the state because there was not contact between the residents; however, an incident report and internal investigation should have been conducted. On 08/18/21 at 12:50 PM, LVN 20 was interviewed via telephone and stated she worked for an agency. LVN20 stated the interaction on 05/02/20 happened between R8 and R20. LVN20 stated she thought she had completed an incident report for each resident, and reported the incident to LVN14, who served as one of two ADONs. On 08/19/21 at 11:15 AM, LVN14 stated the incident on 05/02/21 was not reported to her. This incident was not reflected on either R8's or R20's Care Plan. H. An 05/04/21 Nurse's Note documented, At about [4:17 PM], one of the shift aides came to the nurse station and told nurse that [R8] punched [R2] on the face and [R2] is on the floor. The nurse aide and I ran to the tv dinning [sic] area. [R2] is on the floor, laying supine position. [R2] stated, 'please help me get up. He punched me call police.' [R8] was asked why he punched [R2], he said [R2] get [sic] into his business. What type of business, he did not explain. Review of the Provider Investigation Report dated 05/04/21 revealed, On 05/04/21, Employee notified the Administrator that [R8] punched [R2] on his lips because [R2] refused to move his wheelchair out of the way when he was trying to pass in the dining room. R2 suffered a small laceration to his lower lip. Both residents were monitored for emotional distress with none noted. The Provider Response documented, Will continue to monitor residents and will continue plan of care for both residents. In-service on abuse to begin. The Investigation Summary documented, The staff separated them and helped [R8] to his room. [R2] was assisted back to his room. When [R8] was interviewed, he stated that [R2] refused to move his wheelchair out of the way when he was trying to pass by in the dining room. When [R2] was interviewed, he said, 'he hit me on my lip, call the police, I did not do anything to him' . [R8] reacted and did not premeditate, willfully, or recklessly hit [R2]. The Investigation Findings were Inconclusive. On 05/04/21, the intervention, Removed resident notify psych. Goal: Keep resident safe was added to R8's Care Plan. However, there were no new interventions added to prevent a recurrence of the abusive behavior and tendency to target R2 for abuse. R2's Care Plan was updated on 05/04/21 with the intervention, Resident was hit by another resident in the face. Intervention: assessed resident notified family. Goal: Keep resident safe. However, R2's Care Plan was not updated with ways to keep R2 safe and prevent recurrence of physical abuse by R8, though this was his third instance of physical abuse by R8. Review of R8's Psychiatric Evaluation and Subsequent Review dated 05/12/21 revealed, Per staff this [patient and] another (male) resident bumped into each other became angry [and] exchanged verbal insults and this resident punched the other resident in the face causing a bruised lip. He says he has no further hostilities toward the other resident. he says, 'I've already forgotten about it.' He shows no signs of further psychological sequelae. R8's 01/13/21 Psychiatric Evaluation and Subsequent Review did not reflect the episode of physical aggression on 05/02/21. The form documented R8 did not appear to be an imminent danger to self or others but was not safe in the nursing home. There were no new interventions documented on the form. I.R8's Nurse's Note, dated 06/08/21 written by RN15, documented, Resident was seen getting up off his wheeled walker and hitting the other resident on the [left] side of the face. On 08/17/21 at 1:00 PM, the Administrator stated there was no internal incident report or investigation completed, because the incident probably had not been reported to him. The Administrator and DON were unaware of this incident. The Administrator stated it was a reportable incident to the State Agency, and an incident report and internal investigation should have been conducted. On 08/18/21 at 9:50 AM, RN15 stated this incident was between R8 and R2; however, she could not remember details. RN15 stated, All I can say is somebody told me what he did. It was 1:00 in the evening and my first objective was to separate the residents. R8 was seen hitting R2 on the left side of his face . I probably reported to the DON or ADON. I reported to somebody and let them know what was going on. In the heat of the moment, I don't pay attention to all that. I did an assessment of [R2] to see about injuries. I didn't witness it, but it was told to me. They went to their rooms to be assessed . Typically I report incidents right away to management. I'll make a call in the middle of the night if I have to . I know I notified someone in person. It was around shift change, so somebody got told. Review of R8's Care Plan revealed the update, 06/08/21: Physical Aggression Initiated. However, there were no new interventions to prevent recurrence, even though this was his fourth episode of physical abuse toward R2. Review of R2's Care Plan revealed the update, 06/08/21: Physical Aggression Received. However, there were no new interventions to prevent recurrence, even though this was his fourth episode of physical abuse by R8. Review of R8's Psychological Services Progress Note dated 06/11/21 revealed the incident was not addressed, and no new interventions were provided. R8's 07/02/21 Social Services Note documented, [at the] directive of facility [Administrator], SW [social worker] to refer [R8] to a/any inpatient psych hospital due to ongoing aggressive behaviors [and] physical altercations [with] other residents. Upon SW speaking [with R8] regarding psych hospital referral, [R8] said he didn't want to go to inpatient psych hospital [and] wouldn't voluntarily agree to inpatient psych hospitalization . SW voiced understanding [and] spoke [with R8] regarding his rights [and] other options facility may pursue such as seeking mental health warrant for inpatient psych placement. [R8] voiced understanding. In an interview on 08/17/21 at 2:07 PM, R2 stated he had never been hit, pushed, kicked, or punched in the facility. He stated he had no problems with other residents and was not afraid of anyone in the facility. J. Per the EMR Profile tab, R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect of residents by failing to provide adequate supervision to prevent accidents for 1 of 13 residents (Resident #1) reviewed for neglect. The facility failed to ensure CNAs A and B failed were trained to notify the administrative staff on 06/12/17, when Resident #1, a cognitively impaired resident, expressed a desire to leave the facility. Resident # 1 eloped that day (06/12/17) at or around 4:30 p.m. and was returned to the facility the following morning (06/13/17) at 9:00 a.m. (over 12 hours later). Resident #1 was found approximately one mile from the facility sitting in an alley. She sustained no injuries; however, she was placed at risk of serious injury or death. An Immediate Jeopardy (IJ) exited from 06/12/17 to 06/13/17. This was determined to be an IJ at past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of this survey. This failure placed 13 residents, who were identified as an elopement risk at risk of elopement, at risk of leaving the facility unsupervised and sustaining serious injury or death. Findings included: Review of the facility's Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property (no date) revealed This includes the facility's identification of resident's whose personal histories render them at risk and development of intervention strategies to prevent occurrences, monitoring for changes, .and reassessment of the interventions on a regular basis. Resident #1's MDS assessment, dated 04/26/17 revealed the [AGE] year old female resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 04/14/17, revealed she was severely cognitively impaired with a BIMS (brief interview for mental status) score of 5 (a score of 0-7 indicated severe cognitive impairment). Resident #1's Elopement Risk, dated 03/14/17, revealed the resident was identified as being cognitively impaired with poor decision making skills; she was also identified as having a history of leaving the facility without informing staff. The document included the following question under the evaluation section, Based on assessment, dose resident present an elopement risk? No or yes was to be checked, and the resident was determined to be not at risk for elopement. The facility does not have a secured unit. She had no behaviors, no rejection of care and no wandering. The resident had no elopement interventions initiated. Resident #1's care plan, dated 05/01/17, revealed the resident had been identified as Believes that she is in her old neighborhood and needs to run errands and the approaches included assess and document impaired behavior patterns, monitor for signs of wandering, and attach wander guard as needed for wandering. Review of Nurses note, dated 06/12/17 and completed by RN A, revealed Resident #1 was last seen on the halls at 4:30 p.m. ambulating as was her usual. RN A entered the resident's room in order to give her a evening snack and resident was not in her room. RN A had not noted any unusual behavior or any attempts to leave the facility by Resident #1. Upon searching the facility and surrounding areas it was determined that the resident was not in the facility. The DON and Administrator were notified. Resident #1's Patient/Resident Incident/Accident Investigation Worksheet, dated 06/12/17 at 8:40 p.m., revealed the resident was last seen inside the building on 06/12/17 at or about 4:30 p.m. The report did not note the use of a wanderguard at the time of the incident. Further review of Resident #1's record provided no evidence a wander guard had been in use at the time of the incident. Review of nurses note, dated 06/13/17 and completed by LVN D, revealed she was present when Resident #1 was found in the alley way of a cross street approximately 1 mile from the facility. Resident #1 was sitting on ground, alert and oriented to person only, but denied pain upon assessment. She had no visible injury or distress at the time she was located. Resident #1 was then transported to a nearby hospital for evaluation via EMS (emergency medical services). Review of the facility's Provider Investigation Report, signed by Administrator and dated 06/19/17, provided the following timeline: -- On 06/12/17 at 4:30 p.m. Resident #1 was seen ambulating in the hallways of the facility. When charge nurse (RN A) went in to Resident #1s room to give her an evening snack, Resident #1 was not in her room, facility staff searched the facility and surrounding grounds. When it was determined that Resident #1 was not in facility- RN A notified the DON (at 9:15 p.m.) who then notified the Administrator. A head count was performed at that time and all 88 remaining residents were accounted for. --On 06/12/17 at 9:30 p.m., the NP (nurse practitioner) for the attending physician was notified with no new orders received. --On 06/12/17 at 10:00 p.m. the local police department was notified of the incident. The police continued the search throughout the night. -- On 06/13/17 at approximately 9:07 a.m., Resident #1 was found at a nearby middle school and was taken to the hospital for evaluation. Resident #1 returned to the facility the same day. Review of nurse's note, dated 06/13/17 at 3:00 p.m. and completed by ADON, revealed Resident #1 returned to the facility from the hospital with no injuries, no distress and no new orders received. A wanderguard device was placed on the resident's left ankle. Resident #1's Elopement Risk assessment was updated on 06/13/17 by the DON. It identified the resident as having a [DIAGNOSES REDACTED]., status or routine. the intervention noted a wander guard was applied for safety to left ankle. Observation of Resident #1 on 06/22/17 at 10:48 a.m. revealed she was sitting in a wheelchair in the hallway in front of nurses station with no visible signs of injury. She was wearing a wanderguard to her left ankle. Resident #1 was able to recognize her name but she was unaware of her location. At that time, Resident #1 stated she was going to her to sister's home to help fold laundry so that the children could have clothes to wear for school the following morning. Interview with CNA A on 07/07/17 at 12:25 a.m. revealed on 06/12/17 at 11:00 a.m., he was obtaining the monthly weights for residents. Upon obtaining the weight for Resident#1, she told CNA A she needed to go to the bank. CNA A stated he told Resident #1 that she would need to speak with the facility administration before she went anywhere. Resident #1 agreed and CNA A did not advise facility administration of the resident's comment because he was needing to complete the monthly weights and he did not normally have much contact with Resident #1 and he did not feel her statement was anything to be alarmed about and did not know the resident was at risk for elopement. Interview with CNA B on 07/07/17 at 2:00 p.m. revealed on 06/12/17, she overheard Resident #1 talking about going to the bank. Resident#1 had not mentioned leaving the facility prior to that date. CNA B did not mention Resident #1's comments to facility staff because she felt the statements were due to her disease process and felt that the resident was just talking and did not know the resident was at risk for elopement. Interview with RN A on 06/22/17 at 3:57 p.m. revealed on 6/12/17, Resident #1 was last seen in the halls at 4:30 p.m. ambulating as was her usual. RN A entered the resident's room in order to give her a evening snack and resident was not in her room. RN A had not noted any unusual behavior or any attempts to leave the facility by Resident #1. Upon searching the facility and surrounding areas it was determined that Resident #1 was not in the facility . The DON and Administrator were notified. Review of the meal intake report, dated 06/12/17, revealed the resident consumed her evening meal and would have been in the facility during the evening meal. Interview conducted with LVN D on 07/07/17 at 1:30 p.m. confirmed she was present when Resident #1 was located approximately 1 mile from the facility in an alley way. LVN D conducted a brief assessment and found no visible injury, no distress but did note that Resident #1 was more confused exhibited some increased confusion. LVN D could not recall any instance when Resident #1 verbalized the desire to leave the facility nor physically seek to exit the facility. She was unaware of the elopement risk or the care plan which indicated the need to monitor the resident. To the knowledge of LVN D, Resident #1 was not wearing a wanderguard at the time of the incident. Interview with Activity Director conducted on 07/07/17 at 2:05 p.m. revealed she was present at the time Resident #1 was located. Activity Director and LVN D were in the same vehicle. Activity Director stated Resident #1 exhibited no distress, had no visible injury and did seem to be more confused than is her usual state. The Activity Director was not aware of any instance of Resident #1 seeking to exit the facility, she had not verbalized any need to leave the facility. The Activity Director was not aware of the care plan which indicated the need to monitor the Resident #1. During an interview with the DON on 06/22/17 at 9:30 a.m.,she stated the resident had not left the facility prior to the incident on 06/12/17; however, she noted Resident #1 had previously been allowed to sit in a chair on the front porch. The DON stated that at the time of the incident, Resident #1 was not wearing a wanderguard device. The resident did not sign out at the desk as is the facility policy. When asked how the residents are identified as at risk of elopement the DON stated they perform risk assessments upon admission, quarterly, and with significant change. Since the incident all residents were evaluated and any resident with a BIMS score of 11 or under is now identified as a wander risk and are not permitted to sign out supervision. DON also stated she was not aware Resident had ever gotten outside of the facility prior to the incident on 06/12/17. During an interview with the Administrator on 06/22/17 at 1:10 p.m. , he said Resident #1 had not previously attempted to leave the facility. He stated the DON notified him of the incident on 06/1217 at or about 8:45 p.m. He stated he instructed staff to perform a head counts to verify remaining residents were present. He stated after the incident, staff performed elopement risk assessments for each resident as well as a BIMS. The Administrator also revealed that staff were in-serviced regarding elopement risk, interventions and steps to take in the event of an elopement. Review of the facility's Wandering/Missing Policy (no date) revealed .some of (corporation's) facilities do not have secured units and it becomes very important to identify residents who walk or wheel themselves unrestricted and become a threat to leave the facility unattended due to their own confusion. The facility must ensure the resident's safety while utilizing the least restrictive means available a plan of care will be developed and implemented with specific approaches and goals for the wanderer. Review of the facility's Elopement Risk Assessment (no date) revealed 9. The care plan is immediately updated the initiation of the interventions and changes in the interventions, as needed by the MDS Nurse/Designee .11. An Interim Plan of Care should be completed on admission if elopement risk is identified. Review of the elopement risk assessments confirmed all 88 residents had current assessments that were completed by facility nurses on 06/12/17. The DON, ADONs, and charge nurses were responsible for updating the elopement risk assessments. New residents admitted to the facility since the date of the incident had timely elopement risk assessments. Review of the elopement risk books located at both nurses stations and the reception desk included a picture of each resident at risk of elopement as well as all pertinent information regarding the resident. Interview with DON on 06/22/17 at 10:15 a.m. revealed the elopement books were completed on 06/13/17. Books were placed in nurses stations and front desk on 06/13/17 and are updated by DON . All new admissions were located in the elopement risk books. During an interview with the DON on 06/22/17 at 10:15 a.m., she stated that if a resident's BIMS score was less than 12, staff were not to allow a resident to sign himself out of the facility without staff or family present to supervise them. Review of the Elopement in-service, dated 06/12/17, revealed the Administrator provided 37 staff, representing staff from all three shifts, training on elopement risk factors, who to notify if a resident is exhibiting a new behavior of exit seeking behavior, and what to do if a resident is missing. It also included the need to immediately update car plans and develop new interventions, at the onset of exit seeking behaviors. New staff were to be trained on this process within 14 days. No new staff had been hired. Review of the Abuse and Neglect in-service dated 06/221/17 revealed the DON and Administrator provided 36 of 80 staff from all three shifts, training on Abuse and Neglect prevention . Review of the Abuse and Neglect in-service dated 06/23/17 revealed the DON and Administrator provided 42 of 80 staff from all three shifts, training on Abuse and Neglect prevention . Review of documentation of wanderguard system checks on 07/07/27 at 2:10 p.m. confirmed daily checks of the wanderguard bracelets by charge nurses on each shift for placement and function was checked by ADONs. On 07/07/17 at 10:45 a.m. the 14 residents with wanderguards were checked to verify their device functioned . On 07/07/17 interviews were conducted with 22 staff, representing staff from all three shifts and weekend staff, to confirm their knowledge obtained from the in-service training, drills and how they could identify residents at risk of elopement. Questions also included how they distinguished which residents could be released fro the facility without supervision. Staff interviewed were 7 housekeeping staff , 8 CNAs, 3 LVNs, 2 RNs, 1 Admissions staffer, 1 Social worker, and 1 facility receptionist. An Immediate Jeopardy (IJ) exited from 06/12/17 to 06/13/17. This was determined to be an IJ at past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of this survey. There were 88 residents in the facility upon surveyor entry on 06/22/17 as noted on the facility census. Facility census, dated 06/21/17, reflected thirteen (13) residents were identified as wander risks

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 13 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure CNAs A and B were trained to notify the administrative staff when on 06/12/17, Resident #1, a cognitively impaired resident, expressed a desire to leave the facility. Resident # 1 eloped that day (06/12/17) at or around 4:30 p.m. and was returned to the facility the following morning (06/13/17) at 9:00 a.m. (over 12 hours later). Resident #1 was found approximately one mile from the facility sitting in an alley. She sustained no injuries; however, she was placed at risk of serious injury or death. An Immediate Jeopardy (IJ) exited from 06/12/17 to 06/13/17. This was determined to be an IJ at past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of this survey. This failure placed 13 residents, who were identified as an elopement risk at risk of elopement, at risk of leaving the facility unsupervised and sustaining serious injury or death. Findings included: Resident #1's MDS assessment, dated 04/26/17 revealed the [AGE] year old female resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 04/14/17, revealed she was severely cognitively impaired with a BIMS (brief interview for mental status) score of 5 (a score of 0-7 indicated severe cognitive impairment). Resident #1's Elopement Risk, dated 03/14/17, revealed the resident was identified as being cognitively impaired with poor decision making skills; she was also identified as having a history of leaving the facility without informing staff. The document included the following question under the evaluation section, Based on assessment, dose resident present an elopement risk? No or yes was to be checked, and the resident was determined to be not at risk for elopement. The facility does not have a secured unit. She had no behaviors, no rejection of care and no wandering. The resident had no elopement interventions initiated. Resident #1's care plan, dated 05/01/17, revealed the resident had been identified as Believes that she is in her old neighborhood and needs to run errands and the approaches included assess and document impaired behavior patterns, monitor for signs of wandering, and attach wander guard as needed for wandering. Review of Nurses note, dated 06/12/17 and completed by RN A, revealed Resident #1 was last seen on the halls at 4:30 p.m. ambulating as was her usual. RN A entered the resident's room in order to give her a evening snack and resident was not in her room. RN A had not noted any unusual behavior or any attempts to leave the facility by Resident #1. Upon searching the facility and surrounding areas it was determined that the resident was not in the facility. The DON and Administrator were notified. Resident #1's Patient/Resident Incident/Accident Investigation Worksheet, dated 06/12/17 at 8:40 p.m., revealed the resident was last seen inside the building on 06/12/17 at or about 4:30 p.m. The report did not note the use of a wanderguard at the time of the incident. Further review of Resident #1's record provided no evidence a wander guard had been in use at the time of the incident. Review of nurses note, dated 06/13/17 and completed by LVN D, revealed she was present when Resident #1 was found in the alley way of a cross street approximately 1 mile from the facility. Resident #1 was sitting on ground, alert and oriented to person only, but denied pain upon assessment. She had no visible injury or distress at the time she was located. Resident #1 was then transported to a nearby hospital for evaluation via EMS (emergency medical services). Review of the facility's Provider Investigation Report, signed by Administrator and dated 06/19/17, provided the following timeline: -- On 06/12/17 at 4:30 p.m. Resident #1 was seen ambulating in the hallways of the facility. When charge nurse (RN A) went in to Resident #1s room to give her an evening snack, Resident #1 was not in her room, facility staff searched the facility and surrounding grounds. When it was determined that Resident #1 was not in facility- RN A notified the DON (at 9:15 p.m.) who then notified the Administrator. A head count was performed at that time and all 88 remaining residents were accounted for. --On 06/12/17 at 9:30 p.m., the NP (nurse practitioner) for the attending physician was notified with no new orders received. --On 06/12/17 at 10:00 p.m. the local police department was notified of the incident. The police continued the search throughout the night. -- On 06/13/17 at approximately 9:07 a.m., Resident #1 was found at a nearby middle school and was taken to the hospital for evaluation. Resident #1 returned to the facility the same day. Review of nurse's note, dated 06/13/17 at 3:00 p.m. and completed by ADON, revealed Resident #1 returned to the facility from the hospital with no injuries, no distress and no new orders received. A wanderguard device was placed on the resident's left ankle. Resident #1's Elopement Risk assessment was updated on 06/13/17 by the DON. It identified the resident as having a [DIAGNOSES REDACTED]., status or routine. the intervention noted a wander guard was applied for safety to left ankle. Observation of Resident #1 on 06/22/17 at 10:48 a.m. revealed she was sitting in a wheelchair in the hallway in front of nurses station with no visible signs of injury. She was wearing a wanderguard to her left ankle. Resident #1 was able to recognize her name but she was unaware of her location. At that time, Resident #1 stated she was going to her to sister's home to help fold laundry so that the children could have clothes to wear for school the following morning. Interview with CNA A on 07/07/17 at 12:25 a.m. revealed on 06/12/17 at 11:00 a.m., he was obtaining the monthly weights for residents. Upon obtaining the weight for Resident#1, she told CNA A she needed to go to the bank. CNA A stated he told Resident #1 that she would need to speak with the facility administration before she went anywhere. Resident #1 agreed and CNA A did not advise facility administration of the resident's comment because he was needing to complete the monthly weights and he did not normally have much contact with Resident #1 and he did not feel her statement was anything to be alarmed about and did not know the resident was at risk for elopement. Interview with CNA B on 07/07/17 at 2:00 p.m. revealed on 06/12/17, she overheard Resident #1 talking about going to the bank. Resident#1 had not mentioned leaving the facility prior to that date. CNA B did not mention Resident #1's comments to facility staff because she felt the statements were due to her disease process and felt that the resident was just talking and did not know the resident was at risk for elopement. Interview with RN A on 06/22/17 at 3:57 p.m. revealed on 6/12/17, Resident #1 was last seen in the halls at 4:30 p.m. ambulating as was her usual. RN A entered the resident's room in order to give her a evening snack and resident was not in her room. RN A had not noted any unusual behavior or any attempts to leave the facility by Resident #1. Upon searching the facility and surrounding areas it was determined that Resident #1 was not in the facility . The DON and Administrator were notified. Review of the meal intake report, dated 06/12/17, revealed the resident consumed her evening meal and would have been in the facility during the evening meal. Interview conducted with LVN D on 07/07/17 at 1:30 p.m. confirmed she was present when Resident #1 was located approximately 1 mile from the facility in an alley way. LVN D conducted a brief assessment and found no visible injury, no distress but did note that Resident #1 was more confused exhibited some increased confusion. LVN D could not recall any instance when Resident #1 verbalized the desire to leave the facility nor physically seek to exit the facility. She was unaware of the elopement risk or the care plan which indicated the need to monitor the resident. To the knowledge of LVN D, Resident #1 was not wearing a wanderguard at the time of the incident. Interview with Activity Director conducted on 07/07/17 at 2:05 p.m. revealed she was present at the time Resident #1 was located. Activity Director and LVN D were in the same vehicle. Activity Director stated Resident #1 exhibited no distress, had no visible injury and did seem to be more confused than is her usual state. The Activity Director was not aware of any instance of Resident #1 seeking to exit the facility, she had not verbalized any need to leave the facility. The Activity Director was not aware of the care plan which indicated the need to monitor the Resident #1. During an interview with the DON on 06/22/17 at 9:30 a.m.,she stated the resident had not left the facility prior to the incident on 06/12/17; however, she noted Resident #1 had previously been allowed to sit in a chair on the front porch. The DON stated that at the time of the incident, Resident #1 was not wearing a wanderguard device. The resident did not sign out at the desk as is the facility policy. When asked how the residents are identified as at risk of elopement the DON stated they perform risk assessments upon admission, quarterly, and with significant change. Since the incident all residents were evaluated and any resident with a BIMS score of 11 or under is now identified as a wander risk and are not permitted to sign out supervision. DON also stated she was not aware Resident had ever gotten outside of the facility prior to the incident on 06/12/17. During an interview with the Administrator on 06/22/17 at 1:10 p.m. , he said Resident #1 had not previously attempted to leave the facility. He stated the DON notified him of the incident on 06/1217 at or about 8:45 p.m. He stated he instructed staff to perform a head counts to verify remaining residents were present. He stated after the incident, staff performed elopement risk assessments for each resident as well as a BIMS. The Administrator also revealed that staff were in-serviced regarding elopement risk, interventions and steps to take in the event of an elopement. Review of the facility's Wandering/Missing Policy (no date) revealed .some of (corporation's) facilities do not have secured units and it becomes very important to identify residents who walk or wheel themselves unrestricted and become a threat to leave the facility unattended due to their own confusion. The facility must ensure the resident's safety while utilizing the least restrictive means available a plan of care will be developed and implemented with specific approaches and goals for the wanderer. Review of the facility's Elopement Risk Assessment (no date) revealed 9. The care plan is immediately updated the initiation of the interventions and changes in the interventions, as needed by the MDS Nurse/Designee .11. An Interim Plan of Care should be completed on admission if elopement risk is identified. Review of the elopement risk assessments confirmed all 88 residents had current assessments that were completed by facility nurses on 06/12/17. The DON, ADONs, and charge nurses were responsible for updating the elopement risk assessments. New residents admitted to the facility since the date of the incident had timely elopement risk assessments. Review of the elopement risk books located at both nurses stations and the reception desk included a picture of each resident at risk of elopement as well as all pertinent information regarding the resident. Interview with DON on 06/22/17 at 10:15 a.m. revealed the elopement books were completed on 06/13/17. Books were placed in nurses stations and front desk on 06/13/17 and are updated by DON . All new admissions were located in the elopement risk books. During an interview with the DON on 06/22/17 at 10:15 a.m., she stated that if a resident's BIMS score was less than 12, staff were not to allow a resident to sign himself out of the facility without staff or family present to supervise them. Review of the Elopement in-service, dated 06/12/17, revealed the Administrator provided training for 37 staff, representing staff from all three shifts, regarding elopement risk factors, who to notify if a resident is exhibiting a new behavior of exit seeking behavior, and what to do if a resident is missing. It also included the need to immediately update car plans and develop new interventions, at the onset of exit seeking behaviors. New staff were to be trained on this process within 14 days. No new staff had been hired. Review of documentation of wanderguard system checks on 07/07/27 at 2:10 p.m. confirmed daily checks of the wanderguard bracelets by charge nurses on each shift for placement and function was checked by ADONs. On 07/07/17 at 10:45 a.m. the 14 residents with wanderguards were checked to verify their device functioned . On 07/07/17 interviews were conducted with 22 staff, representing staff from all three shifts and weekend staff, to confirm their knowledge obtained from the in-service training, drills and how they could identify residents at risk of elopement. Questions also included how they distinguished which residents could be released fro the facility without supervision. Staff interviewed were 7 housekeeping staff , 8 CNAs, 3 LVNs, 2 RNs, 1 Admissions staffer, 1 Social worker, and 1 facility receptionist. An Immediate Jeopardy (IJ) exited from 06/12/17 to 06/13/17. This was determined to be an IJ at past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of this survey. There were 88 residents in the facility upon surveyor entry on 06/22/17 as noted on the facility census. Facility census, dated 06/21/17, reflected thirteen (13) residents were identified as wander risks.

Based on observation, interview, and record review, the facility failed to ensure resident was free from neglect by failing to provide adequate supervision to prevent accidents for 1 of 13 residents (Resident #1) reviewed for neglect. The facility failed to ensure CNAs A and B failed were trained to notify the administrative staff when on 06/12/17, Resident #1, a cognitively impaired resident, expressed a desire to leave the facility. Resident # 1 eloped that day (06/12/17) at or around 4:30 p.m. and was returned to the facility the following morning (06/13/17) at 9:00 a.m. (over 12 hours later). Resident #1 was found approximately one mile from the facility sitting in an alley. She sustained no injuries; however, she was placed at risk of serious injury or death. An Immediate Jeopardy (IJ) exited from 06/12/17 to 06/13/17. This was determined to be an IJ at past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of this survey. This failure placed 13 residents, who were identified as an elopement risk at risk of elopement, at risk of leaving the facility unsupervised and sustaining serious injury or death. Findings included: Resident #1's MDS assessment, dated 04/26/17 revealed the [AGE] year old female resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 04/14/17, revealed she was severely cognitively impaired with a BIMS (brief interview for mental status) score of 5 (a score of 0-7 indicated severe cognitive impairment). Resident #1's Elopement Risk, dated 03/14/17, revealed the resident was identified as being cognitively impaired with poor decision making skills; she was also identified as having a history of leaving the facility without informing staff. The document included the following question under the evaluation section, Based on assessment, dose resident present an elopement risk? No or yes was to be checked, and the resident was determined to be not at risk for elopement. The facility does not have a secured unit. She had no behaviors, no rejection of care and no wandering. The resident had no elopement interventions initiated. Resident #1's care plan, dated 05/01/17, revealed the resident had been identified as Believes that she is in her old neighborhood and needs to run errands and the approaches included assess and document impaired behavior patterns, monitor for signs of wandering, and attach wander guard as needed for wandering. Review of Nurses note, dated 06/12/17 and completed by RN A, revealed Resident #1 was last seen on the halls at 4:30 p.m. ambulating as was her usual. RN A entered the resident's room in order to give her a evening snack and resident was not in her room. RN A had not noted any unusual behavior or any attempts to leave the facility by Resident #1. Upon searching the facility and surrounding areas it was determined that the resident was not in the facility. The DON and Administrator were notified. Resident #1's Patient/Resident Incident/Accident Investigation Worksheet, dated 06/12/17 at 8:40 p.m., revealed the resident was last seen inside the building on 06/12/17 at or about 4:30 p.m. The report did not note the use of a wanderguard at the time of the incident. Further review of Resident #1's record provided no evidence a wander guard had been in use at the time of the incident. Review of nurses note, dated 06/13/17 and completed by LVN D, revealed she was present when Resident #1 was found in the alley way of a cross street approximately 1 mile from the facility. Resident #1 was sitting on ground, alert and oriented to person only, but denied pain upon assessment. She had no visible injury or distress at the time she was located. Resident #1 was then transported to a nearby hospital for evaluation via EMS (emergency medical services). Review of the facility's Provider Investigation Report, signed by Administrator and dated 06/19/17, provided the following timeline: -- On 06/12/17 at 4:30 p.m. Resident #1 was seen ambulating in the hallways of the facility. When charge nurse (RN A) went in to Resident #1s room to give her an evening snack, Resident #1 was not in her room, facility staff searched the facility and surrounding grounds. When it was determined that Resident #1 was not in facility- RN A notified the DON (at 9:15 p.m.) who then notified the Administrator. A head count was performed at that time and all 88 remaining residents were accounted for. --On 06/12/17 at 9:30 p.m., the NP (nurse practitioner) for the attending physician was notified with no new orders received. --On 06/12/17 at 10:00 p.m. the local police department was notified of the incident. The police continued the search throughout the night. -- On 06/13/17 at approximately 9:07 a.m., Resident #1 was found at a nearby middle school and was taken to the hospital for evaluation. Resident #1 returned to the facility the same day. Review of nurse's note, dated 06/13/17 at 3:00 p.m. and completed by ADON, revealed Resident #1 returned to the facility from the hospital with no injuries, no distress and no new orders received. A wanderguard device was placed on the resident's left ankle. Resident #1's Elopement Risk assessment was updated on 06/13/17 by the DON. It identified the resident as having a [DIAGNOSES REDACTED]., status or routine. the intervention noted a wander guard was applied for safety to left ankle. Observation of Resident #1 on 06/22/17 at 10:48 a.m. revealed she was sitting in a wheelchair in the hallway in front of nurses station with no visible signs of injury. She was wearing a wanderguard to her left ankle. Resident #1 was able to recognize her name but she was unaware of her location. At that time, Resident #1 stated she was going to her to sister's home to help fold laundry so that the children could have clothes to wear for school the following morning. Interview with CNA A on 07/07/17 at 12:25 a.m. revealed on 06/12/17 at 11:00 a.m., he was obtaining the monthly weights for residents. Upon obtaining the weight for Resident#1, she told CNA A she needed to go to the bank. CNA A stated he told Resident #1 that she would need to speak with the facility administration before she went anywhere. Resident #1 agreed and CNA A did not advise facility administration of the resident's comment because he was needing to complete the monthly weights and he did not normally have much contact with Resident #1 and he did not feel her statement was anything to be alarmed about and did not know the resident was at risk for elopement. Interview with CNA B on 07/07/17 at 2:00 p.m. revealed on 06/12/17, she overheard Resident #1 talking about going to the bank. Resident#1 had not mentioned leaving the facility prior to that date. CNA B did not mention Resident #1's comments to facility staff because she felt the statements were due to her disease process and felt that the resident was just talking and did not know the resident was at risk for elopement. Interview with RN A on 06/22/17 at 3:57 p.m. revealed on 6/12/17, Resident #1 was last seen in the halls at 4:30 p.m. ambulating as was her usual. RN A entered the resident's room in order to give her a evening snack and resident was not in her room. RN A had not noted any unusual behavior or any attempts to leave the facility by Resident #1. Upon searching the facility and surrounding areas it was determined that Resident #1 was not in the facility . The DON and Administrator were notified. Review of the meal intake report, dated 06/12/17, revealed the resident consumed her evening meal and would have been in the facility during the evening meal. Interview conducted with LVN D on 07/07/17 at 1:30 p.m. confirmed she was present when Resident #1 was located approximately 1 mile from the facility in an alley way. LVN D conducted a brief assessment and found no visible injury, no distress but did note that Resident #1 was more confused exhibited some increased confusion. LVN D could not recall any instance when Resident #1 verbalized the desire to leave the facility nor physically seek to exit the facility. She was unaware of the elopement risk or the care plan which indicated the need to monitor the resident. To the knowledge of LVN D, Resident #1 was not wearing a wanderguard at the time of the incident. Interview with Activity Director conducted on 07/07/17 at 2:05 p.m. revealed she was present at the time Resident #1 was located. Activity Director and LVN D were in the same vehicle. Activity Director stated Resident #1 exhibited no distress, had no visible injury and did seem to be more confused than is her usual state. The Activity Director was not aware of any instance of Resident #1 seeking to exit the facility, she had not verbalized any need to leave the facility. The Activity Director was not aware of the care plan which indicated the need to monitor the Resident #1. During an interview with the DON on 06/22/17 at 9:30 a.m.,she stated the resident had not left the facility prior to the incident on 06/12/17; however, she noted Resident #1 had previously been allowed to sit in a chair on the front porch. The DON stated that at the time of the incident, Resident #1 was not wearing a wanderguard device. The resident did not sign out at the desk as is the facility policy. When asked how the residents are identified as at risk of elopement the DON stated they perform risk assessments upon admission, quarterly, and with significant change. Since the incident all residents were evaluated and any resident with a BIMS score of 11 or under is now identified as a wander risk and are not permitted to sign out supervision. DON also stated she was not aware Resident had ever gotten outside of the facility prior to the incident on 06/12/17. During an interview with the Administrator on 06/22/17 at 1:10 p.m. , he said Resident #1 had not previously attempted to leave the facility. He stated the DON notified him of the incident on 06/1217 at or about 8:45 p.m. He stated he instructed staff to perform a head counts to verify remaining residents were present. He stated after the incident, staff performed elopement risk assessments for each resident as well as a BIMS. The Administrator also revealed that staff were in-serviced regarding elopement risk, interventions and steps to take in the event of an elopement. Review of the facility's Wandering/Missing Policy (no date) revealed .some of (corporation's) facilities do not have secured units and it becomes very important to identify residents who walk or wheel themselves unrestricted and become a threat to leave the facility unattended due to their own confusion. The facility must ensure the resident's safety while utilizing the least restrictive means available a plan of care will be developed and implemented with specific approaches and goals for the wanderer. Review of the facility's Elopement Risk Assessment (no date) revealed 9. The care plan is immediately updated the initiation of the interventions and changes in the interventions, as needed by the MDS Nurse/Designee .11. An Interim Plan of Care should be completed on admission if elopement risk is identified. Review of the facility's Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property (no date) revealed each resident had the right to be free from neglect. This includes the facility's identification of resident's whose personal histories render them at risk and development of intervention strategies to prevent occurrences, monitoring for changes, .and reassessment of the interventions on a regular basis. Review of the elopement risk assessments confirmed all 88 residents had current assessments that were completed by facility nurses on 06/12/17. The DON, ADONs, and charge nurses were responsible for updating the elopement risk assessments. New residents admitted to the facility since the date of the incident had timely elopement risk assessments. Review of the elopement risk books located at both nurses stations and the reception desk included a picture of each resident at risk of elopement as well as all pertinent information regarding the resident. Interview with DON on 06/22/17 at 10:15 a.m. revealed the elopement books were completed on 06/13/17. Books were placed in nurses stations and front desk on 06/13/17 and are updated by DON . All new admissions were located in the elopement risk books. During an interview with the DON on 06/22/17 at 10:15 a.m., she stated that if a resident's BIMS score was less than 12, staff were not to allow a resident to sign himself out of the facility without staff or family present to supervise them. Review of the Elopement in-service, dated 06/12/17, revealed the Administrator provided 37 staff, representing staff from all three shifts, training on elopement risk factors, who to notify if a resident is exhibiting a new behavior of exit seeking behavior, and what to do if a resident is missing. It also included the need to immediately update car plans and develop new interventions, at the onset of exit seeking behaviors. New staff were to be trained on this process within 14 days. No new staff had been hired. Review of the Abuse and Neglect in-service dated 06/221/17 revealed the DON and Administrator provided 36 of 80 staff from all three shifts, training on Abuse and Neglect prevention . Review of the Abuse and Neglect in-service dated 06/23/17 revealed the DON and Administrator provided 42 of 80 staff from all three shifts, training on Abuse and Neglect prevention . Review of documentation of wanderguard system checks on 07/07/27 at 2:10 p.m. confirmed daily checks of the wanderguard bracelets by charge nurses on each shift for placement and function was checked by ADONs. On 07/07/17 at 10:45 a.m. the 14 residents with wanderguards were checked to verify their device functioned . On 07/07/17 interviews were conducted with 22 staff, representing staff from all three shifts and weekend staff, to confirm their knowledge obtained from the in-service training, drills and how they could identify residents at risk of elopement. Questions also included how they distinguished which residents could be released fro the facility without supervision. Staff interviewed were 7 housekeeping staff , 8 CNAs, 3 LVNs, 2 RNs, 1 Admissions staffer, 1 Social worker, and 1 facility receptionist. An Immediate Jeopardy (IJ) exited from 06/12/17 to 06/13/17. This was determined to be an IJ at past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of this survey. There were 88 residents in the facility upon surveyor entry on 06/22/17 as noted on the facility census. Facility census, dated 06/21/17, reflected thirteen (13) residents were identified as wander risks.

Based on observation, interview, and record review, it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficienty to attain or maintain the highest practicable physicial, mental, and psychosocial well-being of each resident for one of (Resident #4) of 16 residents observed during the medication pass. 1. The Administrator failed to supervise the DON to ensure she carried out her job responsibilities, which included supervising ADON C and the Charge Nurses and verifying the nurses' compentencies to care for the residents. 2. The DON failed to do the following: a. Implement the facility's policy "Setting Up a Primary Infusion." b. To supervise ADON C and LVN E to ensure they were competent to provide care to and maintain a central venous catheter, which included admininstering antibiotics. c. To train the nurses regarding the care and maintenance of central venous catheters. d. To verify all the nurses had IV certification and to check off the skills of those nurses prior to allowing them to care for residents with central venous catheters. 3. LVN E administered the antibiotic, [MEDICATION NAME], intravenously to Resident #4. LVN E also failed to expel air from the normal saline flush syringe before injecting it into the resident's central line. Resident #4 received 1 - 1 1/2 cc of air pushed into her blood stream through the central intravenous line during the flush procedure. LVN E administered the [MEDICATION NAME] at the wrong administration rate. ADON C administered the antibiotic, Aztreonam, intravenously to Resident #4. ADON C failed to prime the IV tubing leaving air bubbles in the tubing that were infusing into the resident. The DON failed to squeeze the drip chamber of the intravenous tubing to fill it during priming. Leaving the drip chamber less than half full during infusion increased the chances of it running dry and forcing air into the tubing and then into the resident. Failure to remove air from the tubing can result in an air embolism which can cause temporary paralysis or death. An Immediate Jeopardy (IJ) was identified on 04/27/12. While the IJ was removed on 04/28/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. This failure could affect Resident #1, who was the only resident with a central line. Findings included: 1. On 04/27/12 at 3:33 PM, the ADM was interviewed. The ADM was asked what type of procedure was there to make sure the nursing needs of resident's were being met? The ADM stated they had standards of care meetings weekly, stand-up daily meetings, and monthly safety committe meetings. He stated he did QA rounds bi-weekly. When asked how did he monitor staff (including the DON and Maintenance) to ensure the systems they monitor were being done sufficiently? He responded in stand-up meetings concerns were addressed if the nurse were not addressing concerns. The ADM was asked how did he think this incident (the IJ) came about? He stated he thought the DON let him know if something was not the way it was supposed to be. He stated the DON reports to him step by step. The ADM stated last month the ADONs had an opportunity for candid feedback. He met with them and asked what could be done better and how burn-out could be prevented. The following questions were asked of the DON on 04/27/12 at 4:00 PM: What training did you ensure nurses/CNA/MAs had in order to care for a resident(s)? The DON stated look at experience when staff was hired. How did you ensure nurses/CNAs/MAs were competent in their skills to care for a resident? The DON stated "med administration including IV." She stated she hired experienced staff and did reference checks to make sure the staff had no past problems. What type of plan was in place for medication administration? She stated she did in-services on med errors, the med policy and correct transcription of orders. Have there been in-services since you were notified of the IJ? The DON stated the Corporate Nurse just started an insulin administration in-service. How do you thind this IJ occurred? The DON replied, by not following physician's orders [REDACTED]. The DON stated her plan of action was to updated all IV training on all nurses. The DON was asked how did she monitor staff after in-service. She stated she talks to them. 2. The job description for the DON dated February 2012 reflected, "RESPONSIBLE TO: Administrator RESPONSIBILITIES: Develop and maintain nursing service objectives, standards of nursing practice, nursing policy and procedures, scheduling of daily rounds to see all residents, hiring firing and staffing the recommended number and levels of nursing personnel to be employed and staff development. Under the direction of the Administrator is responsible for planning, organizing, staffing, directing, coordinating, reporting, budgeting, and management of the facility, staff, supplies and equipment in such a way that meaningful nursing services is established to render the optimum of resident care. Fulfills policies and objectives insuring quality nursing care as set for the by the Administrator and standards of the facility. Supports and practices the philosophy, objectives and standards of (corporate name) and the Nursing Department, and directs the revision of these as necessary to ensure the quality of care to all residents...." 3. The MDS assessment dated [DATE] reflected Resident #4 was a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident # 4's [DIAGNOSES REDACTED]. Resident #4's April 2012 consolidated physician's orders [REDACTED]. ? Aztreonam 1 gm. IV Q 12 hr. x 6 weeks. Start date 04/19/12. ? Flush before and after medication administration using the SASH method (saline,administer medication, saline, and [MEDICATION NAME]) use 5 mL of saline in a 10 mL syringe ending with 5 mL of 10 units per cc of [MEDICATION NAME] in a 10 mL syringe. ? [MEDICATION NAME] 1.5 g/200 ml over 90 min. IV Q 12 hr. X six weeks. Start date 04/19/12. Change IV tubing daily. On 04/26/12 at 3:15 PM, LVN E was observed during IV medication administration to Resident #4. LVN E brought [MEDICATION NAME] 1.25 gm in 250 ml normal saline, some alcohol prep pads, two prefilled normal saline syringes, and a syringe of [MEDICATION NAME] flush solution to Resident #4's room in a plastic green basket. LVN E placed the basket on the bedside table and went to the sink to wash her hands. LVN E donned gloves, went to the resident and picked up the IV line with a paper towel. She arranged some more paper towels under the catheter's port. She unclipped the safety clip on the central line and wiped the blue port with alcohol wipes. LVN E opened a prefilled syringe of normal saline flush from the wrapper and placed it back in the basket. LVN E stated resident's IV tubing for the [MEDICATION NAME] was not dated and she needed a new one. LVN E gathered her supplies and left the room to get more tubing. During preparation for administration, LVN E spiked the 250 ml bag of NS with 1.25 grams of [MEDICATION NAME] (antibiotic) with IV tubing. She then unclamped the tubing and allowed the solution to flow through the line without first filling the drip chamber (a chamber at the top of the tubing to prevent air from entering the tubing.) The surveyor saw bubbles forming in the line. LVN E then picked up a pre-filled 10 cc syringe filled with 5 ml of NS used to ensure patency of the IV catheter and to verify placement. The syringe was observed to also contain approximately 1-2 ml of air. Without first expressing the air from the syringe, LVN E connected the syringe onto the central line. Without aspirating to check placement of the line, LVN E began pushing the fluid and the air into the resident. The surveyor attempted to stop the LVN by putting her hand over the LVN's hand and saying, "Stop! There is air in the syringe!" LVN E stated, "I expressed the air from the syringe already" and continued to inject the contents of the syringe, including the 1-2 ml of air. http://www.nursingcenter.com/prodev/ce_article.asp?tid= 73 reflected, "Air embolism is a well-published complication arising from central venous catheter use. Literature and case studies provide information regarding clinical sequelae. Preventable mistakes still occur despite following what is considered appropriate protocol...Venous air embolism (VAE) occurs from air entering the venous system via the CVC itself or the track from removal of the CVC (Fink et al., 2005). Air is transported to the [MEDICAL CONDITION] arteries, hindering gas exchange and causing [MEDICAL CONDITION] hypertension. This can result in right ventricular strain and, ultimately, cardiovascular collapse (Fink et al., 2005; Wittenberg et al., 2006). A large enough [MEDICATION NAME] of air can create an obstruction to the outflow of blood from the right ventricle, essentially forming an airlock (Wittenberg et al., 2006)...." (Retrieved on 05/11/12). LVN E then attached the IV tubing for the antibiotic to Resident #4's central line. An in-line regulator (Control-a-Flo) was observed on the tubing, but LVN E adjusted the safety clamp to approximately half open stating, "I'm setting the clamp halfway so it only runs half open. I use this clamp to set the rate. Then I make sure the thing here (LVN E gestured to the Control-a-Flo dial) is set at between 10 and 30 (ml/hr)." At that time, the surveyor counted the flow rate for the antibiotic to be at 36 drops per minute (10 drops equal 1 ml). An interview during the procedure on 04/26/12 at 3:30 PM with LVN E revealed she did not calculate the rate, but the antibiotic was ordered by the physician to infuse in over 90 minutes. LVN E stated, "This drip rate should make it done in about an hour and a half or so." Resident #4's physician's orders [REDACTED]. NOTE: Calculation of the flow rate Volume in ml X drip factor (10) = drops per minute Time 250 ml X 10 = 28 drops per minute 90 On 04/26/12 at 4:10 PM, LVN E was observed at Resident #4's bedside. At that time, LVN E pointed to the numbers on the Control-a-Flo. LVN E pointed to the number "100," indicating 100 ml. hr. LVN E stated the number was, "Ten." LVN E pointed to the number "125," indicating 125 ml/hr. LVN E stated the number was, "Thirty." LVN E was queried as to where she saw "10" and "30" on the Control-a-Flo because the surveyor saw "100" and "125." LVN E replied, "I guess I need my glasses." LVN E was not wearing glasses at this time. Interview with LVN E on 04/26/12 at 5:42 PM revealed she needed reading glasses to enlarge things. LVN E stated she did not need the glasses all of the time, but did need glasses to look at fine print. LVN E stated she worked on Hall One and did not work with IVs on Hall Two. She stated the nurse currently working Hall Two was not IV certified, so ADON C asked her to take care of the IV on Hall Two. LVN E stated she told ADON C she needed to look at the procedure. LVN E stated she was called away and did not get a chance to review the IV procedure. She stated she recalled the procedure which was saline, antibiotic, saline, [MEDICATION NAME] flush. LVN E continued to explain before any IV medication was given, a saline flush was done. She stated the saline came in a prepackaged syringe. LVN E stated she had to ensure the fluid was all the way up to the top of the syringe and had to waste some of the fluid out the top of the syringe. LVN E stated next the medication which was ordered was administered. LVN E stated she calculated the dose, if the dose was not calculated for her. LVN E stated one of the ADONs calculated the dose behind them. LVN E stated she did not ask one of the ADONs to calculate the dose today, but usually asked one of the ADONs to calculate the dose with her. LVN E stated today she forgot she was not supposed to clamp off the flow. She stated the Control-a-Flo (in line regulator) was used in this facility, but most IVs were on a pump. LVN E stated ADON C asked her to take care of the IV, because ADON C was " tired." LVN E showed the surveyor a blank piece of paper with handwritten numbers on it and stated it was ADON C's calculations for the flow rate for the IV. On 04/26/12 at 5:20 PM, ADON C was observed during IV medication administration of Aztreonam to Resident #4. ADON C connected the new bag of medication and started the infusion. The drip chamber was observed to be empty with air in the tubing. The surveyor immediately stopped the infusion by clamping off the tubing to prevent air from going into Resident #4's body. The empty drip chamber and air in the line was pointed out to ADON C. The DON was requested to come to the room. When the DON arrived at 3:45 PM on 04/26/12, the air in the line was measured with a ruler. There was a total of 3.1 cm of air in the line. The DON told ADON C to get more IV tubing and another antibiotic solution and start all over. ADON C attempted to prime the IV line without filling the drip chamber. The surveyor requested the DON to assist ADON C with priming the IV line. The DON did not fill the drip chamber. Under the DON's supervision, ADON C picked up a prefilled syringe of normal saline, expressed the air from the syringe, wiped the end of the port on the central line and attached the luer lock syringe to the port. ADON C did not aspirate to check the placement of the line, flushed with 5 ml of normal saline, attached the IV tubing and set the control a flow regulator to 150 ml per hour An interview was conducted with the DON about the LVN training for intravenous medication administration on 04/27/12 at 9:20 AM. When queried about the training the LVNs received, the DON stated she was sure all the certificates and skills checklists were in the nurses' personnel files. The surveyor presented the certificates and IV skills checklists that were found in the personnel files. The DON stated she did not know why the staff did not have certificates for intravenous medication classroom training. During an interview on 04/27/12 at 11:50 AM, the DON was asked how she determined if staff had the necessary skills to work with central lines and IV's. The DON stated, "I go over check off sheets with them. They are individualized in their folders. I do it when they come to work here. I look at if they have had any training. I don't do IV skills check off every year. I have had classes here and the last one was in 2007." The DON was then asked if the nurses needed an IV course before performing the skills check off. The DON responded, "Not all of them have the certificate. I do go over the skills check off list to determine the skill levels of the nurses. I do the procedure for hanging IVPB rather than placement of IV's if they haven't had the class." When asked if the nurses were required to have an IV class before administering IV medications, the DON stated, "Most are already certified. We have made arrangements for them to go out and have the class soon. I don't have the date yet for the class." The DON was asked how she checked the nurses' IV competency. The DON stated, "We don't always have an IV in the building. I directly oversee the nurses and directly train them." When queried regarding the number of nurses on each shift that have IV training, the DON stated, "Two per shift, one treatment nurse, one weekend RN." When asked, "How do you demonstrate the competency of your staff?", the DON stated, "The ADONs help me to check the check off lists. When there is an opportunity to watch, we do a demo (demonstration), but mostly we do question and answer sessions. We do return demonstration only if we have a patient who has a particular skill (like IV's). Otherwise we do annual check-offs of skills." An interview with LVN F was conducted on 04/27/12 at 8:45 PM. LVN F was asked what training she had regarding IV medications. She stated, "I went to a class and got a certification for IVs." When queried about the procedure for an IV flush of a central line, she stated, "Flush the line with normal saline, attach the antibiotic at the ordered rate, flush the IV when the antibiotic is done and flush the line with [MEDICATION NAME] when done." An interview with the Human Resources Director was conducted on 04/27/12 at 11:00 AM. When queried about in-services for IV medications or IV care, she stated, "There were no previous in-services last year for IVs. The last IV in-service was from an outside vendor given in 06/06/2007. Other than that there were no IV in-services or in-services about caring for IV's." Upon request for IV training verification, at 7:20 PM on 04/26/12 the Corporate Nurse provided ten LVNs' personnel files. The Corporate Nurse stated he could not find all of the files. Review of the ten LVN personnel files provided by the Corporate Nurse revealed three LVNs had the classroom training to administer IVs. The most recently trained LVN had a classroom training date of 04/12/11. The other 2 had certificates from 2006 and 2007. The DON had done IV skills evaluation for five of the ten LVNs. Some LVNs had the skills check list and no IV classroom training. The skills procedure was a checklist that had the following categories with a check mark area beside it: ? Has successfully demonstrated IV placement. ? Has successfully demonstrated IV fluids/medication administration/maintenance ? Has successfully demonstrated the procedure for disconnecting IV therapy There was a second skills checklist in some of the personnel files it was titled central venous catheter care. The checklist reflected the following expected behaviors: ? Verify orders ? Explained procedure ? Gathers supplies and inspect for integrity ? Wash hands and put on non-sterile gloves ? Remove old CVL dressing ? Assess site for infection ? Set up and maintain a sterile field ? Clean insertion site for protocol apply appropriate dressing ? Secure online per protocol ? Draw up appropriate flush solution and flush central venous line for protocol ? Change injection port per protocol ? Clean work area and dispose of waste appropriately ? Document the procedure appropriately I V Certification of LVNs Name Date of Hire IV Class IV checklist LVN L 10/03/11 No No LVN F 01/03/12 No No LVN N 04/11/07 06/06/07 03/23/09 LVN E 09/21/01 No 03/11/09 LVN G 06/06/11 No No LVN O 08/26/09 04/12/11 No LVN P 05/10/11 No 01/10/12 ADON C 12/01/04 No 06/06/07 LVN Q 04/11/08 10/08/05 03/10/09 ADON R No No An interview was conducted with the DON about the LVN training for intravenous medication administration on 04/27/12 at 9:20 AM. When queried about the training the LVNs received, the DON stated she was sure all the certificates and skills checklists were in the nurses' personnel files. The surveyor presented the certificates and IV skills checklists that were found in the personnel files. The DON stated she did not know why the staff did not have certificates for intravenous medication classroom training. The facility's policy, Infusion Rate Control (section 7.5), dated October 2011, reflected, "an infusion pump will be used for administration of [MEDICATION NAME] Nutrition, medications with rate related complications and all therapies given through a [MEDICAL CONDITION] (central venous access device), including a PICC (peripherally inserted central catheter)." The facility's policy, Setting up A Primary Infusion (section 7.2), dated October 2011, reflected, "Only a professional nurse with documented IV education, as designated by the facility and as allowed by state regulations may set up a primary infusion. Equipment to be used was listed ...infusion pump...Procedure included ...Squeeze drip chamber until 1/4 - 1/2 full." Potter and Perry's Fundamentals of Nursing 7th edition, 2009, reflected: " INITIATING INTRAVENOUS THERAPY ( pages 996-997) ...Preparing IV tubing and solution ... 14 ...f. Prime infusion tubing by filling with IV solution: Compress the drip chamber and release, allowing it to fill one-third to one-half full ...Ensures tubing is cleared of air before connection with IV site. Creates suction effect; fluid enters drip chamber to prevent air from entering tubing g. Remove protector cap on end of tubing ...and slowly open roller clamp to allow fluid to travel from drip chamber through tubing ...Slow fill of tubing decreases turbulence and chance of bubble formation. Removes air from tubing and permits tubing to fill with solution ... h. Be certain tubing is clear of air and air bubbles ...Check entire length of tubing to ensure that all air bubbles are removed ...Large air bubbles may acts as emboli .... " " The patency of the IV line is checked to insure that the line is intact and not leaking ... Intermittent IV drug doses are usually calculated in cc per hour. They are given in larger amounts of fluid that are usually given with an IV pump and most IV pumps are set in cc per hour, not cc per minute. " (Retrieved at <http://www.healthline.com/galecontent/intravenous-medication-administration#1> on 5/09/12) The Intravenous Nurse Society's Standard of Practice, 2006 retrieved on 5/09/12 at <http://www.cathflo.com/media/professional_cathetermanagebroch.pdf> reflected: " ...catheter patency should always be checked " prior to administration of [MEDICATION NAME] medications and solutions. " When checking placement it is important to confirm the patency of the Central Central Venous Catheter ' s patency by " ... aspirating the device for confirmation of positive blood return.... " An IJ was identified on 04/27/12 at 3:03 PM. The Administrator and the DON were notified of the IJ on 04/27/12 at 3:03 PM and a Plan of Removal was requested at that time. The Plan of Removal was accepted on 04/28/12 and reflected: 1. The attending physicians were notified of the errors found by the surveyors. 2. The DON and Weekend RN supervisor will be responsible for administering Resident #4's antibiotics and the flushing of the central catheter. All licensed nurses will complete IV education and training on 04/30/12 and 05/01/12. The DON and ADONs will monitor new hires to ensure completion and compliance. 3. Re-educate all licensed nurses and medication aides regarding medication administration. Re-educate licensed nurses regarding implementation of physician's orders [REDACTED]. licensed nurses will be responsible for re-ordering new medications as well as refills from the pharmacy. A competency based test will be given to each licensed nurse and certified medication aides to validate comprehension and compliance. This re-education and competency based test will be completed on 04/27/12 at 9:00 PM by the DON and the ADONs. Licensed nurses certified medication aides, including weekend licensed nurses and certified medication aides, will not be allowed to return to work without completing this re-education and competency based tests. New hire licensed nurses will not be allowed to work without completing education and competency based test as well completed by DON and ADONs. 4. Full facility audit of current Physician's Telephone Orders, residents' clinical records MARs, and medications in the medication carts will be completed by the DON and/or designee to ensure current medications and physician's orders [REDACTED]. This full audit will be completed on 04/27/12 at 10:00 p.m. 5. Licensed nurses and medication aides will be validated by a proficiency check-off on proper medication administration. Licensed nurses will be validated by proficiency check-off on proper insulin administration. This proficiency check-off will be completed by the DON or RN designee and nursing management staff on 04/27/12 at 9:00 PM. Any licensed nurses and medication aides, including the weekend staff, who had not completed this proficiency check-off, will not be allowed to return to work. The DON and nursing management staff will monitor new hires to ensure completion in compliance. Staff members that fail competencies will be re-educated until successful skills are achieved. 6. All telephone orders, new admissions/re-admissions and 24 reports will be reviewed and discussed in daily morning meetings during the week for completion, accuracy, and compliance. The ADONs check that telephone orders are transcribed correctly in the MAR/TAR, documented in resident's clinical record, families are notified and medication/treatment supply is available. Any identified issues will be addressed immediately by the ADONs. This meeting will be attended by the DON, ADONs, MDS nurse, and treatment nurse. All telephone orders, new admissions/re-admissions and 24-hour report will be reviewed on the weekend by the weekend supervisor for completion, accuracy and compliance. The weekend supervisor will check that telephone orders are transcribed correctly in the MAR/TAR, documented in resident's clinical record, families are notified and medication/treatment supply is available. Any identified issues will be addressed immediately by the weekend supervisor. 7. Starting in May 2012 and going forward pharmacy consultant facility visits, random medication pass and insulin administration observations will be completed by the pharmacy consultant. Pharmacy consultant will review medication pass and insulin administration observations with the DON. Any identified issues will be immediately corrected by the DON and/or designee. 8. QAA (Quality Assurance Committee) meeting is scheduled for 04/27/12 at 9 PM to be attended by the administrator, DON, ADONs to discuss current IJ situation and plan of removal. The medical director will attend QA meeting via telephone conference. The DON, ADONs, and administrator will monitor the reeducation and training program to ensure effectiveness and compliance. Any identified issues will be reviewed during the monthly quality assurance meeting for three months and randomly thereafter. 9. The medical director was notified by the administrator of the IJ situation on 04/27/12 at 4:15 PM. 10. A systematic review of each resident with current orders for insulin therapy will be conducted by the director pharmacy utilization and outcomes for senior care centers to recommend individualized insulin plants for consideration of the medical director this review will incorporate principles of insulin pattern management referenced in the attached document entitled, "strategies to reduce reliance on sliding scale in the elderly." There review has begun effective April 28 and will be completed by May for, 2012. 11. A process to reduce the monitor transcription of telephone orders will be initiated effective April 28 who could the following core components: A. MDS coordinator will double check all new MEDICATION ORDERS FOR [REDACTED]. Any discrepancies identified will be addressed and resolved immediately. B. After entry of the medication orders into the computerized medical record, the copies of the telephone order will be saved for the consultant pharmacist to select a sample and audit for accuracy of transcription to Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s quality assurance process. During an interview on 04/28/12 at 6:45 PM, LVN S (the MDS coordinator), DON and the consultant pharmacist assigned to the facility were queried about how the plan of correction would be implemented to verify MD orders were transcribed correctly. LVN S (the MDS Coordinator) stated she routinely gathered information for the MDS assessments. For the plan of correction, she is to review all new doctors' orders and be certain the orders are transcribed properly on the MAR. After this, she will put the physician's orders [REDACTED]. The ADONs will enter all new orders into the computer. LVN S (the MDS Coordinator) will then check the new orders in the computer against the physician's orders [REDACTED]. The assigned consulting pharmacist stated he will be reviewing all orders from the previous month using the folder with the physician order [REDACTED]. On 04/28/12 at 6:35 PM, LVN U was interviewed regarding any recent training. LVN U revealed, "I was here until after 12 PM. I am the charge nurse for the two to ten shift." She was trained on proper transcription of orders, what to do when you find something you didn't understand and the five rights of medication administration. The training lasted from 15 to 20 minutes and was done by the corporate pharmacist. She had to complete demonstration of a "checklist of items." On 04/28/12 at 6:40 PM, LVN E was interviewed regarding any recent training. When surveyor queried LVN E, she replied, "I received the medication pass training." When asked about the course content, LVN related, "Remember to hold liquids at eye level. Give 75 ml. of water to flush the tubing before after [DEVICE] medications. Use a 60 ml syringe. Be sure to check the stomach for residual and return the residual back to the patient. Give [MEDICATION NAME] at the same time everyday. I took the test last night I believe I passed the test." On 4/28/12 at 6:50 PM CMA V was interviewed. When queried by surveyor about any recent training she had received, CMA V indicated he was trained on the medication cart. The DON went over information on a handout about stocking the cart and being certain all supplies such as gloves and supplements are available. The ADON watched him give medications for "three tries." The ADON checked him off and said he did okay. He had to show use of gloves, eyedrops and supplements as well as handwashing and use of hand sanitizer. Review of medication administration observation report from the lead corporate pharmacist reflected medication pass review was done of the staff on 04/28/12. Review of the competency-based written test for medication, insulin administration, transcription of physicians orders reflected fifteen staff took the five question test on 04/28/12. The Administrator, DON and Corporate Nurse were informed the IJ was removed at 6:00 PM on 04/28/12. While the IJ was removed, the facility remained out of compliance at scope of "pattern" and a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy," because the facility was monitoring the Plan of Removal.

Based on observation, interview and record review, the facility failed to ensure three (Residents #4, #20, and 23 ) of sixteen residents observed for the medication pass were free from significant medication errors. 1) LVN E administered the antibiotic, [MEDICATION NAME], intravenously to Resident #4. LVN E also failed to expel air from the normal saline flush syringe before injecting it into the resident's central line. Resident #4 received 1 - 1 1/2 cc of air pushed into her blood stream through the central intravenous line during the flush procedure. LVN E administered the [MEDICATION NAME] at the wrong administration rate. 2) ADON C administered the antibiotic, Aztreonam, intravenously to Resident #4. ADON C failed to prime the IV tubing leaving air bubbles in the tubing that were infusing into the resident. The DON failed to squeeze the drip chamber of the intravenous tubing to fill it during priming. Leaving the drip chamber less than half full during infusion increased the chances of it running dry and forcing air into the tubing and then into the resident. Failure to remove air from the tubing can result in an air embolism which can cause temporary paralysis or death. An Immediate Jeopardy (IJ) was identified on 04/27/12 and the Administrator and DON were informed at 3:30 PM. While the IJ was removed on 04/28/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. This failure could affect Resident #1, who was the only resident with a central line. 3) LVN G administered 20 units of 70/30 insulin to Resident #20 at 5:00 PM. The physician's orders [REDACTED]. 4) Resident #23's [MEDICATION NAME] 50 mg and [MEDICATION NAME] 100 mg were not available when MA H gave him his medications. These failures could affect the 44 residents, including Residents #20 and #23, who resided on the 200 Hall, by placing them at risk for exacerbation of medical conditions. Findings included: 1. On 04/26/12 at 3:15 PM, LVN E was observed during IV medication administration to Resident #4. During preparation for administration, LVN E spiked the 250 ml bag of NS with 1.25 grams of [MEDICATION NAME] with IV tubing. She then unclamped the tubing and allowed the solution to flow through the line without first filling the drip chamber (a chamber at the top of the tubing to prevent air from entering the tubing.) The surveyor saw bubbles forming in the line. LVN E then picked up a pre-filled 10 cc syringe filled with 5 ml of NS used to ensure patency of the IV catheter and to verify placement. The syringe was observed to also contain approximately 1-2 ml of air. Without first expressing the air from the syringe, LVN E connected the syringe onto the central line. Without aspirating to check placement of the line, LVN E began pushing the fluid and the air into the resident. The surveyor attempted to stop the LVN by putting her hand over the LVN's hand and saying, "Stop! There is air in the syringe!" LVN E stated, "I expressed the air from the syringe already" and continued to inject the contents of the syringe, including the 1-2 ml of air. http://www.nursingcenter.com/prodev/ce_article.asp?tid= 73 reflected, "Air embolism is a well-published complication arising from central venous catheter use. Literature and case studies provide information regarding clinical sequelae. Preventable mistakes still occur despite following what is considered appropriate protocol...Venous air embolism (VAE) occurs from air entering the venous system via the CVC itself or the track from removal of the CVC (Fink et al., 2005). Air is transported to the [MEDICAL CONDITION] arteries, hindering gas exchange and causing [MEDICAL CONDITION] hypertension. This can result in right ventricular strain and, ultimately, cardiovascular collapse (Fink et al., 2005; Wittenberg et al., 2006). A large enough [MEDICATION NAME] of air can create an obstruction to the outflow of blood from the right ventricle, essentially forming an airlock (Wittenberg et al., 2006)...." (Retrieved on 05/11/12). LVN E then attached the IV tubing for the antibiotic to Resident #4's central line. An in-line regulator (Control-a-Flo) was observed on the tubing, but LVN E adjusted the safety clamp to approximately half open stating, "I'm setting the clamp halfway so it only runs half open. I use this clamp to set the rate. Then I make sure the thing here (LVN E gestured to the Control-a-Flo dial) is set at between 10 and 30 (ml/hr)." At that time, the surveyor counted the flow rate for the antibiotic to be at 36 drops per minute (10 drops equal 1 ml). An interview during the procedure on 04/26/12 at 3:30 PM with LVN E revealed she did not calculate the rate, but the antibiotic was ordered by the physician to infuse in over 90 minutes. LVN E stated, "This drip rate should make it done in about an hour and a half or so." Resident #4's April 2012 physician's orders [REDACTED]. Calculation of the flow rate: Volume in ml X drip factor (10) = drops per minute Time 250 ml X 10 = 28 drops per minute 90 During an interview on 04/26/12 at 5:42 PM, LVN E explained that before any IV medication was administered a saline flush was done. She stated the saline came in a prepackaged syringe. LVN E stated she had to ensure the fluid was all the way up to the top of the syringe and had to waste some of the fluid out the top of the syringe. LVN E also stated she calculated the dose, if the dose was not calculated for her. LVN E stated one of the ADONs calculated the dose behind them. LVN E stated she did not ask one of the ADONs to calculate the dose today, but usually asked one of the ADONs to calculate the dose with her. LVN E stated today she forgot she was not supposed to clamp off the flow. She stated an inline regulator (Control-a flow) was used in this facility, but most IVs were infused via a pump. LVN E stated today she felt rushed. She stated ADON C asked her to take care of the IV because ADON C was tired. LVN E showed this surveyor a blank piece of paper with handwritten numbers on it and stated it was ADON C's calculations for the flow rate for the IV. LVN E set the drip rate at 36 drops per minute which would infuse the 250 ml antibiotic solution in approximately 70 minutes instead of the ordered 90 minutes. On 04/26/12 at 4:10 PM, LVN E was observed at Resident #4's bedside. At that time, LVN E pointed to the numbers on the Control-a-Flo. LVN E pointed to the number "100," indicating 100 ml. hr. LVN E stated the number was, "Ten." LVN E pointed to the number "125," indicating 125 ml/hr. LVN E stated the number was, "Thirty." LVN E was queried as to where she saw "10" and "30" on the Control-a-Flo because the surveyor saw "100" and "125." LVN E replied, "I guess I need my glasses." LVN E was not wearing glasses at this time. Interview with LVN E on 04/26/12 at 5:42 PM revealed she needed reading glasses to enlarge things. LVN E stated she did not need the glasses all of the time, but did need glasses to look at fine print. LVN E stated she worked on Hall One and did not work with IVs on Hall Two. She stated the nurse currently working Hall Two was not IV certified, so ADON C asked her to take care of the IV on Hall Two. LVN E stated she told ADON C she needed to look at the procedure. LVN E stated she was called away and did not get a chance to review the IV procedure. She stated she recalled the procedure which was saline, antibiotic, saline, [MEDICATION NAME] flush. LVN E continued to explain before any IV medication was given, a saline flush was done. She stated the saline came in a prepackaged syringe. LVN E stated she had to ensure the fluid was all the way up to the top of the syringe and had to waste some of the fluid out the top of the syringe. LVN E stated next the medication which was ordered was administered. LVN E stated she calculated the dose, if the dose was not calculated for her. LVN E stated one of the ADONs calculated the dose behind them. LVN E stated she did not ask one of the ADONs to calculate the dose today, but usually asked one of the ADONs to calculate the dose with her. LVN E stated today she forgot she was not supposed to clamp off the flow. She stated the Control-a-Flo (in line regulator) was used in this facility, but most IVs were on a pump. LVN E stated ADON C asked her to take care of the IV, because ADON C was " tired." LVN E showed the surveyor a blank piece of paper with handwritten numbers on it and stated it was ADON C's calculations for the flow rate for the IV. 2. On 04/26/12 at 5:20 PM, ADON C was observed during IV medication administration of Aztreonam to Resident #4. ADON C connected the new bag of medication and started the infusion. The drip chamber was observed to be empty with air in the tubing. The surveyor immediately stopped the infusion by clamping off the tubing to prevent air from going into Resident #4's body. The empty drip chamber and air in the line was pointed out to ADON C. The DON was requested to come to the room. When the DON arrived at 3:45 PM on 04/26/12, the air in the line was measured with a ruler. There was a total of 3.1 cm of air in the line. The DON told ADON C to get more IV tubing and another antibiotic solution and start all over. ADON C attempted to prime the IV line without filling the drip chamber. The surveyor requested the DON to assist ADON C with priming the IV line. The DON did not fill the drip chamber. Under the DON's supervision, ADON C picked up a prefilled syringe of normal saline, expressed the air from the syringe, wiped the end of the port on the central line and attached the luer lock syringe to the port. ADON C did not aspirate to check the placement of the line, flushed with 5 ml of normal saline, attached the IV tubing and set the control a flow regulator to 150 ml per hour Resident #4's April 2012 consolidated physician's orders [REDACTED]. ? Aztreonam (antibiotic) 1 gm IV Q 12 hr x 6 weeks. Start date 04/19/12. ? Flush before and after medication administration using the SASH method (saline, medication, saline, and [MEDICATION NAME]) use 5 ml of saline in a 10 ml syringe ending with 5 ml of 10 units per cc of [MEDICATION NAME] in a 10 ml syringe. ? [MEDICATION NAME] 1.5 g/200 ml over 90 min. IV Q 12 hr. X six weeks. Start date 04/19/12 An interview was conducted with the DON about the LVN training for intravenous medication administration on 04/27/12 at 9:20 AM. When queried about the training the LVNs received, the DON stated she was sure all the certificates and skills checklists were in the nurses' personnel files. The surveyor presented the certificates and IV skills checklists that were found in the personnel files. The DON stated she did not know why the staff did not have certificates for intravenous medication classroom training. During an interview on 04/27/12 at 11:50 AM, the DON was asked how she determined if staff had the necessary skills to work with central lines and IV's. The DON stated, "I go over check off sheets with them. They are individualized in their folders. I do it when they come to work here. I look at if they have had any training. I don't do IV skills check off every year. I have had classes here and the last one was in 2007." The DON was then asked if the nurses needed an IV course before performing the skills check off. The DON responded, "Not all of them have the certificate. I do go over the skills check off list to determine the skill levels of the nurses. I do the procedure for hanging IVPB rather than placement of IV's if they haven't had the class." When asked if the nurses were required to have an IV class before administering IV medications, the DON stated, "Most are already certified. We have made arrangements for them to go out and have the class soon. I don't have the date yet for the class." The DON was asked how she checked the nurses' IV competency. The DON stated, "We don't always have an IV in the building. I directly oversee the nurses and directly train them." When queried regarding the number of nurses on each shift that have IV training, the DON stated, "Two per shift, one treatment nurse, one weekend RN." When asked, "How do you demonstrate the competency of your staff?", the DON stated, "The ADONs help me to check the check off lists. When there is an opportunity to watch, we do a demo (demonstration), but mostly we do question and answer sessions. We do return demonstration only if we have a patient who has a particular skill (like IV's). Otherwise we do annual check-offs of skills." An interview with LVN F was conducted on 04/27/12 at 8:45 PM. LVN F was asked what training she had regarding IV medications. She stated, "I went to a class and got a certification for IVs." When queried about the procedure for an IV flush of a central line, she stated, "Flush the line with normal saline, attach the antibiotic at the ordered rate, flush the IV when the antibiotic is done and flush the line with [MEDICATION NAME] when done." An interview with the Human Resources Director was conducted on 04/27/12 at 11:00 AM. When queried about in-services for IV medications or IV care, she stated, "There were no previous in-services last year for IVs. The last IV in-service was from an outside vendor given in 06/06/2007. Other than that there were no IV in-services or in-services about caring for IV's." D. Upon request for IV training verification, at 7:20 PM on 04/26/12 the Corporate Nurse provided ten LVNs' personnel files. The Corporate Nurse stated he could not find all of the files. Review of the ten LVN personnel files provided by the Corporate Nurse revealed three LVNs had the classroom training to administer IVs. The most recently trained LVN had a classroom training date of 04/12/11. The other 2 had certificates from 2006 and 2007. The DON had done IV skills evaluation for five of the ten LVNs. Some LVNs had the skills check list and no IV classroom training. The skills procedure was a checklist that had the following categories with a check mark area beside it: ? Has successfully demonstrated IV placement. ? Has successfully demonstrated IV fluids/medication administration/maintenance ? Has successfully demonstrated the procedure for disconnecting IV therapy There was a second skills checklist in some of the personnel files it was titled central venous catheter care. The checklist reflected the following expected behaviors: ? Verify orders ? Explained procedure ? Gathers supplies and inspect for integrity ? Wash hands and put on non-sterile gloves ? Remove old CVL dressing ? Assess site for infection ? Set up and maintain a sterile field ? Clean insertion site for protocol apply appropriate dressing ? Secure online per protocol ? Draw up appropriate flush solution and flush central venous line for protocol ? Change injection port per protocol ? Clean work area and dispose of waste appropriately ? Document the procedure appropriately I V Certification of LVNs Name Date of Hire IV Class IV checklist LVN L 10/03/11 No No LVN F 01/03/12 No No LVN N 04/11/07 06/06/07 03/23/09 LVN E 09/21/01 No 03/11/09 LVN G 06/06/11 No No LVN O 08/26/09 04/12/11 No LVN P 05/10/11 No 01/10/12 ADON C 12/01/04 No 06/06/07 LVN Q 04/11/08 10/08/05 03/10/09 ADON R No No An interview was conducted with the DON about the LVN training for intravenous medication administration on 04/27/12 at 9:20 AM. When queried about the training the LVNs received, the DON stated she was sure all the certificates and skills checklists were in the nurses' personnel files. The surveyor presented the certificates and IV skills checklists that were found in the personnel files. The DON stated she did not know why the staff did not have certificates for intravenous medication classroom training. The Facility Policy titled Infusion Rate Control (section 7.5) dated October 2011, reflected an infusion pump would be used for administration of [MEDICATION NAME] Nutrition, medications with rate related complications and all therapies given through a [MEDICAL CONDITION] (central venous access device), including a PICC (peripherally inserted central catheter). The Facility Policy titled Setting up A Primary Infusion (section 7.2) dated October 2011, reflected only a professional nurse with documented IV education, as designated by the facility and as allowed by state regulations could set up a primary infusion. The policy also reflected the equipment to be used included an infusion pump. The policy also reflected to squeeze the drip chamber until 1/4 - 1/2 full." Potter and Perry's Fundamentals of Nursing 7th edition, 2009, reflected: "INITIATING INTRAVENOUS THERAPY ( pages 996-997) ...Preparing IV tubing and solution ... 14 ...f. Prime infusion tubing by filling with IV solution: Compress the drip chamber and release, allowing it to fill one-third to one-half full ...Ensure tubing is cleared of air before connection with IV site. Creates suction effect; fluid enters drip chamber to prevent air from entering tubing g. Remove protector cap on end of tubing ...and slowly open roller clamp to allow fluid to travel from drip chamber through tubing ...Slow fill of tubing decreases turbulence and chance of bubble formation. Removes air from tubing and permits tubing to fill with solution ... h. Be certain tubing is clear of air and air bubbles ...Check entire length of tubing to ensure that all air bubbles are removed ...Large air bubbles may acts as emboli ...." "The patency of the IV line is checked to insure that the line is intact and not leaking ... Intermittent IV drug doses are usually calculated in cc per hour. They are given in larger amounts of fluid that are usually given with an IV pump and most IV pumps are set in cc per hour, not cc per minute. " (Retrieved at <http://www.healthline.com/galecontent/intravenous-medication-administration#1> on 5/09/12) The Intravenous Nurse Society's Standard of Practice, 2006 retrieved on 05/09/12 at <http://www.cathflo.com/media/professional_cathetermanagebroch.pdf> reflected: " ...catheter patency should always be checked "prior to administration of [MEDICATION NAME] medications and solutions." When checking placement it is important to confirm the patency of the Central Central Venous Catheter's patency by "... aspirating the device for confirmation of positive blood return...." An IJ was identified on 04/27/12 at 3:03 PM. The Administrator and the DON were notified of the IJ on 04/27/12 at 3:03 PM and a Plan of Removal was requested at that time. The Plan of Removal was accepted on 04/28/12 and reflected: 1. The attending physicians were notified of the errors found by the surveyors. 2. The DON and Weekend RN supervisor will be responsible for administering Resident #4's antibiotics and the flushing of the central catheter. All licensed nurses will complete IV education and training on 04/30/12 and 05/01/12. The DON and ADONs will monitor new hires to ensure completion and compliance. 3. Re-educate all licensed nurses and medication aides regarding medication administration. Re-educate licensed nurses regarding implementation of physician's orders [REDACTED]. licensed nurses will be responsible for re-ordering new medications as well as refills from the pharmacy. A competency based test will be given to each licensed nurse and certified medication aides to validate comprehension and compliance. This re-education and competency based test will be completed on 04/27/12 at 9:00 PM by the DON and the ADONs. Licensed nurses certified medication aides, including weekend licensed nurses and certified medication aides, will not be allowed to return to work without completing this re-education and competency based tests. New hire licensed nurses will not be allowed to work without completing education and competency based test as well completed by DON and ADONs. 4. Full facility audit of current Physician's Telephone Orders, residents' clinical records MARs, and medications in the medication carts will be completed by the DON and/or designee to ensure current medications and physician's orders [REDACTED]. This full audit will be completed on 04/27/12 at 10:00 p.m. 5. Licensed nurses and medication aides will be validated by a proficiency check-off on proper medication administration. Licensed nurses will be validated by proficiency check-off on proper insulin administration. This proficiency check-off will be completed by the DON or RN designee and nursing management staff on 04/27/12 at 9:00 PM. Any licensed nurses and medication aides, including the weekend staff, who had not completed this proficiency check-off, will not be allowed to return to work. The DON and nursing management staff will monitor new hires to ensure completion in compliance. Staff members that fail competencies will be re-educated until successful skills are achieved. 6. All telephone orders, new admissions/re-admissions and 24 reports will be reviewed and discussed in daily morning meetings during the week for completion, accuracy, and compliance. The ADONs check that telephone orders are transcribed correctly in the MAR/TAR, documented in resident's clinical record, families are notified and medication/treatment supply is available. Any identified issues will be addressed immediately by the ADONs. This meeting will be attended by the DON, ADONs, MDS nurse, and treatment nurse. All telephone orders, new admissions/re-admissions and 24-hour report will be reviewed on the weekend by the weekend supervisor for completion, accuracy and compliance. The weekend supervisor will check that telephone orders are transcribed correctly in the MAR/TAR, documented in resident's clinical record, families are notified and medication/treatment supply is available. Any identified issues will be addressed immediately by the weekend supervisor. 7. Starting in May 2012 and going forward pharmacy consultant facility visits, random medication pass and insulin administration observations will be completed by the pharmacy consultant. Pharmacy consultant will review medication pass and insulin administration observations with the DON. Any identified issues will be immediately corrected by the DON and/or designee. 8. QA(Quality Assurance Committee) meeting is scheduled for 04/27/12 at 9 PM to be attended by the administrator, DON, ADONs to discuss current IJ situation and plan of removal. The medical director will attend QA meeting via telephone conference. The DON, ADONs, and administrator will monitor the reeducation and training program to ensure effectiveness and compliance. Any identified issues will be reviewed during the monthly quality assurance meeting for three months and randomly thereafter. 9. The medical director was notified by the administrator of the IJ situation on 04/27/12 at 4:15 PM. 10. A systematic review of each resident with current orders for insulin therapy will be conducted by the director pharmacy utilization and outcomes for senior care centers to recommend individualized insulin plants for consideration of the medical director this review will incorporate principles of insulin pattern management referenced in the attached document entitled, "strategies to reduce reliance on sliding scale in the elderly." There review has begun effective April 28 and will be completed by May for, 2012. 11. A process to reduce the monitor transcription of telephone orders will be initiated effective April 28 who could the following core components: A. MDS coordinator will double check all new MEDICATION ORDERS FOR [REDACTED]. Any discrepancies identified will be addressed and resolved immediately. B. After entry of the medication orders into the computerized medical record, the copies of the telephone order will be saved for the consultant pharmacist to select a sample and audit for accuracy of transcription to Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s quality assurance process. 7. The DON was interviewed on 04/28/12 at 6:10 PM. The surveyor queried the DON about the facility plan for staff who did not pass the training. The DON replied, "if they do not pass, they will be relieved of duty at that time and replaced with another nurse who has been proven to have proficiency in the medication pass." Individuals who do not pass will be re-inserviced until they do pass. The facility has scheduled an outside vendor with two trainers for return skill demonstrations for Monday 04/30/12 to teach a five hour class for peripheral IVs and Tuesday 05/01/12 to teach a five hour class dealing with central lines. The DON will fax the course outlines and certificates of completion to the Regional office on Monday and Tuesday. If a staff member does not pass the courses offered, they will not be allowed to administer intravenous medications or do intravenous care until they repeat the courses and pass. The surveyor queried the DON at 6:30 PM on 04/28/12 regarding facility plans for caring for Resident #4 over the weekend until staff have completed the two required five hour courses on 05/01/12. The DON replied that she and the RN weekend supervisor will be giving all IV medications and caring for the intravenous site "until the staff are certified in IV therapy." During an interview on 04/28/12 at 6:45 PM, LVN S (MDS coordinator), DON and the consultant pharmacist assigned to the facility were queried about how the Plan of Removal would be implemented to verify MD orders were transcribed correctly. LVN S stated she routinely gathered information for the MDS assessments and she will review all new doctors' orders and be certain the orders were transcribed properly on the MAR. After this, she will put the physician's orders [REDACTED]. The ADONs will enter all new orders into the computer. LVN S will then check the new orders in the computer against the physician's orders [REDACTED]. The assigned consulting pharmacist stated he will be reviewing all orders from the previous month using the folder with the physician order [REDACTED]. On 04/28/12 at 6:35 PM, LVN U was interviewed regarding any recent training. LVN U revealed, "I was here until after 12:00 PM. I am the charge nurse for the 2:00 to 10:00 shift." She stated she was trained on proper transcription of orders, what to do when she found something she did not understand and the five rights of medication administration. LVN U stated the training lasted from 15 to 20 minutes and was completed by the corporate pharmacist. She stated she had to complete demonstration of a "checklist of items." On 04/28/12 at 6:40 PM, LVN E was interviewed regarding any recent training. When surveyor queried LVN E, she replied, "I received the medication pass training." On 4/28/12 at 6:50 PM MA V was interviewed. When queried by surveyor about any recent training she had received, MA V indicated he was trained on the medication cart. The DON went over information on a handout about stocking the cart and being certain all supplies such as gloves and supplements are available. The ADON watched him give medications for "three tries." The ADON checked him off and said he did okay. He had to show use of gloves, eyedrops and supplements as well as handwashing and use of hand sanitizer. Review of medication administration observation report from the lead corporate pharmacist reflected medication pass review was done of the staff on 04/28/12. Review of the competency-based written test for medication, insulin administration, transcription of physicians orders reflected fifteen staff took the five question test on 04/28/12. Review of glucose monitoring proficiency test provided by facility reflected five staff took the test on 04/28/12. The Administrator, DON and Corporate Nurse were informed the IJ was removed at 6:00 PM on 04/28/12. While the IJ was removed, the facility remained out of compliance at scope of "pattern" and a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy," because the facility was monitoring the Plan of Removal. Non-IJ Findings: 1. During medication pass on 04/26/12 at 5:00 PM, LVN G was observed to check Resident #20's blood sugar with a glucometer. Resident #20's blood sugar result was 371. LVN G was observed to administer 20 units of 70/30 insulin to Resident #20. Review of Resident #20's Physician Telephone Order dated 04/11/12 reflected to give [MEDICATION NAME] 70/30 insulin 30 units every morning and 25 units every evening. The physician's orders [REDACTED]. Interview on 04/26/12 at 5:15 PM with LVN G revealed she did not know the physician order [REDACTED]. LVN G was queried why she gave Resident #20 the 70/30 insulin 20 units. LVN G stated that was the PM dose. LVN G was shown the physician's telephone order that changed the dose to 70/30 insulin, 25 units. LVN G stated, "Oh." Review of Resident # 20's MAR for the month of April reflected Resident #20 received a wrong dose of 70/30 insulin 20 units at 4:30 PM on 04/11/12, 04/12/12, 4/13/12, 04/14/12 04/15/12, 04/16/12, 04/17/12, 04/18/12, 04/19/12, 04/20/12, 4/21/12, 04/22/12, 4/23/12, 04/24/12, 04/25/12, and 04/26/12. 2. MA H was observed administering medications to Resident #23 on 04/26/12 at 6:10 PM. After checking the medication cart, MA H reported that neither of the two [MEDICATION NAME] dosages (100 mg and 50 mg.) ordered for Resident #23 was in the cart. MA H reported the missing [MEDICATION NAME] prescriptions to the charge nurse, LVN G, at 6:15 PM. [MEDICATION NAME] is the brand name for [MEDICATION NAME], a drug used to manage [MEDICAL CONDITION] (anti-convulsant). According to the Geriatric Dosage Handbook, the official drug reference for the American Pharmacists Association, the beneficial dosage range for [MEDICATION NAME] is very small. Too little of the drug can result in [MEDICAL CONDITION] or abnormal heart rhythms. [MEDICATION NAME] has a warning label advising that it should not be withdrawn abruptly as [MEDICAL CONDITION] or abnormal heart rhythms may occur. ADON C was observed to immediately check the electronic orders to the pharmacy. ADON C stated Resident #23's [MEDICATION NAME] was part of an outstanding pharmacy order and should be delivered in the evening pharmacy delivery around 7:00 or 8:00 PM. MA H circled her initials by the date and time on the MAR indicated [REDACTED]. MA H documented on the back of the MAR indicated nurse notified." MA H was observed checking with ADON C and LVN G at 7:00 PM, 7:15 PM and 7:30 PM on 04/26/12 to determine if the pharmacy had delivered the [MEDICATION NAME]. Each time the MA was told, "No." Resident #23's consolidated physician's orders [REDACTED]. The [MEDICATION NAME] order for Resident #23 reflected, "[MEDICATION NAME] 100 mg capsule, one cap PO tid. Give W (with) 50 mg Tab = (to equal) 150 mg." The order also reflected, "[MEDICATION NAME] 50 mg Infatab (infant tablet, chewable form), one Tab PO tid. Give W 100 mg capsule = 150 mg." The April 2012 consolidated physician's orders [REDACTED]. Review of Resident #23's physician's orders [REDACTED]." The order was not signed by the physician and the time of the order was not documented. Review of Resident #23's MAR indicated [REDACTED]

Based on observation, record review, and interview, it was determined the facility failed to ensure a medication error rate of less than 5%. During medication pass, a total of forty-eight opportunities were observed. Four LVNs, one RN, and two MAs were observed to make errors involving seven (Residents #4, #15, #19, #20, #21, #22, and #23) of 16 residents observed during medication pass. All halls in the building were observed. Ten medication errors were observed (divided by 48 opportunities observed) resulting in a 20% medication error rate. 1) LVN E administered the antibiotic, [MEDICATION NAME], intravenously to Resident #4. LVN E also failed to expel air from the normal saline flush syringe before injecting it into the resident's central line. Resident #4 received 1 - 1 1/2 cc of air pushed into her blood stream through the central intravenous line during the flush procedure. LVN E administered the [MEDICATION NAME] at the wrong administration rate. 2) ADON C administered the antibiotic, Aztreonam, intravenously to Resident #4. ADON C failed to prime the IV tubing leaving air bubbles in the tubing that were infusing into the resident. The DON failed to squeeze the drip chamber of the intravenous tubing to fill it during priming. Leaving the drip chamber less than half full during infusion increased the chances of it running dry and forcing air into the tubing and then into the resident. Failure to remove air from the tubing can result in an air embolism which can cause temporary paralysis or death. An Immediate Jeopardy (IJ) was identified on 04/27/12 and the Administrator and DON were informed at 3:03 PM. While the IJ was removed on 04/28/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. This failure could affect Resident #1, who was the only resident with a central line. 2) MA D administered 100 mg of [MEDICATION NAME] (used for UTIs) instead of the 200 mg ordered by the physician. 3) MA D administered Vitamin B Complex instead of the Multivitamin, Therapeutic tab ordered by the physician to Resident #19. 4) MA H administered [MEDICATION NAME] Z ([MEDICAL CONDITION]) eye drop to Resident #21. MA H did not wait five minutes before administering Liquid Tear eye drops. MA H administered one drop in both of Resident #21's eyes. The physician's orders [REDACTED]. 5) LVN G administered 20 units of 70/30 insulin to Resident #20 at 5:00 PM. The physician's orders [REDACTED]. 6) MA H did not administer Resident #22's Senna 8.6 mg. 7) Resident #23's [MEDICATION NAME] 50 mg and [MEDICATION NAME] 100 mg were not available when MA H gave him his medications. These failures could affect all 87 residents residing in the facility including Residents #15, #19, #20, #21, #22, and #23 by placing them at risk for not receiving their medications as ordered by their physicians. Findings included: 1. On 04/26/12 at 3:15 PM, LVN E was observed during IV medication administration to Resident #4. During preparation for administration, LVN E spiked the 250 ml bag of NS with 1.25 grams of [MEDICATION NAME] with IV tubing. She then unclamped the tubing and allowed the solution to flow through the line without first filling the drip chamber (a chamber at the top of the tubing to prevent air from entering the tubing.) The surveyor saw bubbles forming in the line. LVN E then picked up a pre-filled 10 cc syringe filled with 5 ml of NS used to ensure patency of the IV catheter and to verify placement. The syringe was observed to also contain approximately 1-2 ml of air. Without first expressing the air from the syringe, LVN E connected the syringe onto the central line. Without aspirating to check placement of the line, LVN E began pushing the fluid and the air into the resident. The surveyor attempted to stop the LVN by putting her hand over the LVN's hand and saying, "Stop! There is air in the syringe!" LVN E stated, "I expressed the air from the syringe already" and continued to inject the contents of the syringe, including the 1-2 ml of air. http://www.nursingcenter.com/prodev/ce_article.asp?tid= 73 reflected, "Air embolism is a well-published complication arising from central venous catheter use. Literature and case studies provide information regarding clinical sequelae. Preventable mistakes still occur despite following what is considered appropriate protocol...Venous air embolism (VAE) occurs from air entering the venous system via the CVC itself or the track from removal of the CVC (Fink et al., 2005). Air is transported to the [MEDICAL CONDITION] arteries, hindering gas exchange and causing [MEDICAL CONDITION] hypertension. This can result in right ventricular strain and, ultimately, cardiovascular collapse (Fink et al., 2005; Wittenberg et al., 2006). A large enough [MEDICATION NAME] of air can create an obstruction to the outflow of blood from the right ventricle, essentially forming an airlock (Wittenberg et al., 2006)...." (Retrieved on 05/11/12). LVN E then attached the IV tubing for the antibiotic to Resident #4's central line. An in-line regulator (Control-a-Flo) was observed on the tubing, but LVN E adjusted the safety clamp to approximately half open stating, "I'm setting the clamp halfway so it only runs half open. I use this clamp to set the rate. Then I make sure the thing here (LVN E gestured to the Control-a-Flo dial) is set at between 10 and 30 (ml/hr)." At that time, the surveyor counted the flow rate for the antibiotic to be at 36 drops per minute (10 drops equal 1 ml). An interview during the procedure on 04/26/12 at 3:30 PM with LVN E revealed she did not calculate the rate, but the antibiotic was ordered by the physician to infuse in over 90 minutes. LVN E stated, "This drip rate should make it done in about an hour and a half or so." Resident #4's April 2012 physician's orders [REDACTED]. Calculation of the flow rate: Volume in ml X drip factor (10) = drops per minute Time 250 ml X 10 = 28 drops per minute 90 During an interview on 04/26/12 at 5:42 PM, LVN E explained that before any IV medication was administered a saline flush was done. She stated the saline came in a prepackaged syringe. LVN E stated she had to ensure the fluid was all the way up to the top of the syringe and had to waste some of the fluid out the top of the syringe. LVN E also stated she calculated the dose, if the dose was not calculated for her. LVN E stated one of the ADONs calculated the dose behind them. LVN E stated she did not ask one of the ADONs to calculate the dose today, but usually asked one of the ADONs to calculate the dose with her. LVN E stated today she forgot she was not supposed to clamp off the flow. She stated an inline regulator (Control-a flow) was used in this facility, but most IVs were infused via a pump. LVN E stated today she felt rushed. She stated ADON C asked her to take care of the IV because ADON C was tired. LVN E showed this surveyor a blank piece of paper with handwritten numbers on it and stated it was ADON C's calculations for the flow rate for the IV. LVN E set the drip rate at 36 drops per minute which would infuse the 250 ml antibiotic solution in approximately 70 minutes instead of the ordered 90 minutes. 2. On 04/26/12 at 5:20 PM, ADON C was observed during IV medication administration of Aztreonam to Resident #4. ADON C connected the new bag of medication and started the infusion. The drip chamber was observed to be empty with air in the tubing. The surveyor immediately stopped the infusion by clamping off the tubing to prevent air from going into Resident #4's body. The empty drip chamber and air in the line was pointed out to ADON C. The DON was requested to come to the room. When the DON arrived at 3:45 PM on 04/26/12, the air in the line was measured with a ruler. There was a total of 3.1 cm of air in the line. The DON told ADON C to get more IV tubing and another antibiotic solution and start all over. ADON C attempted to prime the IV line without filling the drip chamber. The surveyor requested the DON to assist ADON C with priming the IV line. The DON did not fill the drip chamber. Under the DON's supervision, ADON C picked up a prefilled syringe of normal saline, expressed the air from the syringe, wiped the end of the port on the central line and attached the luer lock syringe to the port. ADON C did not aspirate to check the placement of the line, flushed with 5 ml of normal saline, attached the IV tubing and set the control a flow regulator to 150 ml per hour Resident #4's April 2012 consolidated physician's orders [REDACTED]. ? Aztreonam (antibiotic) 1 gm IV Q 12 hr x 6 weeks. Start date 04/19/12. ? Flush before and after medication administration using the SASH method (saline, medication, saline, and [MEDICATION NAME]) use 5 ml of saline in a 10 ml syringe ending with 5 ml of 10 units per cc of [MEDICATION NAME] in a 10 ml syringe. ? [MEDICATION NAME] 1.5 g/200 ml over 90 min. IV Q 12 hr. X six weeks. Start date 04/19/12 The Facility Policy titled Infusion Rate Control (section 7.5) dated October 2011, reflected an infusion pump would be used for administration of [MEDICATION NAME] Nutrition, medications with rate related complications and all therapies given through a [MEDICAL CONDITION] (central venous access device), including a PICC (peripherally inserted central catheter). The Facility Policy titled Setting up A Primary Infusion (section 7.2) dated October 2011, reflected only a professional nurse with documented IV education, as designated by the facility and as allowed by state regulations could set up a primary infusion. The policy also reflected the equipment to be used included an infusion pump. The policy also reflected to squeeze the drip chamber until 1/4 - 1/2 full." Potter and Perry's Fundamentals of Nursing 7th edition, 2009, reflected: "INITIATING INTRAVENOUS THERAPY ( pages 996-997) ...Preparing IV tubing and solution ... 14 ...f. Prime infusion tubing by filling with IV solution: Compress the drip chamber and release, allowing it to fill one-third to one-half full ...Ensure tubing is cleared of air before connection with IV site. Creates suction effect; fluid enters drip chamber to prevent air from entering tubing g. Remove protector cap on end of tubing ...and slowly open roller clamp to allow fluid to travel from drip chamber through tubing ...Slow fill of tubing decreases turbulence and chance of bubble formation. Removes air from tubing and permits tubing to fill with solution ... h. Be certain tubing is clear of air and air bubbles ...Check entire length of tubing to ensure that all air bubbles are removed ...Large air bubbles may acts as emboli ...." "The patency of the IV line is checked to insure that the line is intact and not leaking ... Intermittent IV drug doses are usually calculated in cc per hour. They are given in larger amounts of fluid that are usually given with an IV pump and most IV pumps are set in cc per hour, not cc per minute. " (Retrieved at <http://www.healthline.com/galecontent/intravenous-medication-administration#1> on 5/09/12) The Intravenous Nurse Society's Standard of Practice, 2006 retrieved on 5/09/12 at <http://www.cathflo.com/media/professional_cathetermanagebroch.pdf> reflected: " ...catheter patency should always be checked " prior to administration of [MEDICATION NAME] medications and solutions. " When checking placement it is important to confirm the patency of the Central Central Venous Catheter ' s patency by " ... aspirating the device for confirmation of positive blood return.... " An IJ was identified on 04/27/12 at 3:03 PM. The Administrator and the DON were notified of the IJ on 04/27/12 at 3:03 PM and a Plan of Removal was requested at that time. The Plan of Removal was accepted on 04/28/12 and reflected: 1. The attending physicians were notified of the errors found by the surveyors. 2. The DON and Weekend RN supervisor will be responsible for administering Resident #4's antibiotics and the flushing of the central catheter. All licensed nurses will complete IV education and training on 04/30/12 and 05/01/12. The DON and ADONs will monitor new hires to ensure completion and compliance. 3. Re-educate all licensed nurses and medication aides regarding medication administration. Re-educate licensed nurses regarding implementation of physician's orders [REDACTED]. licensed nurses will be responsible for re-ordering new medications as well as refills from the pharmacy. A competency based test will be given to each licensed nurse and certified medication aides to validate comprehension and compliance. This re-education and competency based test will be completed on 04/27/12 at 9:00 PM by the DON and the ADONs. Licensed nurses certified medication aides, including weekend licensed nurses and certified medication aides, will not be allowed to return to work without completing this re-education and competency based tests. New hire licensed nurses will not be allowed to work without completing education and competency based test as well completed by DON and ADONs. 4. Full facility audit of current Physician's Telephone Orders, residents' clinical records MARs, and medications in the medication carts will be completed by the DON and/or designee to ensure current medications and physician's orders [REDACTED]. This full audit will be completed on 04/27/12 at 10:00 p.m. 5. Licensed nurses and medication aides will be validated by a proficiency check-off on proper medication administration. Licensed nurses will be validated by proficiency check-off on proper insulin administration. This proficiency check-off will be completed by the DON or RN designee and nursing management staff on 04/27/12 at 9:00 PM. Any licensed nurses and medication aides, including the weekend staff, who had not completed this proficiency check-off, will not be allowed to return to work. The DON and nursing management staff will monitor new hires to ensure completion in compliance. Staff members that fail competencies will be re-educated until successful skills are achieved. 6. All telephone orders, new admissions/re-admissions and 24 reports will be reviewed and discussed in daily morning meetings during the week for completion, accuracy, and compliance. The ADONs check that telephone orders are transcribed correctly in the MAR/TAR, documented in resident's clinical record, families are notified and medication/treatment supply is available. Any identified issues will be addressed immediately by the ADONs. This meeting will be attended by the DON, ADONs, MDS nurse, and treatment nurse. All telephone orders, new admissions/re-admissions and 24-hour report will be reviewed on the weekend by the weekend supervisor for completion, accuracy and compliance. The weekend supervisor will check that telephone orders are transcribed correctly in the MAR/TAR, documented in resident's clinical record, families are notified and medication/treatment supply is available. Any identified issues will be addressed immediately by the weekend supervisor. 7. Starting in May 2012 and going forward pharmacy consultant facility visits, random medication pass and insulin administration observations will be completed by the pharmacy consultant. Pharmacy consultant will review medication pass and insulin administration observations with the DON. Any identified issues will be immediately corrected by the DON and/or designee. 8. QA(Quality Assurance Committee) meeting is scheduled for 04/27/12 at 9 PM to be attended by the administrator, DON, ADONs to discuss current IJ situation and plan of removal. The medical director will attend QA meeting via telephone conference. The DON, ADONs, and administrator will monitor the reeducation and training program to ensure effectiveness and compliance. Any identified issues will be reviewed during the monthly quality assurance meeting for three months and randomly thereafter. 9. The medical director was notified by the administrator of the IJ situation on 04/27/12 at 4:15 PM. 10. A systematic review of each resident with current orders for insulin therapy will be conducted by the director pharmacy utilization and outcomes for senior care centers to recommend individualized insulin plants for consideration of the medical director this review will incorporate principles of insulin pattern management referenced in the attached document entitled, "strategies to reduce reliance on sliding scale in the elderly." There review has begun effective April 28 and will be completed by May for, 2012. 11. A process to reduce the monitor transcription of telephone orders will be initiated effective April 28 who could the following core components: A. MDS coordinator will double check all new MEDICATION ORDERS FOR [REDACTED]. Any discrepancies identified will be addressed and resolved immediately. B. After entry of the medication orders into the computerized medical record, the copies of the telephone order will be saved for the consultant pharmacist to select a sample and audit for accuracy of transcription to Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s quality assurance process. The DON was interviewed on 04/28/12 at 6:10 PM. The surveyor queried the DON about the facility plan for staff who did not pass the training. The DON replied, "if they do not pass, they will be relieved of duty at that time and replaced with another nurse who has been proven to have proficiency in the medication pass." Individuals who do not pass will be re-inserviced until they do pass. The facility has scheduled an outside vendor with two trainers for return skill demonstrations for Monday 04/30/12 to teach a five hour class for peripheral IVs and Tuesday 05/01/12 to teach a five hour class dealing with central lines. The DON will fax the course outlines and certificates of completion to the Regional office on Monday and Tuesday. If a staff member does not pass the courses offered, they will not be allowed to administer intravenous medications or do intravenous care until they repeat the courses and pass. The surveyor queried the DON at 6:30 PM on 04/28/12 regarding facility plans for caring for Resident #4 over the weekend until staff have completed the two required five hour courses on 05/01/12. The DON replied that she and the RN weekend supervisor will be giving all IV medications and caring for the intravenous site "until the staff are certified in IV therapy." During an interview on 04/28/12 at 6:45 PM, LVN S (MDS coordinator), DON and the consultant pharmacist assigned to the facility were queried about how the Plan of Removal would be implemented to verify MD orders were transcribed correctly. LVN S stated she routinely gathered information for the MDS assessments and she will review all new doctors' orders and be certain the orders were transcribed properly on the MAR. After this, she will put the physician's orders [REDACTED]. The ADONs will enter all new orders into the computer. LVN S will then check the new orders in the computer against the physician's orders [REDACTED]. The assigned consulting pharmacist stated he will be reviewing all orders from the previous month using the folder with the physician order [REDACTED]. On 04/28/12 at 6:35 PM, LVN U was interviewed regarding any recent training. LVN U revealed, "I was here until after 12:00 PM. I am the charge nurse for the 2:00 to 10:00 shift." She stated she was trained on proper transcription of orders, what to do when she found something she did not understand and the five rights of medication administration. LVN U stated the training lasted from 15 to 20 minutes and was completed by the corporate pharmacist. She stated she had to complete demonstration of a "checklist of items." On 04/28/12 at 6:40 PM, LVN E was interviewed regarding any recent training. When surveyor queried LVN E, she replied, "I received the medication pass training." On 4/28/12 at 6:50 PM MA V was interviewed. When queried by surveyor about any recent training she had received, MA V indicated he was trained on the medication cart. The DON went over information on a handout about stocking the cart and being certain all supplies such as gloves and supplements are available. The ADON watched him give medications for "three tries." The ADON checked him off and said he did okay. He had to show use of gloves, eyedrops and supplements as well as handwashing and use of hand sanitizer. Review of medication administration observation report from the lead corporate pharmacist reflected medication pass review was done of the staff on 04/28/12. Review of the competency-based written test for medication, insulin administration, transcription of physicians orders reflected fifteen staff took the five question test on 04/28/12. Review of glucose monitoring proficiency test provided by facility reflected five staff took the test on 04/28/12. The Administrator, DON and Corporate Nurse were informed the IJ was removed at 6:00 PM on 04/28/12. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy," because the facility was monitoring the Plan of Removal. Non-IJ Findings: 1. During medication pass on 04/26/12 at 5:00 PM, LVN G was observed to check Resident #20's blood sugar with a glucometer. Resident #20's blood sugar result was 371. LVN G was observed to administer 20 units of 70/30 insulin to Resident #20. Review of Resident #20's Physician Telephone Order dated 04/11/12 reflected to give [MEDICATION NAME] 70/30 insulin 30 units every morning and 25 units every evening. The physician's orders [REDACTED]. Interview on 04/26/12 at 5:15 PM with LVN G revealed she did not know the physician order [REDACTED]. LVN G was queried why she gave Resident #20 the 70/30 insulin 20 units. LVN G stated that was the PM dose. LVN G was shown the physician's telephone order that changed the dose to 70/30 insulin, 25 units. LVN G stated, "Oh." Review of Resident # 20's MAR for the month of April reflected Resident #20 received a wrong dose of 70/30 insulin 20 units at 4:30 PM on 04/11/12, 04/12/12, 4/13/12, 04/14/12 04/15/12, 04/16/12, 04/17/12, 04/18/12, 04/19/12, 04/20/12, 4/21/12, 04/22/12, 4/23/12, 04/24/12, 04/25/12, and 04/26/12. 2. MA H was observed administering medications to Resident #23 on 04/26/12 at 6:10 PM. After checking the medication cart, MA H reported that neither of the two [MEDICATION NAME] dosages (100 mg and 50 mg.) ordered for Resident #23 was in the cart. MA H reported the missing [MEDICATION NAME] prescriptions to the charge nurse, LVN G, at 6:15 PM. [MEDICATION NAME] is the brand name for [MEDICATION NAME], a drug used to manage [MEDICAL CONDITION] (anti-convulsant). According to the Geriatric Dosage Handbook, the official drug reference for the American Pharmacists Association, the beneficial dosage range for [MEDICATION NAME] is very small. Too little of the drug can result in [MEDICAL CONDITION] or abnormal heart rhythms. [MEDICATION NAME] has a warning label advising that it should not be withdrawn abruptly as [MEDICAL CONDITION] or abnormal heart rhythms may occur. ADON C was observed to immediately check the electronic orders to the pharmacy. ADON C stated Resident #23's [MEDICATION NAME] was part of an outstanding pharmacy order and should be delivered in the evening pharmacy delivery around 7:00 or 8:00 PM. MA H circled her initials by the date and time on the MAR indicated [REDACTED]. MA H documented on the back of the MAR indicated nurse notified." MA H was observed checking with ADON C and LVN G at 7:00 PM, 7:15 PM and 7:30 PM on 04/26/12 to determine if the pharmacy had delivered the [MEDICATION NAME]. Each time the MA was told, "No." Resident #23's consolidated physician's orders [REDACTED]. The [MEDICATION NAME] order for Resident #23 reflected, "[MEDICATION NAME] 100 mg capsule, one cap PO tid. Give W (with) 50 mg Tab = (to equal) 150 mg." The order also reflected, "[MEDICATION NAME] 50 mg Infatab (infant tablet, chewable form), one Tab PO tid. Give W 100 mg capsule = 150 mg." The April 2012 consolidated physician's orders [REDACTED]. Review of Resident #23's physician's orders [REDACTED]." The order was not signed by the physician and the time of the order was not documented. Review of Resident #23's MAR indicated [MEDICATION NAME] 100 mg, one by mouth, times one dose, now." The medication was initialed as given at 6:00 PM on 04/26/12 by LVN G. A review of Resident #23's Nurses Notes at 9:23 AM on 04/27/12 revealed no documentation reflecting a change in physician's orders [REDACTED]. Review of the Station Two Emergency Kit Documentation Form on 04/27/12 at 9:30 AM revealed [MEDICATION NAME] 100 mg was signed out at 7:30 PM on 04/26/12 for Resident #23. An interview with LVN P at 9:32 AM on 04/27/12 revealed the initials on the Emergency Kit Documentation were those of LVN G. Interview with ADON C at 9:35 AM on 04/27/12 revealed the pharmacy had delivered sixty [MEDICATION NAME] 50 mg Infatab on a "stat" basis during the evening shift. ADON C could not remember the time the pharmacy made the evening delivery. ADON C provided a shipping manifest on 04/27/12 at 9:37 AM dated 04/26/12 and timed 7:46 PM. ADON C stated LVN G had called the physician or his nurse practitioner on 04/26/12 to report that Resident # 23's [MEDICATION NAME] refills had not been delivered. She did not recall the time LVN G called the doctor or nurse practitioner. Since LVN G signed out the [MEDICATION NAME] 100 mg from the Emergency Kit at 7:30 PM, ADON C "guessed" it was about that time. ADON C did not recall the time the pharmacy delivered Resident #23's [MEDICATION NAME] 50 mg. ADON C did not know if Resident #23 had received the additional 50 mg of [MEDICATION NAME] as ordered. ADON C agreed that the MAR indicated [REDACTED]. ADON C stated she thought the order written for [MEDICATION NAME] 100 mg. "now" on 04/26/12 "covered" Resident # 23's [MEDICATION NAME] order. Observation of the 200 Hall medication cart at 9:45 AM on 04/27/12 with MA D revealed a prescription dose pack of thirty [MEDICATION NAME] 50 mg Infatab for Resident #23. One dose was missing. Interview with MA D at that time revealed the pharmacy delivered [MEDICATION NAME] 50 mg [MEDICATION NAME] on the evening shift, but did not deliver the [MEDICATION NAME] 100 mg capsules. In order to administer Resident #23's dosage of [MEDICATION NAME] 100 mg capsules at 9:00 AM on 04/27/12, MA D asked LVN R to sign out a dose from the Emergency Medication Kit. MA D administered the one dose missing from the prescription dose pack of [MEDICATION NAME] 50 mg [MEDICATION NAME] and the [MEDICATION NAME] 100 mg capsule signed out by LVN R from the Emergency Medication Kit to give the total 150 mg dose ordered for the 9:00 AM dose. Review of Resident #23's physician visit from 03/19/12 reflected the resident had not had any recent [MEDICAL CONDITION] on his current [MEDICATION NAME] dose, "but his last level ([MEDICATION NAME] blood test) was slightly low at 7.3." The physician management plan for 03/19/12 stated, "Continue present medication management and meds. If [MEDICATION NAME] level continues to run low, I will adjust [MEDICATION NAME] dose." The physician record reflected the results of a [MEDICATION NAME] level done on 01/24/12. Review of Resident #23's laboratory results for [MEDICATION NAME] verified a level of 7.3 micrograms per milliliter (low) on 01/24/12. Additional laboratory results for [MEDICATION NAME] levels were 6.7 micrograms per milliliter (low) on 02/26/12 and 8.4 micrograms per milliliter (low) on 03/27/12. The desired reference range for clinical control of [MEDICATION NAME] is listed on the laboratory report as 10.0 to 20.0 micrograms per milliliter. An interview with Resident #23 on 04/27/12 at 10:50 AM revealed he remembered getting his medication on 04/26/12 "late." He estimated it was sometime after 7:00 PM. Resident #23 stated he recalled getting his medication late because it made him sick. Resident #23 revealed he usually ate right after he took the medicine in the afternoon. Last night, he recalled, he had eaten supper and it kind of made him sick at his stomach "when he took it that late." 3. MA D was observed administering medications to Resident #15 at 8:20 AM on 04/26/12. MA D administered one [MEDICATION NAME] (antibiotic) 100 mg to Resident #15. Review of Resident #15's physician's orders [REDACTED]. The resident received half the required dose. 4. MA D was observed passing medications to Resident #19 at 8:50 AM on 04/26/12. She poured one tablet of Vitamin B Complex into the cup and gave it to Resident #19. Resident #15's physician's orders [REDACTED]. MA D gave the wrong medication to Resident #19. During an interview with MA D on 04/26/12 at 10 AM, she was queried about the two medication errors. MA D stated, "I did not realize I made an error." 5. Observation on 04/26/12 at 5:10 PM revealed MA H administered [MEDICATION NAME] Z 0.004% eye drops to Resident #21. MA H administered 1 drop of [MEDICATION NAME] Z eye drop to each eye of Resident #21. MA H said, "I am going to wait for 5 minutes before I administer another eye drop." After waiting three minutes, MA H administered Liquid Tears eye drops, one drop on Resident #21's each eye. When queried as to how she determined the amount of time between the eye drop medication, MA H stated, " I used the TV clock." Review of Resident #21's physician's orders [REDACTED]. Review of Resident #21's Physician's Telephone Order dated 04/09/12 reflected Artificial tear drop two drops twice daily on the left eye. The MDS assessment of Resident #21 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #21's admitting [DIAGNOSES REDACTED]. 6. MA H was observed administering medication to Resident #22 at 6:40 PM on 04/26/12. MA H prepared six tablets for administration to Resident #22 including: [MEDICATION NAME] 2 mg, [MEDICATION NAME] HCL 0.2 mg, [MEDICATION NAME] 60 mg, Donepezil HCL 10 mg, [MEDICATION NAME] Sodium extended capsules 100 mg and Oyster Shell Calcium 500 mg with Vitamin D. MA H was asked if she had poured all the medications Resident #22 was to receive at that time. MA H responded, "Yes." MA H counted the number of tablets/capsules in the pill cup and stated there were six. The surveyor documented the number of medications in the pill cup on the Medication Pass worksheet (CMS form 677). MA H initialed the documentation to reflect she agreed she was administering six tablets/capsules to Resident #22. Resident #22's consolidated physician's orders [REDACTED]. In addition, the orders reflected Senna 8.6 mg one tablet twice daily. (Senna is a stimulant laxative.) An interview with LVN G at 7:15 PM on 04/26/12 revealed the facility's procedure was to administer a "bid" medication at 9:00 AM and 5:00 PM unless a physician specified

Based on observation, interview and record review, it was determined the facility failed to provide proper treatment and care for Central Lines for one (Resident #4) of one resident with a Central Line. 1) LVN E administered the antibiotic, [MEDICATION NAME], intravenously to Resident #4. LVN E also failed to expel air from the normal saline flush syringe before injecting it into the resident's central line. Resident #4 received 1 - 1 1/2 cc of air pushed into her blood stream through the central intravenous line during the flush procedure. LVN E administered the [MEDICATION NAME] at the wrong administration rate. 2) ADON C administered the antibiotic, Aztreonam, intravenously to Resident #4. ADON C failed to prime the IV tubing leaving air bubbles in the tubing that were infusing into the resident. The DON failed to squeeze the drip chamber of the intravenous tubing to fill it during priming. Leaving the drip chamber less than half full during infusion increased the chances of it running dry and forcing air into the tubing and then into the resident. Failure to remove air from the tubing can result in an air embolism which can cause temporary paralysis or death. An Immediate Jeopardy (IJ) was identified on 04/27/12. While the IJ was removed on 04/28/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. This failure could affect Resident #1, who was the only resident with a central line. Findings included: The MDS assessment dated [DATE] reflected Resident #4 was a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident # 4's [DIAGNOSES REDACTED]. On 04/26/12 at 3:15 PM, LVN E was observed during IV medication administration to Resident #4. During preparation for administration, LVN E spiked the 250 ml bag of NS with 1.25 grams of [MEDICATION NAME] with IV tubing. She then unclamped the tubing and allowed the solution to flow through the line without first filling the drip chamber (a chamber at the top of the tubing to prevent air from entering the tubing.) The surveyor saw bubbles forming in the line. LVN E then picked up a pre-filled 10 cc syringe filled with 5 ml of NS used to ensure patency of the IV catheter and to verify placement. The syringe was observed to also contain approximately 1-2 ml of air. Without first expressing the air from the syringe, LVN E connected the syringe onto the central line. Without aspirating to check placement of the line, LVN E began pushing the fluid and the air into the resident. The surveyor attempted to stop the LVN by putting her hand over the LVN's hand and saying, "Stop! There is air in the syringe!" LVN E stated, "I expressed the air from the syringe already" and continued to inject the contents of the syringe, including the 1-2 ml of air. http://www.nursingcenter.com/prodev/ce_article.asp?tid= 73 reflected, "Air embolism is a well-published complication arising from central venous catheter use. Literature and case studies provide information regarding clinical sequelae. Preventable mistakes still occur despite following what is considered appropriate protocol...Venous air embolism (VAE) occurs from air entering the venous system via the CVC itself or the track from removal of the CVC (Fink et al., 2005). Air is transported to the [MEDICAL CONDITION] arteries, hindering gas exchange and causing [MEDICAL CONDITION] hypertension. This can result in right ventricular strain and, ultimately, cardiovascular collapse (Fink et al., 2005; Wittenberg et al., 2006). A large enough [MEDICATION NAME] of air can create an obstruction to the outflow of blood from the right ventricle, essentially forming an airlock (Wittenberg et al., 2006)...." (Retrieved on 05/11/12). LVN E then attached the IV tubing for the antibiotic to Resident #4's central line. An in-line regulator (Control-a-Flo) was observed on the tubing, but LVN E adjusted the safety clamp to approximately half open stating, "I'm setting the clamp halfway so it only runs half open. I use this clamp to set the rate. Then I make sure the thing here (LVN E gestured to the Control-a-Flo dial) is set at between 10 and 30 (ml/hr)." At that time, the surveyor counted the flow rate for the antibiotic to be at 36 drops per minute (10 drops equal 1 ml). An interview during the procedure on 04/26/12 at 3:30 PM with LVN E revealed she did not calculate the rate, but the antibiotic was ordered by the physician to infuse in over 90 minutes. LVN E stated, "This drip rate should make it done in about an hour and a half or so." Resident #4's April 2012 physician's orders [REDACTED]. Calculation of the flow rate: Volume in ml X drip factor (10) = drops per minute Time 250 ml X 10 = 28 drops per minute 90 During an interview on 04/26/12 at 5:42 PM, LVN E explained that before any IV medication was administered a saline flush was done. She stated the saline came in a prepackaged syringe. LVN E stated she had to ensure the fluid was all the way up to the top of the syringe and had to waste some of the fluid out the top of the syringe. LVN E also stated she calculated the dose, if the dose was not calculated for her. LVN E stated one of the ADONs calculated the dose behind them. LVN E stated she did not ask one of the ADONs to calculate the dose today, but usually asked one of the ADONs to calculate the dose with her. LVN E stated today she forgot she was not supposed to clamp off the flow. She stated an inline regulator (Control-a flow) was used in this facility, but most IVs were infused via a pump. LVN E stated today she felt rushed. She stated ADON C asked her to take care of the IV because ADON C was tired. LVN E showed this surveyor a blank piece of paper with handwritten numbers on it and stated it was ADON C's calculations for the flow rate for the IV. LVN E set the drip rate at 36 drops per minute which would infuse the 250 ml antibiotic solution in approximately 70 minutes instead of the ordered 90 minutes. On 04/26/12 at 4:10 PM, LVN E was observed at Resident #4's bedside. At that time, LVN E pointed to the numbers on the Control-a-Flo. LVN E pointed to the number "100," indicating 100 ml. hr. LVN E stated the number was, "Ten." LVN E pointed to the number "125," indicating 125 ml/hr. LVN E stated the number was, "Thirty." LVN E was queried as to where she saw "10" and "30" on the Control-a-Flo because the surveyor saw "100" and "125." LVN E replied, "I guess I need my glasses." LVN E was not wearing glasses at this time. Interview with LVN E on 04/26/12 at 5:42 PM revealed she needed reading glasses to enlarge things. LVN E stated she did not need the glasses all of the time, but did need glasses to look at fine print. LVN E stated she worked on Hall One and did not work with IVs on Hall Two. She stated the nurse currently working Hall Two was not IV certified, so ADON C asked her to take care of the IV on Hall Two. LVN E stated she told ADON C she needed to look at the procedure. LVN E stated she was called away and did not get a chance to review the IV procedure. She stated she recalled the procedure which was saline, antibiotic, saline, [MEDICATION NAME] flush. LVN E continued to explain before any IV medication was given, a saline flush was done. She stated the saline came in a prepackaged syringe. LVN E stated she had to ensure the fluid was all the way up to the top of the syringe and had to waste some of the fluid out the top of the syringe. LVN E stated next the medication which was ordered was administered. LVN E stated she calculated the dose, if the dose was not calculated for her. LVN E stated one of the ADONs calculated the dose behind them. LVN E stated she did not ask one of the ADONs to calculate the dose today, but usually asked one of the ADONs to calculate the dose with her. LVN E stated today she forgot she was not supposed to clamp off the flow. She stated the Control-a-Flo (in line regulator) was used in this facility, but most IVs were on a pump. LVN E stated ADON C asked her to take care of the IV, because ADON C was " tired." LVN E showed the surveyor a blank piece of paper with handwritten numbers on it and stated it was ADON C's calculations for the flow rate for the IV. On 04/26/12 at 5:20 PM, ADON C was observed during IV medication administration of Aztreonam to Resident #4. ADON C connected the new bag of medication and started the infusion. The drip chamber was observed to be empty with air in the tubing. The surveyor immediately stopped the infusion by clamping off the tubing to prevent air from going into Resident #4's body. The empty drip chamber and air in the line was pointed out to ADON C. The DON was requested to come to the room. When the DON arrived at 3:45 PM on 04/26/12, the air in the line was measured with a ruler. There was a total of 3.1 cm of air in the line. The DON told ADON C to get more IV tubing and another antibiotic solution and start all over. ADON C attempted to prime the IV line without filling the drip chamber. The surveyor requested the DON to assist ADON C with priming the IV line. The DON did not fill the drip chamber. Under the DON's supervision, ADON C picked up a prefilled syringe of normal saline, expressed the air from the syringe, wiped the end of the port on the central line and attached the luer lock syringe to the port. ADON C did not aspirate to check the placement of the line, flushed with 5 ml of normal saline, attached the IV tubing and set the control a flow regulator to 150 ml per hour Resident #4's April 2012 consolidated physician's orders [REDACTED]. ? Aztreonam (antibiotic) 1 gm IV Q 12 hr x 6 weeks. Start date 04/19/12. ? Flush before and after medication administration using the SASH method (saline, medication, saline, and [MEDICATION NAME]) use 5 ml of saline in a 10 ml syringe ending with 5 ml of 10 units per cc of [MEDICATION NAME] in a 10 ml syringe. ? [MEDICATION NAME] 1.5 g/200 ml over 90 min. IV Q 12 hr. X six weeks. Start date 04/19/12 An interview was conducted with the DON about the LVN training for intravenous medication administration on 04/27/12 at 9:20 AM. When queried about the training the LVNs received, the DON stated she was sure all the certificates and skills checklists were in the nurses' personnel files. The surveyor presented the certificates and IV skills checklists that were found in the personnel files. The DON stated she did not know why the staff did not have certificates for intravenous medication classroom training. During an interview on 04/27/12 at 11:50 AM, the DON was asked how she determined if staff had the necessary skills to work with central lines and IV's. The DON stated, "I go over check off sheets with them. They are individualized in their folders. I do it when they come to work here. I look at if they have had any training. I don't do IV skills check off every year. I have had classes here and the last one was in 2007." The DON was then asked if the nurses needed an IV course before performing the skills check off. The DON responded, "Not all of them have the certificate. I do go over the skills check off list to determine the skill levels of the nurses. I do the procedure for hanging IVPB rather than placement of IV's if they haven't had the class." When asked if the nurses were required to have an IV class before administering IV medications, the DON stated, "Most are already certified. We have made arrangements for them to go out and have the class soon. I don't have the date yet for the class." The DON was asked how she checked the nurses' IV competency. The DON stated, "We don't always have an IV in the building. I directly oversee the nurses and directly train them." When queried regarding the number of nurses on each shift that have IV training, the DON stated, "Two per shift, one treatment nurse, one weekend RN." When asked, "How do you demonstrate the competency of your staff?", the DON stated, "The ADONs help me to check the check off lists. When there is an opportunity to watch, we do a demo (demonstration), but mostly we do question and answer sessions. We do return demonstration only if we have a patient who has a particular skill (like IV's). Otherwise we do annual check-offs of skills." An interview with LVN F was conducted on 04/27/12 at 8:45 PM. LVN F was asked what training she had regarding IV medications. She stated, "I went to a class and got a certification for IVs." When queried about the procedure for an IV flush of a central line, she stated, "Flush the line with normal saline, attach the antibiotic at the ordered rate, flush the IV when the antibiotic is done and flush the line with [MEDICATION NAME] when done." An interview with the Human Resources Director was conducted on 04/27/12 at 11:00 AM. When queried about in-services for IV medications or IV care, she stated, "There were no previous in-services last year for IVs. The last IV in-service was from an outside vendor given in 06/06/2007. Other than that there were no IV in-services or in-services about caring for IV's." Upon request for IV training verification, at 7:20 PM on 04/26/12 the Corporate Nurse provided ten LVNs' personnel files. The Corporate Nurse stated he could not find all of the files. Review of the ten LVN personnel files provided by the Corporate Nurse revealed three LVNs had the classroom training to administer IVs. The most recently trained LVN had a classroom training date of 04/12/11. The other 2 had certificates from 2006 and 2007. The DON had done IV skills evaluation for five of the ten LVNs. Some LVNs had the skills check list and no IV classroom training. The skills procedure was a checklist that had the following categories with a check mark area beside it: ? Has successfully demonstrated IV placement. ? Has successfully demonstrated IV fluids/medication administration/maintenance ? Has successfully demonstrated the procedure for disconnecting IV therapy There was a second skills checklist in some of the personnel files it was titled central venous catheter care. The checklist reflected the following expected behaviors: ? Verify orders ? Explained procedure ? Gathers supplies and inspect for integrity ? Wash hands and put on non-sterile gloves ? Remove old CVL dressing ? Assess site for infection ? Set up and maintain a sterile field ? Clean insertion site for protocol apply appropriate dressing ? Secure online per protocol ? Draw up appropriate flush solution and flush central venous line for protocol ? Change injection port per protocol ? Clean work area and dispose of waste appropriately ? Document the procedure appropriately I V Certification of LVNs Name Date of Hire IV Class IV checklist LVN L 10/03/11 No No LVN F 01/03/12 No No LVN N 04/11/07 06/06/07 03/23/09 LVN E 09/21/01 No 03/11/09 LVN G 06/06/11 No No LVN O 08/26/09 04/12/11 No LVN P 05/10/11 No 01/10/12 ADON C 12/01/04 No 06/06/07 LVN Q 04/11/08 10/08/05 03/10/09 ADON R No No An interview was conducted with the DON about the LVN training for intravenous medication administration on 04/27/12 at 9:20 AM. When queried about the training the LVNs received, the DON stated she was sure all the certificates and skills checklists were in the nurses' personnel files. The surveyor presented the certificates and IV skills checklists that were found in the personnel files. The DON stated she did not know why the staff did not have certificates for intravenous medication classroom training. The Facility Policy titled Infusion Rate Control (section 7.5) dated October 2011, reflected an infusion pump would be used for administration of [MEDICATION NAME] Nutrition, medications with rate related complications and all therapies given through a [MEDICAL CONDITION] (central venous access device), including a PICC (peripherally inserted central catheter). The Facility Policy titled Setting up A Primary Infusion (section 7.2) dated October 2011, reflected only a professional nurse with documented IV education, as designated by the facility and as allowed by state regulations could set up a primary infusion. The policy also reflected the equipment to be used included an infusion pump. The policy also reflected to squeeze the drip chamber until 1/4 - 1/2 full." Potter and Perry's Fundamentals of Nursing 7th edition, 2009, reflected: "INITIATING INTRAVENOUS THERAPY ( pages 996-997) ...Preparing IV tubing and solution ... 14 ...f. Prime infusion tubing by filling with IV solution: Compress the drip chamber and release, allowing it to fill one-third to one-half full ...Ensure tubing is cleared of air before connection with IV site. Creates suction effect; fluid enters drip chamber to prevent air from entering tubing g. Remove protector cap on end of tubing ...and slowly open roller clamp to allow fluid to travel from drip chamber through tubing ...Slow fill of tubing decreases turbulence and chance of bubble formation. Removes air from tubing and permits tubing to fill with solution ... h. Be certain tubing is clear of air and air bubbles ...Check entire length of tubing to ensure that all air bubbles are removed ...Large air bubbles may acts as emboli ...." "The patency of the IV line is checked to insure that the line is intact and not leaking ... Intermittent IV drug doses are usually calculated in cc per hour. They are given in larger amounts of fluid that are usually given with an IV pump and most IV pumps are set in cc per hour, not cc per minute. " (Retrieved at <http://www.healthline.com/galecontent/intravenous-medication-administration#1> on 5/09/12) The Intravenous Nurse Society's Standard of Practice, 2006 retrieved on 5/09/12 at <http://www.cathflo.com/media/professional_cathetermanagebroch.pdf> reflected: " ...catheter patency should always be checked " prior to administration of [MEDICATION NAME] medications and solutions. " When checking placement it is important to confirm the patency of the Central Central Venous Catheter's patency by " ... aspirating the device for confirmation of positive blood return.... " An IJ was identified on 04/27/12 at 3:03 PM. The Administrator and the DON were notified of the IJ on 04/27/12 at 3:03 PM and a Plan of Removal was requested at that time. The Plan of Removal was accepted on 04/28/12 and reflected: 1. The attending physicians were notified of the errors found by the surveyors. 2. The DON and Weekend RN supervisor will be responsible for administering Resident #4's antibiotics and the flushing of the central catheter. All licensed nurses will complete IV education and training on 04/30/12 and 05/01/12. The DON and ADONs will monitor new hires to ensure completion and compliance. 3. Re-educate all licensed nurses and medication aides regarding medication administration. Re-educate licensed nurses regarding implementation of physician's orders [REDACTED]. licensed nurses will be responsible for re-ordering new medications as well as refills from the pharmacy. A competency based test will be given to each licensed nurse and certified medication aides to validate comprehension and compliance. This re-education and competency based test will be completed on 04/27/12 at 9:00 PM by the DON and the ADONs. Licensed nurses certified medication aides, including weekend licensed nurses and certified medication aides, will not be allowed to return to work without completing this re-education and competency based tests. New hire licensed nurses will not be allowed to work without completing education and competency based test as well completed by DON and ADONs. 4. Full facility audit of current Physician's Telephone Orders, residents' clinical records MARs, and medications in the medication carts will be completed by the DON and/or designee to ensure current medications and physician's orders [REDACTED]. This full audit will be completed on 04/27/12 at 10:00 p.m. 5. Licensed nurses and medication aides will be validated by a proficiency check-off on proper medication administration. Licensed nurses will be validated by proficiency check-off on proper insulin administration. This proficiency check-off will be completed by the DON or RN designee and nursing management staff on 04/27/12 at 9:00 PM. Any licensed nurses and medication aides, including the weekend staff, who had not completed this proficiency check-off, will not be allowed to return to work. The DON and nursing management staff will monitor new hires to ensure completion in compliance. Staff members that fail competencies will be re-educated until successful skills are achieved. 6. All telephone orders, new admissions/re-admissions and 24 reports will be reviewed and discussed in daily morning meetings during the week for completion, accuracy, and compliance. The ADONs check that telephone orders are transcribed correctly in the MAR/TAR, documented in resident's clinical record, families are notified and medication/treatment supply is available. Any identified issues will be addressed immediately by the ADONs. This meeting will be attended by the DON, ADONs, MDS nurse, and treatment nurse. All telephone orders, new admissions/re-admissions and 24-hour report will be reviewed on the weekend by the weekend supervisor for completion, accuracy and compliance. The weekend supervisor will check that telephone orders are transcribed correctly in the MAR/TAR, documented in resident's clinical record, families are notified and medication/treatment supply is available. Any identified issues will be addressed immediately by the weekend supervisor. 7. Starting in May 2012 and going forward pharmacy consultant facility visits, random medication pass and insulin administration observations will be completed by the pharmacy consultant. Pharmacy consultant will review medication pass and insulin administration observations with the DON. Any identified issues will be immediately corrected by the DON and/or designee. 8. QA(Quality Assurance Committee) meeting is scheduled for 04/27/12 at 9 PM to be attended by the administrator, DON, ADONs to discuss current IJ situation and plan of removal. The medical director will attend QA meeting via telephone conference. The DON, ADONs, and administrator will monitor the reeducation and training program to ensure effectiveness and compliance. Any identified issues will be reviewed during the monthly quality assurance meeting for three months and randomly thereafter. 9. The medical director was notified by the administrator of the IJ situation on 04/27/12 at 4:15 PM. 10. A systematic review of each resident with current orders for insulin therapy will be conducted by the director pharmacy utilization and outcomes for senior care centers to recommend individualized insulin plants for consideration of the medical director this review will incorporate principles of insulin pattern management referenced in the attached document entitled, "strategies to reduce reliance on sliding scale in the elderly." There review has begun effective April 28 and will be completed by May for, 2012. 11. A process to reduce the monitor transcription of telephone orders will be initiated effective April 28 who could the following core components: A. MDS coordinator will double check all new MEDICATION ORDERS FOR [REDACTED]. Any discrepancies identified will be addressed and resolved immediately. B. After entry of the medication orders into the computerized medical record, the copies of the telephone order will be saved for the consultant pharmacist to select a sample and audit for accuracy of transcription to Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s quality assurance process. 7. The DON was interviewed on 04/28/12 at 6:10 PM. The surveyor queried the DON about the facility plan for staff who did not pass the training. The DON replied, "if they do not pass, they will be relieved of duty at that time and replaced with another nurse who has been proven to have proficiency in the medication pass." Individuals who do not pass will be re-inserviced until they do pass. The facility has scheduled an outside vendor with two trainers for return skill demonstrations for Monday 04/30/12 to teach a five hour class for peripheral IVs and Tuesday 05/01/12 to teach a five hour class dealing with central lines. The DON will fax the course outlines and certificates of completion to the Regional office on Monday and Tuesday. If a staff member does not pass the courses offered, they will not be allowed to administer intravenous medications or do intravenous care until they repeat the courses and pass. The surveyor queried the DON at 6:30 PM on 04/28/12 regarding facility plans for caring for Resident #4 over the weekend until staff have completed the two required five hour courses on 05/01/12. The DON replied that she and the RN weekend supervisor will be giving all IV medications and caring for the intravenous site "until the staff are certified in IV therapy." During an interview on 04/28/12 at 6:45 PM, LVN S (MDS coordinator), DON and the consultant pharmacist assigned to the facility were queried about how the Plan of Removal would be implemented to verify MD orders were transcribed correctly. LVN S stated she routinely gathered information for the MDS assessments and she will review all new doctors' orders and be certain the orders were transcribed properly on the MAR. After this, she will put the physician's orders [REDACTED]. The ADONs will enter all new orders into the computer. LVN S will then check the new orders in the computer against the physician's orders [REDACTED]. The assigned consulting pharmacist stated he will be reviewing all orders from the previous month using the folder with the physician order [REDACTED]. On 04/28/12 at 6:35 PM, LVN U was interviewed regarding any recent training. LVN U revealed, "I was here until after 12:00 PM. I am the charge nurse for the 2:00 to 10:00 shift." She stated she was trained on proper transcription of orders, what to do when she found something she did not understand and the five rights of medication administration. LVN U stated the training lasted from 15 to 20 minutes and was completed by the corporate pharmacist. She stated she had to complete demonstration of a "checklist of items." On 04/28/12 at 6:40 PM, LVN E was interviewed regarding any recent training. When surveyor queried LVN E, she replied, "I received the medication pass training." On 4/28/12 at 6:50 PM MA V was interviewed. When queried by surveyor about any recent training she had received, MA V indicated he was trained on the medication cart. The DON went over information on a handout about stocking the cart and being certain all supplies such as gloves and supplements are available. The ADON watched him give medications for "three tries." The ADON checked him off and said he did okay. He had to show use of gloves, eyedrops and supplements as well as handwashing and use of hand sanitizer. Review of medication administration observation report from the lead corporate pharmacist reflected medication pass review was done of the staff on 04/28/12. The Administrator, DON and Corporate Nurse were informed the IJ was removed at 6:00 PM on 04/28/12. While the IJ was removed, the facility remained out of compliance at scope of "pattern" and a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy," because the facility was monitoring the Plan of Removal. The facility's Form CMS- 672, Resident Census and Conditions of Residents, dated 04/26/12 and signed by the DON and the MDS coordinator reflected one resident receiving intravenous therapy, [MEDICATION NAME] nutrition, and/or blood.

Based on observation, interview, and record review, the facility failed to provide services that met professional standards of quality for one (Resident #4) of one resident with a central tunneled internal jugular intravenous line (a catheter that is tunneled under the skin and ends in the resident's internal jugular vein in her neck). 1) LVN E administered the antibiotic, [MEDICATION NAME], intravenously to Resident #4. LVN E also failed to expel air from the normal saline flush syringe before injecting it into the resident's central line. Resident #4 received 1 - 1 1/2 cc of air pushed into her blood stream through the central intravenous line during the flush procedure. LVN E administered the [MEDICATION NAME] at the wrong administration rate. LVN E accepted the assignment of administering IV medications to Resident #4 when she was not knowledgeable regarding the care of the line. 2) ADON C administered the antibiotic, Aztreonam, intravenously to Resident #4. ADON C failed to prime the IV tubing leaving air bubbles in the tubing that were infusing into the resident. ADON C accepted the assignment of administering IV medications to Resident #4 when she was not knowledgeable regarding the care of the line. 3) The DON failed to squeeze the drip chamber of the intravenous tubing to fill it during priming. Leaving the drip chamber less than half full during infusion increased the chances of it running dry and forcing air into the tubing and then into the resident. The DON did not verify the licensed nurses were IV certified and she did not provide training to the licensed nurses regarding the care of a Central Line. Failure to remove air from the tubing can result in an air embolism which can cause temporary paralysis or death. An Immediate Jeopardy (IJ) was identified on 04/27/12. While the IJ was removed on 04/28/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. This failure could affect Resident #1, who was the only resident with a central line. Findings included: 1. Review of the Board of Nursing Practice Position Statement (http:www.bon.state.tx.us/practice/position, html #15.3) on 04/26/12 reflected: "... It is the opinion of the Board that the LVN shall not engage in IV therapy related to either peripheral or central venous catheters, including venipuncture, administration of IV fluids, and/or administration of IV push medications, until successful completion of the validation course that instructs the LVN in the knowledge and skills acceptable to the LVN's IV therapy practice. The BON does not define or set qualifications for an "IV validation course" or for "LVN IV certification." The LVN who chooses to engage intravenous therapy must first have been instructed in the principles of intravenous venous therapy congruent with prevailing nursing practice standards... All nursing actions related to peripheral and/or central intravenous lines, as well as IV administration of medications must be completed in accordance with the orders of the prescribing practitioner, as well as written policies, procedures and job descriptions approved by the healthcare employer ..." 2. The MDS assessment dated [DATE] reflected Resident #4 was a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident # 4's [DIAGNOSES REDACTED]. Resident #4's April 2012 consolidated physician's orders [REDACTED]. ? Aztreonam 1 gm. IV Q 12 hr. x 6 weeks. Start date 04/19/12. ? Flush before and after medication administration using the SASH method (saline,administer medication, saline, and [MEDICATION NAME]) use 5 ml of saline in a 10 ml syringe ending with 5 ml of 10 units per cc of [MEDICATION NAME] in a 10 ml syringe. ? [MEDICATION NAME] 1.5 g/200 ml over 90 min. IV Q 12 hr. X six weeks. Start date 04/19/12. Change IV tubing daily. On 04/26/12 at 3:15 PM, LVN E was observed during IV medication administration to Resident #4. LVN E brought [MEDICATION NAME] 1.25 gm in 250 ml normal saline, some alcohol prep pads, two prefilled normal saline syringes, and a syringe of [MEDICATION NAME] flush solution to Resident #4's room in a plastic green basket. LVN E placed the basket on the bedside table and went to the sink to wash her hands. LVN E donned gloves, went to the resident and picked up the IV line with a paper towel. She arranged some more paper towels under the catheter's port. She unclipped the safety clip on the central line and wiped the blue port with alcohol wipes. LVN E opened a prefilled syringe of normal saline flush from the wrapper and placed it back in the basket. LVN E stated resident's IV tubing for the [MEDICATION NAME] was not dated and she needed a new one. LVN E gathered her supplies and left the room to get more tubing. During preparation for administration, LVN E spiked the 250 ml bag of NS with 1.25 grams of [MEDICATION NAME] (antibiotic) with IV tubing. She then unclamped the tubing and allowed the solution to flow through the line without first filling the drip chamber (a chamber at the top of the tubing to prevent air from entering the tubing.) The surveyor saw bubbles forming in the line. LVN E then picked up a pre-filled 10 cc syringe filled with 5 ml of NS used to ensure patency of the IV catheter and to verify placement. The syringe was observed to also contain approximately 1-2 ml of air. Without first expressing the air from the syringe, LVN E connected the syringe onto the central line. Without aspirating to check placement of the line, LVN E began pushing the fluid and the air into the resident. The surveyor attempted to stop the LVN by putting her hand over the LVN's hand and saying, "Stop! There is air in the syringe!" LVN E stated, "I expressed the air from the syringe already" and continued to inject the contents of the syringe, including the 1-2 ml of air. http://www.nursingcenter.com/prodev/ce_article.asp?tid= 73 reflected, "Air embolism is a well-published complication arising from central venous catheter use. Literature and case studies provide information regarding clinical sequelae. Preventable mistakes still occur despite following what is considered appropriate protocol...Venous air embolism (VAE) occurs from air entering the venous system via the CVC itself or the track from removal of the CVC (Fink et al., 2005). Air is transported to the [MEDICAL CONDITION] arteries, hindering gas exchange and causing [MEDICAL CONDITION] hypertension. This can result in right ventricular strain and, ultimately, cardiovascular collapse (Fink et al., 2005; Wittenberg et al., 2006). A large enough [MEDICATION NAME] of air can create an obstruction to the outflow of blood from the right ventricle, essentially forming an airlock (Wittenberg et al., 2006)...." (Retrieved on 05/11/12). LVN E then attached the IV tubing for the antibiotic to Resident #4's central line. An in-line regulator (Control-a-Flo) was observed on the tubing, but LVN E adjusted the safety clamp to approximately half open stating, "I'm setting the clamp halfway so it only runs half open. I use this clamp to set the rate. Then I make sure the thing here (LVN E gestured to the Control-a-Flo dial) is set at between 10 and 30 (ml/hr)." At that time, the surveyor counted the flow rate for the antibiotic to be at 36 drops per minute (10 drops equal 1 ml). An interview during the procedure on 04/26/12 at 3:30 PM with LVN E revealed she did not calculate the rate, but the antibiotic was ordered by the physician to infuse in over 90 minutes. LVN E stated, "This drip rate should make it done in about an hour and a half or so." Resident #4's physician's orders [REDACTED]. NOTE: Calculation of the flow rate Volume in ml X drip factor (10) = drops per minute Time 250 ml X 10 = 28 drops per minute 90 On 04/26/12 at 4:10 PM, LVN E was observed at Resident #4's bedside. At that time, LVN E pointed to the numbers on the Control-a-Flo. LVN E pointed to the number "100," indicating 100 ml. hr. LVN E stated the number was, "Ten." LVN E pointed to the number "125," indicating 125 ml/hr. LVN E stated the number was, "Thirty." LVN E was queried as to where she saw "10" and "30" on the Control-a-Flo because the surveyor saw "100" and "125." LVN E replied, "I guess I need my glasses." LVN E was not wearing glasses at this time. Interview with LVN E on 04/26/12 at 5:42 PM revealed she needed reading glasses to enlarge things. LVN E stated she did not need the glasses all of the time, but did need glasses to look at fine print. LVN E stated she worked on Hall One and did not work with IVs on Hall Two. She stated the nurse currently working Hall Two was not IV certified, so ADON C asked her to take care of the IV on Hall Two. LVN E stated she told ADON C she needed to look at the procedure. LVN E stated she was called away and did not get a chance to review the IV procedure. She stated she recalled the procedure which was saline, antibiotic, saline, [MEDICATION NAME] flush. LVN E continued to explain before any IV medication was given, a saline flush was done. She stated the saline came in a prepackaged syringe. LVN E stated she had to ensure the fluid was all the way up to the top of the syringe and had to waste some of the fluid out the top of the syringe. LVN E stated next the medication which was ordered was administered. LVN E stated she calculated the dose, if the dose was not calculated for her. LVN E stated one of the ADONs calculated the dose behind them. LVN E stated she did not ask one of the ADONs to calculate the dose today, but usually asked one of the ADONs to calculate the dose with her. LVN E stated today she forgot she was not supposed to clamp off the flow. She stated the Control-a-Flo (in line regulator) was used in this facility, but most IVs were on a pump. LVN E stated ADON C asked her to take care of the IV, because ADON C was " tired." LVN E showed the surveyor a blank piece of paper with handwritten numbers on it and stated it was ADON C's calculations for the flow rate for the IV. On 04/26/12 at 5:20 PM, ADON C was observed during IV medication administration of Aztreonam to Resident #4. ADON C connected the new bag of medication and started the infusion. The drip chamber was observed to be empty with air in the tubing. The surveyor immediately stopped the infusion by clamping off the tubing to prevent air from going into Resident #4's body. The empty drip chamber and air in the line was pointed out to ADON C. The DON was requested to come to the room. When the DON arrived at 3:45 PM on 04/26/12, the air in the line was measured with a ruler. There was a total of 3.1 cm of air in the line. The DON told ADON C to get more IV tubing and another antibiotic solution and start all over. ADON C attempted to prime the IV line without filling the drip chamber. The surveyor requested the DON to assist ADON C with priming the IV line. The DON did not fill the drip chamber. Under the DON's supervision, ADON C picked up a prefilled syringe of normal saline, expressed the air from the syringe, wiped the end of the port on the central line and attached the luer lock syringe to the port. ADON C did not aspirate to check the placement of the line, flushed with 5 ml of normal saline, attached the IV tubing and set the control a flow regulator to 150 ml per hour An interview was conducted with the DON about the LVN training for intravenous medication administration on 04/27/12 at 9:20 AM. When queried about the training the LVNs received, the DON stated she was sure all the certificates and skills checklists were in the nurses' personnel files. The surveyor presented the certificates and IV skills checklists that were found in the personnel files. The DON stated she did not know why the staff did not have certificates for intravenous medication classroom training. During an interview on 04/27/12 at 11:50 AM, the DON was asked how she determined if staff had the necessary skills to work with central lines and IV's. The DON stated, "I go over check off sheets with them. They are individualized in their folders. I do it when they come to work here. I look at if they have had any training. I don't do IV skills check off every year. I have had classes here and the last one was in 2007." The DON was then asked if the nurses needed an IV course before performing the skills check off. The DON responded, "Not all of them have the certificate. I do go over the skills check off list to determine the skill levels of the nurses. I do the procedure for hanging IVPB rather than placement of IV's if they haven't had the class." When asked if the nurses were required to have an IV class before administering IV medications, the DON stated, "Most are already certified. We have made arrangements for them to go out and have the class soon. I don't have the date yet for the class." The DON was asked how she checked the nurses' IV competency. The DON stated, "We don't always have an IV in the building. I directly oversee the nurses and directly train them." When queried regarding the number of nurses on each shift that have IV training, the DON stated, "Two per shift, one treatment nurse, one weekend RN." When asked, "How do you demonstrate the competency of your staff?", the DON stated, "The ADONs help me to check the check off lists. When there is an opportunity to watch, we do a demo (demonstration), but mostly we do question and answer sessions. We do return demonstration only if we have a patient who has a particular skill (like IV's). Otherwise we do annual check-offs of skills." An interview with LVN F was conducted on 04/27/12 at 8:45 PM. LVN F was asked what training she had regarding IV medications. She stated, "I went to a class and got a certification for IVs." When queried about the procedure for an IV flush of a central line, she stated, "Flush the line with normal saline, attach the antibiotic at the ordered rate, flush the IV when the antibiotic is done and flush the line with [MEDICATION NAME] when done." An interview with the Human Resources Director was conducted on 04/27/12 at 11:00 AM. When queried about in-services for IV medications or IV care, she stated, "There were no previous in-services last year for IVs. The last IV in-service was from an outside vendor given in 06/06/2007. Other than that there were no IV in-services or in-services about caring for IV's." Upon request for IV training verification, at 7:20 PM on 04/26/12 the Corporate Nurse provided ten LVNs' personnel files. The Corporate Nurse stated he could not find all of the files. Review of the ten LVN personnel files provided by the Corporate Nurse revealed three LVNs had the classroom training to administer IVs. The most recently trained LVN had a classroom training date of 04/12/11. The other 2 had certificates from 2006 and 2007. The DON had done IV skills evaluation for five of the ten LVNs. Some LVNs had the skills check list and no IV classroom training. The skills procedure was a checklist that had the following categories with a check mark area beside it: ? Has successfully demonstrated IV placement. ? Has successfully demonstrated IV fluids/medication administration/maintenance ? Has successfully demonstrated the procedure for disconnecting IV therapy There was a second skills checklist in some of the personnel files it was titled central venous catheter care. The checklist reflected the following expected behaviors: ? Verify orders ? Explained procedure ? Gathers supplies and inspect for integrity ? Wash hands and put on non-sterile gloves ? Remove old CVL dressing ? Assess site for infection ? Set up and maintain a sterile field ? Clean insertion site for protocol apply appropriate dressing ? Secure online per protocol ? Draw up appropriate flush solution and flush central venous line for protocol ? Change injection port per protocol ? Clean work area and dispose of waste appropriately ? Document the procedure appropriately I V Certification of LVNs Name Date of Hire IV Class IV checklist LVN L 10/03/11 No No LVN F 01/03/12 No No LVN N 04/11/07 06/06/07 03/23/09 LVN E 09/21/01 No 03/11/09 LVN G 06/06/11 No No LVN O 08/26/09 04/12/11 No LVN P 05/10/11 No 01/10/12 ADON C 12/01/04 No 06/06/07 LVN Q 04/11/08 10/08/05 03/10/09 ADON R No No An interview was conducted with the DON about the LVN training for intravenous medication administration on 04/27/12 at 9:20 AM. When queried about the training the LVNs received, the DON stated she was sure all the certificates and skills checklists were in the nurses' personnel files. The surveyor presented the certificates and IV skills checklists that were found in the personnel files. The DON stated she did not know why the staff did not have certificates for intravenous medication classroom training. The facility's policy, Infusion Rate Control (section 7.5), dated October 2011, reflected, "an infusion pump will be used for administration of [MEDICATION NAME] Nutrition, medications with rate related complications and all therapies given through a [MEDICAL CONDITION] (central venous access device), including a PICC (peripherally inserted central catheter)." The facility's policy, Setting up A Primary Infusion (section 7.2), dated October 2011, reflected, "Only a professional nurse with documented IV education, as designated by the facility and as allowed by state regulations may set up a primary infusion. Equipment to be used was listed ...infusion pump...Procedure included ...Squeeze drip chamber until 1/4 - 1/2 full." Potter and Perry's Fundamentals of Nursing 7th edition, 2009, reflected: " INITIATING INTRAVENOUS THERAPY ( pages 996-997) ...Preparing IV tubing and solution ... 14 ...f. Prime infusion tubing by filling with IV solution: Compress the drip chamber and release, allowing it to fill one-third to one-half full ...Ensures tubing is cleared of air before connection with IV site. Creates suction effect; fluid enters drip chamber to prevent air from entering tubing g. Remove protector cap on end of tubing ...and slowly open roller clamp to allow fluid to travel from drip chamber through tubing ...Slow fill of tubing decreases turbulence and chance of bubble formation. Removes air from tubing and permits tubing to fill with solution ... h. Be certain tubing is clear of air and air bubbles ...Check entire length of tubing to ensure that all air bubbles are removed ...Large air bubbles may acts as emboli .... " " The patency of the IV line is checked to insure that the line is intact and not leaking ... Intermittent IV drug doses are usually calculated in cc per hour. They are given in larger amounts of fluid that are usually given with an IV pump and most IV pumps are set in cc per hour, not cc per minute. " (Retrieved at <http://www.healthline.com/galecontent/intravenous-medication-administration#1> on 5/09/12) The Intravenous Nurse Society's Standard of Practice, 2006 retrieved on 5/09/12 at <http://www.cathflo.com/media/professional_cathetermanagebroch.pdf> reflected: " ...catheter patency should always be checked " prior to administration of [MEDICATION NAME] medications and solutions. " When checking placement it is important to confirm the patency of the Central Central Venous Catheter's patency by " ... aspirating the device for confirmation of positive blood return.... " An IJ was identified on 04/27/12 at 3:03 PM. The Administrator and the DON were notified of the IJ on 04/27/12 at 3:03 PM and a Plan of Removal was requested at that time. The Plan of Removal was accepted on 04/28/12 and reflected: 1. The attending physicians were notified of the errors found by the surveyors. 2. The DON and Weekend RN supervisor will be responsible for administering Resident #4's antibiotics and the flushing of the central catheter. All licensed nurses will complete IV education and training on 04/30/12 and 05/01/12. The DON and ADONs will monitor new hires to ensure completion and compliance. 3. Re-educate all licensed nurses and medication aides regarding medication administration. Re-educate licensed nurses regarding implementation of physician's orders [REDACTED]. licensed nurses will be responsible for re-ordering new medications as well as refills from the pharmacy. A competency based test will be given to each licensed nurse and certified medication aides to validate comprehension and compliance. This re-education and competency based test will be completed on 04/27/12 at 9:00 PM by the DON and the ADONs. Licensed nurses certified medication aides, including weekend licensed nurses and certified medication aides, will not be allowed to return to work without completing this re-education and competency based tests. New hire licensed nurses will not be allowed to work without completing education and competency based test as well completed by DON and ADONs. 4. Full facility audit of current Physician's Telephone Orders, residents' clinical records MARs, and medications in the medication carts will be completed by the DON and/or designee to ensure current medications and physician's orders [REDACTED]. This full audit will be completed on 04/27/12 at 10:00 p.m. 5. Licensed nurses and medication aides will be validated by a proficiency check-off on proper medication administration. Licensed nurses will be validated by proficiency check-off on proper insulin administration. This proficiency check-off will be completed by the DON or RN designee and nursing management staff on 04/27/12 at 9:00 PM. Any licensed nurses and medication aides, including the weekend staff, who had not completed this proficiency check-off, will not be allowed to return to work. The DON and nursing management staff will monitor new hires to ensure completion in compliance. Staff members that fail competencies will be re-educated until successful skills are achieved. 6. All telephone orders, new admissions/re-admissions and 24 reports will be reviewed and discussed in daily morning meetings during the week for completion, accuracy, and compliance. The ADONs check that telephone orders are transcribed correctly in the MAR/TAR, documented in resident's clinical record, families are notified and medication/treatment supply is available. Any identified issues will be addressed immediately by the ADONs. This meeting will be attended by the DON, ADONs, MDS nurse, and treatment nurse. All telephone orders, new admissions/re-admissions and 24-hour report will be reviewed on the weekend by the weekend supervisor for completion, accuracy and compliance. The weekend supervisor will check that telephone orders are transcribed correctly in the MAR/TAR, documented in resident's clinical record, families are notified and medication/treatment supply is available. Any identified issues will be addressed immediately by the weekend supervisor. 7. Starting in May 2012 and going forward pharmacy consultant facility visits, random medication pass and insulin administration observations will be completed by the pharmacy consultant. Pharmacy consultant will review medication pass and insulin administration observations with the DON. Any identified issues will be immediately corrected by the DON and/or designee. 8. QAA (Quality Assurance Committee) meeting is scheduled for 04/27/12 at 9 PM to be attended by the administrator, DON, ADONs to discuss current IJ situation and plan of removal. The medical director will attend QA meeting via telephone conference. The DON, ADONs, and administrator will monitor the reeducation and training program to ensure effectiveness and compliance. Any identified issues will be reviewed during the monthly quality assurance meeting for three months and randomly thereafter. 9. The medical director was notified by the administrator of the IJ situation on 04/27/12 at 4:15 PM. 10. A systematic review of each resident with current orders for insulin therapy will be conducted by the director pharmacy utilization and outcomes for senior care centers to recommend individualized insulin plants for consideration of the medical director this review will incorporate principles of insulin pattern management referenced in the attached document entitled, "strategies to reduce reliance on sliding scale in the elderly." There review has begun effective April 28 and will be completed by May for, 2012. 11. A process to reduce the monitor transcription of telephone orders will be initiated effective April 28 who could the following core components: A. MDS coordinator will double check all new MEDICATION ORDERS FOR [REDACTED]. Any discrepancies identified will be addressed and resolved immediately. B. After entry of the medication orders into the computerized medical record, the copies of the telephone order will be saved for the consultant pharmacist to select a sample and audit for accuracy of transcription to Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s quality assurance process. During an interview on 04/28/12 at 6:45 PM, LVN S (the MDS coordinator), DON and the consultant pharmacist assigned to the facility were queried about how the plan of correction would be implemented to verify MD orders were transcribed correctly. LVN S (the MDS Coordinator) stated she routinely gathered information for the MDS assessments. For the plan of correction, she is to review all new doctors' orders and be certain the orders are transcribed properly on the MAR. After this, she will put the physician's orders [REDACTED]. The ADONs will enter all new orders into the computer. LVN S (the MDS Coordinator) will then check the new orders in the computer against the physician's orders [REDACTED]. The assigned consulting pharmacist stated he will be reviewing all orders from the previous month using the folder with the physician order [REDACTED]. On 04/28/12 at 6:35 PM, LVN U was interviewed regarding any recent training. LVN U revealed, "I was here until after 12 PM. I am the charge nurse for the two to ten shift." She was trained on proper transcription of orders, what to do when you find something you didn't understand and the five rights of medication administration. The training lasted from 15 to 20 minutes and was done by the corporate pharmacist. She had to complete demonstration of a "checklist of items." On 04/28/12 at 6:40 PM, LVN E was interviewed regarding any recent training. When surveyor queried LVN E, she replied, "I received the medication pass training." On 4/28/12 at 6:50 PM MA V was interviewed. When queried by surveyor about any recent training she had received, MA V indicated he was trained on the medication cart. The DON went over information on a handout about stocking the cart and being certain all supplies such as gloves and supplements are available. The ADON watched him give medications for "three tries." The ADON checked him off and said he did okay. He had to show use of gloves, eyedrops and supplements as well as handwashing and use of hand sanitizer. Review of medication administration observation report from the lead corporate pharmacist reflected medication pass review was done of the staff on 04/28/12. Review of the competency-based written test for medication, insulin administration, transcription of physicians orders reflected fifteen staff took the five question test on 04/28/12. The Administrator, DON and Corporate Nurse were informed the IJ was removed at 6:00 PM on 04/28/12. While the IJ was removed, the facility remained out of compliance at scope of "pattern" and a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy," because the facility was monitoring the Plan of Removal. The facility's Form CMS- 672, Resident Census and Conditions of Residents, dated 04/26/12 and signed by the DON and the MDS coordinator reflected one resident receiving intravenous therapy, [MEDICATION NAME] nutrition, and/or blood.