Every finding on record at Glenvue Health and Rehab

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Fingernails/Toenails, Care of, the facility failed to ensure Activities of Daily Living (ADL) care was provided for two of five sampled residents (R) (R110 and R22). This deficient practice had the potential to place R110 and R22 at risk of infection and cause the residents to feel self-conscious about their appearance.Findings include:Review of the facility policy titled, Fingernails/Toenails, Care of, revised February 2018, revealed the Purpose section included, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The General Guidelines section included, 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed.1. Review of the clinical record for R110 revealed diagnoses including, but not limited to, peripheral vascular disease, mood disorder due to known physiological condition with depressive features, unsteadiness on feet, cellulitis, personal history of other diseases of the musculoskeletal system and connective tissueReview of the quarterly Minimum Data Set (MDS) for R110, dated 05/24/2026, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Section E (Behaviors) documented no rejection of care. Section GG (Physical Abilities and Goals) documented that the resident was dependent for showers/baths.Review of the care plan for R110 revealed a focus area stating the resident requires assistance with personal hygiene and bathing. The goal stated that the resident will be clean, neatly groomed, dressed appropriately, and free of odors daily through the next review. Interventions included providing assistance with bathing, dressing, and grooming.During an observation and interview on 07/07/2026 at 10:35 AM, R110's fingernails were observed to be long, jagged, and contained a buildup of dark brown substance under the fingernails. R110 stated, I would trim them myself if I could. I wish they had a regular schedule.Observation on 07/08/2026 at 11:39 AM revealed that R110 was in bed, and his nail condition remained unchanged. During walking observation rounds with the Corporate Nurse on 07/09/2026 at 12:05 PM, R110's fingernails were observed to be long and jagged with a dark brown substance underneath the nails. The Corporate Nurse observed the nails and confirmed they needed to be trimmed and cleaned.2. Review of the clinical record for R22 revealed diagnoses including, but not limited to, Type 2 diabetes mellitus with hyperglycemia and generalized muscle weakness.Review of the quarterly MDS for R22, dated 04/24/2026, revealed that section C (Cognitive Patterns) documented a BIMS score of 8 (indicating moderate cognitive impairment). Section E (Behaviors) documented no indicators of rejecting care. Section GG (Physical Abilities and Goals) documented that the resident requires assistance with ADLs.Review of the care plan for R22 revealed a focus area stating the resident requires assistance with personal hygiene and bathing. The goal was for the resident to be clean and neatly groomed. Interventions included providing assistance with bathing, dressing, and grooming.During an observation and interview on 07/09/2026 at 12:05 PM, R22's fingernails were observed to be long and jagged. R22 stated he would like them to be trimmed. The Corporate Nurse concurrently observed the nails and confirmed they needed to be trimmed.In an interview on 07/09/2026 at 11:42 AM, Certified Medication Aide (CMA) AA stated that the CNAs usually provide nail care during showers if the residents request the care be provided. She stated they will talk to the Podiatrist about any diabetic residents, but that CNAs should be providing nail care during showers and baths.In an interview on 07/9/2026 at 11:42 AM, Wound Care Nurse BB stated that sometimes staff will ask her to trim the nails of residents, but that the CNAs usually perform the task during daily hygiene.During a concurrent interview on 070/9/2026 at 11:55 AM, Licensed Practical Nurse (LPN) CC and Registered Nurse (RN) Unit Manager DD revealed that CNAs should provide nail care for residents.In an interview on 07/09/2026 at 12:00 PM, CNA EE stated that they did not have a specific task area for documentation for nail care and that it falls under the personal hygiene task.In an interview on 07/09/2026 at 12:10 PM, the Director of Nursing (DON) revealed that the facility does not have a specific CNA task for trimming resident nails. She stated the CNAs are generally responsible for nail care during baths and showers. She stated that untrimmed, dirty nails could cause self-injury and the possible transmission of infections.In an interview on 07/09/2026 at 1:45 PM, the Social Services Director revealed that nurses or the Wound Care Nurse generally refer residents for podiatry when they need toenails trimmed. She called the Podiatrist and confirmed that they do not provide fingernail trimming as part of routine services.

Based on observations, staff interview, and record review, the facility failed to ensure that the preplanned menu portion serving sizes and standardized recipes were followed. Failure to meet these requirements altered the intended calorie and nutritional content of the meal offered and could place residents at risk for weight loss and health complications associated with malnutrition. The deficient practice had the potential to affect all residents who receive an oral diet from the kitchen. Findings include: On 04/15/25 at 4:45 PM, [NAME] (C) 3 was observed setting up the tray line for the meal service. After removing the main entree from the oven, C3 tested the temperature, and stated the menu included chicken pot pie, and could be served without any alteration to the residents with altered textured diets. C3 then stated he needed to prepare the casserole for puree foods. When asked if a standardized recipe was used to prepare the casserole, C3 explained he had added cheese to the recipe and provided assurance the resident really liked it. It was also noted that biscuits had been placed on the top of the pot pie while baking. C3 then used a gray handled scoop (which held a four (4) ounce serving) to place four scoops of the pot pie into the blender, added a liquid and blended the food to a smooth texture. After placing the puree on the steam table in the pan, C3 began to plate foods for residents sitting in the dining room. After serving approximately 10 plates to residents, the Dietary Manager (DM) was asked about the portion serving size used for the entree. The DM stated the scoop was not the right portion size, and advised C3 the portion size should be six ounces, she then obtained a six-ounce scoop and provided it to C3. Which was the portion serving size identified on the spread sheet for the entree. Review found the standardized recipe, provided by the facility, revealed the recipe did not include any cheese. In addition, the recipe included a pie crust being cooked on top of the casserole, the recipe was not followed and changed the calorie and nutrient value of the meal. During a follow-up interview with the DM on 04/16/25 at 10:30 am the following day, a copy of the diet count was provided. The diet count showed the eight residents had physician orders for puree diet. When asked how 16 ounces (four scoops) of the casserole prepared in a blender with liquid met the nutritional needs for the eight puree diets, she stated she did not know. The menu extension verified a six-ounce portion serving size was intended portion to be served the puree diets.

Based on observations, staff interviews, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions; as evidenced by failure to ensure food preparation equipment was stored under sanitary conditions; and ensure food storage areas were kept clean and sanitary. In addition, the facility failed to ensure foods were cooked to the appropriate temperature before placing them in a warmer (a low temperature oven intended to hold hot food), and failure to ensure ready to eat foods were handled in a manner that prevented contamination. The deficient practice increased the risk for all residents residing in the facility who receive a diet from the kitchen could experience a food borne illness. Findings include: On 04/14/25 at 9:20 AM, during the initial tour of the kitchen, the following observations for food preparation equipment, and food storage areas were kept in a clean and sanitary manner. The floor in the kitchen was soiled with food crumbs, and particulate matter, broken linoleum tiles were observed exposing the sub-floor. Food particulate matter was adhered to the cracked and broken edges of the tiles. The doors and handles on the reach in refrigerators were visibly soiled with food splash and spills. A deep fryer had splash guard that was heavily soiled with food spills and crumbs. The Dietary Manager (DM) stated it was used the previous day and should have been cleaned after use. The microwave handle was soiled and the interior had food crumbs inside. A juice dispenser machine was observed on the counter, the DM reported the dispenser spigots are cleaned weekly. The steam table wells had food spills and splash inside the water. When asked how often the water was changed, the DM responded it should have been emptied and cleaned the previous day and appeared that it was not completed. On 04/14/25 at 9:20 AM, the DM stated the cleaning schedule was being revised to meet the facility's needs, and stated a new contractor had just taken over the food service department that week. On 04/15/25, at 4:45 PM, [NAME] (C)3 observed preparing and setting up for meal service. C3 removed a deep steamtable pan from the oven containing chicken pot pie. C3 obtained a blender, prepared the pureed entree, and placed it in the steam table for service. C3 began serving plates using utensils to plate hot foods, and then placed a biscuit on the plate using gloves (which had touched multiple surfaces throughout the kitchen) and could contaminate the ready-to-eat food. C3 served several plates and then obtained a pair of tongs to serve the biscuits, stopped handling them with the gloves. On 04/16/25 at 10:55 AM, several pans of food were observed in the warming oven (intended for hot holding). The thermometer inside the unit displayed a temperature of 200 degrees Fahrenheit (F). When asked to test the temperature of the pureed meat, the thermometer reading was below 100 F. When asked how long the item had been in the warming oven, the DM asked the staff, who responded it was just prepared and placed in the warmer. When asked about the facilities practice for heating foods, the DM explained food should be heated to 165 F prior to placing the item in the warmer. On 04/16/25 at 2:45 PM, during a follow up interview with the DM, when asked about the manufacturers' recommendations for a clean the juice machine, she revealed the instructions were found on the interior of the door, the recommendation was to clean and sanitize the spigots daily.

Based on record review, interviews, and policy reviews, the facility failed to ensure five of 10 residents and their representatives (Resident (R) 8, R7, R23, R45, and R74) reviewed for facility initiated emergent hospital transfer from a total sample of 31 were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to affect the residents and their Resident Representative (RP) by not having the knowledge of where and why a resident was transferred, and/or how to appeal a transfer, if desired. Findings included: Review of the facility policy titled, Transfer or Discharge, Facility Initiated, dated 10/2022, revealed, .Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy .Notice of Transfer is provided to the resident and representative as soon as practicable .notices are provided in a form and manner that the resident can understand .Upon notice of transfer or discharge, the resident will be provided with a statement of his or her right to appeal the transfer or discharge . 1. Review of R8' s, admission Record (AR) under the Profile tab in the Electronic Medical Record (EMR) revealed an admission date 12/22/21. Review of the significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/08/24 identified the R8 experienced a significant change in condition and experienced a decline in the ability to participate in walking, toileting, and transfers after sustaining a fracture of her lower leg. Review of the Nursing Progress Note dated 04/06/25 at 2:00 PM, documented R8, refused breakfast and lunch. The entry noted R8 stated she .did not feel well, and was hurting all over. The entry noted the staff contacted the physician, who ordered the resident to be transferred to the emergency room (ER) for further evaluation, the entry documented the family was contacted to notify them of the transfer, however there was no documentation the reason behind the transfer was provided with the discharge paperwork. Review of the Notice of Transfer or Discharge dated 04/06/25, did not identify the reason for the discharge. Review of the Situation Change In Condition note sent to the physician, documented the R8 had low and/or high Blood Pressure, heart rate, respiratory rate, weight change, and a change in her level of consciousness. However, there was no evidence, the reason for the transfer was provided in writing to R8 or family member. 2. Review of R7's admission Record under the Profile tab in the EMR revealed R7 had an admission date was 03/08/24. Review R7's last discharge MDS assessment, with an ARD of 11/08/24, identified multiple diagnoses, including a non-traumatic brain injury and was dependent on staff for most Activities of Daily Living (ADL i.e, dressing, grooming, hygiene, toileting transfers and mobility.) Review of the Notice of Transfer or Discharge dated 11/08/24, revealed the resident was transferred to the hospital but did not identify the reason for the transfer. The reason for the transfer was not identified in writing and provided to the R7 or the family member. Review of a Nursing Progress Note, dated 11/08/24, documented Licensed Practical Nurse (LPN) 5 contacted the Physician after identifying swelling in scrotum. The resident received order to send patient out to ER for further evaluation, for enlarged left testical (sic) with pain upon touch. 3. Review of R23's admission Record located in the EMR under the Profile tab, showed an admission date of 12/24/21 with a primary medical diagnosis of chronic pulmonary edema. Responsible Party (RP)1 was the emergency contact/RP for R23. Review of R23's discharge MDS Assessment was not completed for this transfer/discharge to the hospital. Review of R23's Notice of Transfer or Discharge document provided by the facility and dated 01/23/25 revealed the resident was transferred to an unknown hospital for an unknown reason. A phone call was made to the RP on 01/23/25 at 6:00 AM. No documentation was located to confirm complete information was provided to the RP regarding the transfer to the hospital. Review of R23's Progress Notes located in the EMR under the Progress Notes tab did not indicate written notification was sent to the RP regarding transfer/discharge. During an interview on 04/15/25 at 11:31 AM RP1 stated that when R23 had to be sent to the hospital the facility calls to notify her of the transfer, but does not send any documents explaining where/why R23 was being sent. During an interview on 04/16/25 at 9:00 AM with R23 stated that her granddaughter handles her paperwork and wasn't sure if the facility sent Notice of Transfer or Discharge. R23 confirmed that the facility did not provide her with any documentation related to hospital transfer/discharges. 4. Review of R45's admission Record located in the EMR under the Profile tab, showed an admission date of 12/15/20 with a primary medical diagnosis of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side. Review of R45's discharge MDS Assessment, with an ARD of 09/09/24, indicated the resident was discharged to a short-term general hospital. Review of R45's Notice of Transfer or Discharge document provided by the facility and dated 09/09/24 revealed the resident was transferred to an unknown hospital for an unknown reason. A phone call was made to the RP on 01/23/25 at 12:00 AM. No documentation was located to confirm complete information was provided to the RP regarding the transfer to the hospital. Review of R45's Progress Notes located in the EMR under the Progress Notes tab did not indicate written notification was sent to the RP regarding transfer/discharge. During an interview on 04/14/25 at 12:47 PM stated that he did not recall going to the hospital on [DATE] and had not received any documents related to a hospital visit. 5. Review of R74's admission Record located in the EMR under the Profile tab, showed an admission date of 01/20/25 with a primary medical diagnosis of emphysema. Review of R74's discharge MDS Assessment with an ARD of 02/14/25, indicated the resident was discharged to a short-term general hospital. Review of R74's Notice of Transfer or Discharge document provided by the facility and dated 02/14/25 revealed the resident was transferred to an unknown hospital for an unknown reason. A phone call was made to the RP on 02/14/25 at 9:00 AM. No documentation was located to confirm complete information was provided to the RP regarding the transfer to the hospital. During an interview on 04/15/25 at 3:48 PM, the Interim Administrator and Corporate Compliance Nurse (CCN) stated that the nurse on duty fills out a Notice of Transfer or Discharge which accompanies the resident to the hospital. The nurse on duty fills out a Bed Hold form that is to be mailed to the RP. No other forms are mailed to the RP and the Administrator/CCN stated they were not aware of the requirement to provide written transfer/discharge notice that stated the reason and location of the transfer. During an interview on 04/17/25 at 4:21 PM with LPN3 stated that when the nurse sends a resident out to the hospital, they call the RP to let them know the resident had been sent out, Notice of Transfer or Discharge document is filled out and is sent with the resident to the hospital. The packet also includes current orders, advance directives, face sheet, and the Notice of Transfer or Discharge. The Notice of Transfer or Discharge form is not sent to the RP and does not include a reason for transfer/discharge. Additionally, the facility had not been sending a copy of this notification to the resident/RP and was not aware that the facility needed to do so. During an interview on 04/15/25 at 4:40 PM with the Director of Nursing (DON) stated that the Notice of Transfer or Discharge was one of the forms that was to be sent with the resident to the hospital, this form was not sent to the RP. She was not aware that the Notice of Transfer or Discharge form did not include an area for the nurse sending the resident to the hospital to indicate the reason for the hospitalization/discharge. The DON stated that she was not aware of this requirement.

Based on staff interviews, and record review, the facility failed to provide staff assistance with activities of daily living for one of four residents (Resident (R) 244) reviewed for activities of daily living out of a total sample of 24 residents. This failure had the potential to lead to a decline in activities of daily living. Findings include: Review of R244's Admission Record located under the Profile tab in the electronic medical record (EMR), revealed R244 was initially admitted on [DATE] with diagnoses including acute respiratory failure, epilepsy, cerebral palsy, cognitive communication deficit, bipolar, and intellectual disabilities. The resident went out to the hospital on 2/28/29, readmitted on [DATE], and discharged on [DATE]. Review of R244's Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 02/28/24 revealed the resident was unable to complete a Brief Interview of Mental Status (BIMS) assessment. A Staff Assessment for Mental Status was conducted and determined that the resident's cognitive skills for daily decision making was severely impaired. The MDS also indicated R244 required substantial/maximal assistance to complete bathing. Review of R244's Baseline Care Plan located in the EMR under the Assessments tab revealed the resident required the assistance of one person for bathing. Review of R244's Documentation Survey Report - Feb-24 located under the Reports tab in the EMR revealed there was no documentation that the resident was bathed from 02/23/24 through 02/28/24. The resident was scheduled to be bathed on 02/27/24 but was not marked as completed. During an interview on 04/17/25 at 4:50 PM, Certified Nursing Assistant (CNA) 6 stated, There is a bath sheet at nurses desk indicating when residents are scheduled to be bathed. We, then, documented in EMR. If a resident refuses their bath/shower, we ask them three times and then notify the nurse. We then document the refusal in the EMR and select refused. If a resident wants to be bathed the next day, then we would bathe them the next day. New admissions would be scheduled on the bath sheet as soon as they are admitted . If a resident was admitted on Tues, then they would be scheduled for one on the next day. Residents are scheduled either Monday, Wednesday, Friday, or Tuesday, Thursday, Saturday. If a resident needs a bath when they are admitted , then they would get one right away. I do not recall a resident by the name of [R244]. During an interview on 04/17/25 at 5:00 PM, CNA5 stated, A list of the residents' bath schedule is at the nurses' desk. We look at the list when we come in each day. Residents are scheduled either Monday, Wednesday, Friday or Tuesday, Thursday, Saturday. Baths would be scheduled between day, evening, and night shift depending on the resident's preference. Residents who refuse are reapproached three times, then we notify the charge nurse. I document in EMR the refusal. I note it on the bath list and notify the nurse. The nurse also documents the refusal in the chart. New admissions would be scheduled either the same day or the next day. I do not recall a resident by name of [R244]. During an interview on 04/17/25 at 5:10 PM, the DON stated. New admissions are scheduled by the nurse manager for Monday, Wednesday, Friday or Tuesday, Thursday, Saturday and based on the resident's preference for the time of day. The expectation is that residents receive a bath immediately if needed or the next day. [R244] was admitted on [DATE]. The expectation was that [R244] should have been scheduled for a bath on 02/24/24. The CNAs that worked then have retired and no longer work here. The CNA scheduled that day did not document any baths in the chart for the day. There was no documentation that the resident was offered a bath or refused. [R244] was scheduled for baths beginning 02/27/24. The documentation for bathing was blank on 02/27/24. No documentation would mean that the task was not completed.

Based on record reviews, and staff interviews, the facility failed to ensure physician orders were followed related to laboratory monitoring for one of one (Resident (R)45) residents reviewed for laboratory services. Specifically, the facility failed to ensure that R45's HbA1c (blood test measuring average blood sugar levels over the past two to three months) labs were drawn in October 2024 and January 2025. Findings included: Review of R45's Admission Record located in the Electronic Medical Record (EMR) under the Profile tab, showed an admitted [DATE] with a primary medical diagnosis of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side. Review of R45's Care Plan revised 04/11/25 located in the EMR under the Care Plan tab included diabetic status and .labs as ordered . Review of R45's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Review Date (ARD) of 01/07/25 revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating that he was moderately cognitively impaired. Review of R45's Order Summary Report located in the EMR under the Orders tab included an order, dated 03/13/24, for HbA1c to be drawn quarterly in January/April/July/October. Review of R45's HbA1c results located in the EMR under the Results tab revealed the most recent HgA1c was drawn on 03/19/24 at the facility. The resident was hospitalized [DATE] and had HgA1c drawn while hospitalized . No HgA1c was collected for October 2024 or January 2025. Review of Pharmacy Progress Notes, dated 11/05/24, located in the EMR under the Progress Notes tab included a recommendation to update HbA1c lab monitoring. Review of Pharmacy Progress Notes, dated 02/03/25, located in the EMR under the Progress Notes tab included a recommendation to update HbA1c lab monitoring. During an interview on 04/16/25 at 4:07 PM with the Director of Nursing (DON) stated that the expectation was for labs to be drawn as ordered by the physician. The expectation for pharmacist review recommendations was for the physician or the nurse practitioner to bring back any signed recommendations or new orders that resulted from the pharmacist reviews. The DON confirmed that she was unable to locate proof of HgA1c being drawn in October 2024 or January 2025. Additionally, the Unit Managers receive a list of which residents are due for labs from Clinical Laboratory Services (CLS) which generates from standing orders. The DON showed this surveyor an email that she received for October 2024 and January 2025 which did not include R45 for HgA1c. The DON did not know why the order did not trigger with the pharmacy, and the facility had no protocol in place to ensure laboratory monitoring was in place. The DON stated that the facility did not have a policy related to following physician orders or laboratory monitoring. During an interview on 04/17/25 at 2:28 PM with Corporate Compliance Nurse (CCN) confirmed that R45 had orders for HbA1c to be drawn January/April/July/October. CCN confirmed that lab results could not be located to confirm that HbA1c was drawn in October 2024 or January 2025.

Based on staff interview and record review, the facility failed to maintain a complete and accurate medical record for one of 31 sampled residents (Resident (R) 8). Specifically, the facility failed to include the physician order for metoprolol tartrate 25 milligrams (mg) into the electronic medical record (EMR) following a readmission after hospital discharge. This failure had the potential to cause a medication error that could be harmful to the resident. Findings include: Review of R8's Admission Record located in the EMR under the Profile tab indicated R8 was readmitted to the facility on [DATE] with a primary diagnosis of encounter for surgical aftercare following surgery on the circulatory system. Review of R8's Order Summary Report, dated 04/17/25, did not include orders for metoprolol 25mg tablets. An order for gabapentin 100mg capsule, give 2 capsules by mouth twice daily for neuropathy was ordered 08/01/24 and atorvastatin 20mg tablet, give one tablet by mouth every evening for hyperlipidemia was ordered 02/04/25. Review of R8's .Discharge to Acute/Chronic Medical Facility Medication Orders, dated 04/12/25, included metoprolol 25 mg, one tablet to be given by mouth twice daily. During an observation and interview on 04/16/25 at 4:38 PM with Licensed Practical Nurse (LPN) included administration of metoprolol tartrate 25mg. The medication was delivered by the pharmacy in a packet, dated 04/16/25, which included atorvastatin, gabapentin, and metoprolol. LPN1 stated that the resident was recently hospitalized and was on multiple cardiac medications and she knew that R8 had been on metoprolol for a long time. LPN1 stated she would let her Unit Manager (LPN4) know that the medication order was not in the EMR. LPN1 administered metoprolol 25mg without having active orders for the medication. Administration of the medication was not documented in the EMR due to no order triggering documentation after administration. During an interview on 04/17/25 at 10:55 AM with LPN4 confirmed that R8 was recently hospitalized and that the hospital sends the pharmacy the medication orders for packaging and delivery. The hospital sends Discharge to Acute/Chronic Medical Facility Medication Orders document to the facility. LPN4 stated that the protocol was for the nurse readmitting the resident to review the hospital discharge orders, review with the physician, and then transcribe the orders into the EMR. During an interview on 04/16/25 at 5:48 PM with Director of Nursing (DON) stated that R8 recently went to the hospital and was prescribed metoprolol tartrate 25mg oral tablets, give one tab by mouth twice daily, she was discharged from the hospital 04/12/25. Her expectation was for the Unit Manager to fax the pharmacy the medication orders and then the nurse that re-admits the resident puts the orders in the EMR. The DON stated that it appeared that the nurse that did the re-admission failed to add the metoprolol order but should have. During an interview on 04/17/25 at 6:06 PM the DON stated the facility did not have a policy related to complete/accurate medical records

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure infection control was maintained for five of 31 sampled residents (Resident (R) 17, R53, R59, R61, and R84). Specifically, the facility failed to ensure that hand hygiene was completed during medication administration, meal service, and housekeeping tasks. Additionally, a personal drink was on top of the medication cart during medication pass which increased the risk for cross contamination and infections. Findings include: Review of the facility policy titled, Handwashing/Hand Hygiene provided by the facility and revised 08/2019 indicated, This facility considers hand hygiene the primary means to prevent the spread of infections .Use an alcohol-based hand rub .before preparing or handling medications .before handling clean or soiled dressings .after handling used dressings, contaminated equipment .after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . 1. During an observation and interview of medication administration on 04/16/25 at 4:26 PM Licensed Practical Nurse (LPN1) 1 had an open can of soda on top of the medication cart for D Hall. LPN1 confirmed that the soda was hers and that it should not be on top of the medication cart at any time. She said that she just got braces yesterday and her mouth was very sore and dry and that's why she had her drink on the cart. 2. Observation of medication administration pass on 04/16/25 from 5:20 to 5:30 PM with LPN2 revealed the following: At 5:20 PM, LPN2 provided medication to R59 and did not perform hand hygiene after medication administration. At 5:24 PM, LPN2 prepared and administered medications for R84. LPN2 did not perform hand hygiene after administration of medications to R84. At 5:28 PM LPN2, prepared and administered medications for R53. LPN2 did not perform hand hygiene after administration of medications to R53. During an interview on 04/16/25 at 5:30 PM with LPN2, she confirmed that she had not performed hand hygiene between residents receiving medications and should have. She did not give a reason why hand hygiene was not performed. Review of R53's Admission Record located in the Electronic Medical Record (EMR) under the Profile tab, showed an admitted [DATE] with a primary medical diagnosis of alcohol dependence with alcohol-induced persisting dementia. Review of R53's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Review Date (ARD) of 03/01/25 revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating that he was severely cognitively impaired. Review of R59's Admission Record located in the EMR under the Profile tab, showed an admitted [DATE] with a primary medical diagnosis of chronic pancreatitis. Review of R59's annual MDS located in the EMR under the MDS tab with an ARD of 15 revealed a BIMS score of 15 out of 15 indicating that he was cognitively intact. Review of R84's Admission Record located in the EMR under the Profile tab, showed an admitted [DATE] with a primary medical diagnosis of urinary tract infection. Review of R45's quarterly MDS located in the EMR under the MDS tab with an ARD of 0/13/25 revealed a BIMS score of nine out of 15 indicating that he was moderately cognitively impaired. During an interview on 04/17/25 at 5:05 PM with the Director of Nursing (DON) stated that her expectation was for the nurse to perform hand hygiene before medication administration, between residents, and at completion of medication pass. Additionally, staff are not allowed to have personal beverages on the medication cart or at the nurses' station. All food and drinks are to be consumed in the staff break room. The DON stated the facility did not have a policy regarding personal beverages on the medication carts. 3. Review of R61's Admission Record found under the Profile tab of EMR revealed R6 was admitted to the facility on [DATE]. Review of the annual MDS assessment with an ARD of 11/10/24, documented R61 had a score of 15 out of 15 on the Brief Interview for Mental Status and had multiple diagnoses on admission, which included an unstageable chronic wound. Review of the Care Plan, dated 01/10/25, indicated the resident was on Enhanced Barrier Precautions. The posting on the door indicated all staff who enter the room should complete hand hygiene when entering and before leaving the room. Review of the R17's Admission Record revealed an admitted [DATE]. Review of the annual MDS assessment with an ARD date of 11/10/24, indicated the resident was admitted to the facility with a progressive neurological disease, and needed assistance from staff with the Activities of Daily Living (ADL's I.e. Dressing, grooming, hygiene, transfers and eating), but had independent mobility after being transferred to a motorized wheelchair. Review of the Care Plan, dated 01/10/25, indicated the resident was on Enhanced Barrier Precautions. On 04/16/25 at 10:00 AM, Housekeeper (HK) 1, was observed in R61's room cleaning the floor with a floor mop, after completing the task HK1 exited the room, wearing gloves. After placing the mop on the cart, the staff removed the gloves, and obtained another pair of clean gloves, and placed them on. HK1 then obtained a cleaning cloth from a locked cupboard on the cart and a spray bottle. After spraying the cleaning solution on the cloth HK 1 then entered R17's room and begin cleaning the bathroom. Although a sign was hung on R61's door directing any staff that entered the room to complete hand hygiene prior to leaving the room, HK1 did not wash her hands or sanitize them prior to exiting the room. On 04/1625 at 10:10 AM, HK1 was interviewed. When asked about hand hygiene after removing the gloves, she acknowledged the error. On 04/16/25 at 3:20 PM, Licensed Practical Nurse (LPN) 5 was observed preparing to provide wound care for R61. After placing the Personal Protective Equipment (PPE's) on to provide wound care (a gown and gloves), LPN 5 stated he had forgotten supplies. The LPN5 removed the PPE's, exited the room, closed the door, then returned to the room with additional supplies. The staff entered the room, placed a new gown and gloves on without completing hand hygiene, and then completed the dressing change. On 04/16/25 at 5:50 PM, during a follow up interview, LPN5 acknowledged the error and explained hand hygiene should have been completed after reentering R61's room, but it was not.

Based on record review, staff interviews, and review of the facility policy titled, Discharging the Resident the facility failed to complete a recapitulation of stay and discharge summary for one resident (R) R#92 of 11residents discharged from the facility in the last three (3) months. The deficient practice had the potential to affect the continuance of care for R#92 after being discharged from the facility. Findings include: Review of the facility policy titled; Discharging the Resident revised 10/2010 revealed: Documentation-The following information should be recorded in the resident's medical record: 1. The date and time the discharge was made. 2. The name and title of the individuals who assisted in the discharge. 3. All assessment data obtained during the procedure, if possible. R#92 was discharged from the facility on 9/14/2022 with return not anticipated. Diagnoses included but not limited to hypertension, COVID-19, diabetes, chronic kidney disease and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C- Cognitive Pattern: Brief Interview of Mental Status (BIMS) score of 3 indicating very poor cognition; Section G-Functional Status: resident required supervision with bed mobility, transfers, walking, eating and locomotion; extensive assistance with dressing, toileting, personal hygiene, and bathing. Review of R#92's care plans revealed resident will be long term. Review of the electronic medical record (EMR) Department Notes revealed a note dated 9/14/2022 at 8:53 a.m. indicating R#92 left facility via transport with belongings and medications. Review of the EMR Department Note dated 9/8/2022 revealed the Social Worker (SW) started discharge planning with the residents' daughter. Review of the EMR and the physical paper chart revealed no order to discharge resident, no recapitulation of stay and no discharge summary. The Director of Nursing (DON) later produced a Telephone Order dated 9/14/2022 that revealed Discharge resident to another facility, continue medications and treatments as ordered. An interview on 12/14/2022 at 10:52 a.m. with the DON revealed she verified the EMR, and the physical paper chart did not contain a recapitulation of stay or a discharge summary. She indicated the nurses are responsible for writing an order to discharge a resident. She indicated they do not do a recapitulation of stay or a discharge summary. An interview on 12/15/2022 at 11:46 a.m. with the facility SW and the Administrator both revealed they do not do a recapitulation of stay or a discharge summary. The SW indicated she chart notes in the medical record indicating discharge planning and she makes a follow up call after discharge.

Based on observations, record review, staff interviews and review of the facility policy titled, Medication Monitoring and Management, the facility failed to ensure that a psychotropic medication was not ordered as needed (PRN) for more than 14 days unless clinically indicated for one (1) resident (R) R#33 of five (5) residents reviewed for unnecessary medications. Specifically, the facility failed to ensure that there was a stop order date for Klonopin prescribed for R#33. Finding include: Review of the facility policy titled, Medication Monitoring and Management effective 5/1/2020 revealed: A. 6) As needed (PRN) orders include an indication for use. a. If the PRN medication is used to modify behavior, the indication for use is clearly defined in objective terms, what specific symptom is being addressed. b. The resident is monitored for the effectiveness of the medication or possible adverse consequence. the results are documented in the medical record. Diagnoses for R#33 included but not limited to upper respiratory infection, ortho aftercare, weight loss, atrial fibrillation, left knee osteoarthritis and dementia. Review of the Annual Minimum Data Set (MDS) for R#33 dated 10/26/2022 revealed Section C-Cognitive Pattern: Brief Interview of Mental Status (BIMS) score of three (3) indicating poor cognition; Section D-Mood: Mood score of 1; Section E-Behavior: behaviors not directed to others: Section N-Medications: resident received an antipsychotic, antidepressant, antianxiety seven (7) during the 7-day look back period. Review of the Care Plan for R#33 dated 10/31/2022 revealed (partial list): Dementia-At risk for side effects related to use of psychotropic medications Resident is at risk for altered cognition related to diagnosis of dementia with behaviors, agitation, and restlessness. Resident is at risk for mood state issues related to dementia with behaviors, agitation, and restlessness. Resident exhibits inappropriate behaviors due to cognitive loss, poor insight and decreased judgement related to diagnosis of dementia with behaviors, agitation, and restlessness. Resident is at risk for side effects and complications related to the use of psychotropic medications. Review of R#33's December 2022 Physician Orders (partial list) revealed an order for: Klonopin (clonazepam) 0.5 milligrams (MG) tablet give 1 tablet by mouth (PO) at bedtime (HS) PRN, ordered 11/14/2022. Order did not include a diagnosis, indication for use or a stop date. Observations made of R#33 throughout the Recertification /survey revealed no behavioral concerns. An interview held on 12/15/2022 at 11:09 a.m. with the Director of Nursing (DON) revealed the Pharmacist comes to the facility monthly. He makes recommendations. Those recommendations are reviewed by the Nurse Practitioner (NP). After she reviews the recommendations, she will write an order if changes are made. She verified the Klonopin order did not have an indication for use or a stop date.

Based on observations, interviews, record reviews, and facility documents the facility failed to test residents and staff for the COVID-19 virus the required number of times per week based on recommendations from the Centers of Disease Control (CDC), The Centers for Medicare and Medicaid (CMS) and the level of community transmission rates. The facility was considered in an Outbreak Status starting on December 28, 2021 and had a community transmission rate above the 10% . This deficient practice affected five of five residents (R#1, R#10, R#11, R#12, and R#13) sampled and five of five staff sampled. Findings include: Review of facility document titled QSO Memo 20-38-NH: Complying with 483.80(h) Testing of Staff and Residents Regulations dated 4/30/21 revealed the following: Testing Frequency: Outbreak Testing: Test all staff and residents, regardless of vaccination status, in response to an outbreak (defined any single new infection in staff or any nursing home onset infection in a resident). Continue to test all staff and residents that tested negative every three days to seven days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive test result. Routine Testing: Test all except fully vaccinated staff based on the extent of the virus in the community and should use the county positivity rate in the prior week as the trigger for staff testing frequency. If the county positivity increases to a higher level of activity, the facility should immediately adjust to that testing frequency. If the county positivity rate in the past week was high (greater than 10%) there should be a minimum of twice a week testing. A Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] Week of 12/27/21 was 11.70%, which required testing two times per week. Week of 1/3/22 was 17.90%, which required testing two times per week. Week of 1/10/22 was 29%, which required testing two times per week. Week of 1/17/22 was 39.50%, which required testing two times per week. Week of 1/24/22 was 38.10%, which required testing two times per week. Week of 1/31/22 was 34.505%, which required testing two times per week. Week of 2/7/22 was 26.20%, which required testing two times per week. Week of 2/14/22 was 18.62%, which required testing two times per week. A sample of five residents was chosen to review for the required number of testing dates, per the community transmission rate and Outbreak Status of the facility beginning December 28, 2021. 1. R#1 admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#1's COVID-19 testing schedule for the Outbreak period beginning 12/28/21 revealed the following missing tests: The week of 12/26/21-1/1/22 R#1 was tested on [DATE]. The week of 1/2/22-1/8/22, R#1 was tested on [DATE]. The week of 1/30/22-2/5/22, R#1 was tested on [DATE]. The week of 2/6/22-2/12/22, R#1 was tested on [DATE]. R#1 missed a total of four tests during the current COVID-19 Outbreak period in the facility. 2. R#10 admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#10's COVID-19 testing schedule for the Outbreak period beginning 12/28/21 revealed the following missing tests: The week of 12/26/21-1/1/2022, R#10 was tested on [DATE]. The week of 1/2/22-1/8/22, R#10 was tested on 1/3/22. R#10 tested positive for COVID on 1/31/22. R#10 missed a total of two tests during the current COVID-19 Outbreak period in the facility. 3. R#11 admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#11's COVID-19 testing schedule for the Outbreak period beginning 12/28/21 revealed the following missing tests: The week of 12/26/21- 1/1/22, R#11 was tested on [DATE]. The week of 1/2/22-1/8/22, R#11 was tested on [DATE]. R#11 tested positive for COVID on 1/25/22. R#11 missed a total of two tests during the current COVID-19 Outbreak period in the facility. 4. R#12 admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#12's COVID-19 testing schedule for the Outbreak period beginning 12/28/21 revealed the following missing tests: The week of 12/26/21-1/1/22, R#12 was tested on [DATE]. The week of 1/2/22-1/8/22, R#12 was tested on [DATE]. Resident #12 tested positive for COVID-19 on 1/28/22. Resident #12 missed a total of two tests during the current COVID-19 Outbreak period in the facility. 5. R#13 admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#13's COVID-19 testing schedule for the Outbreak period beginning 12/28/2021 revealed the following missing tests: The week of 12/26/21- 1/1/22, R#13 was tested on [DATE]. The week of 1/2/22-1/8/22, R#13 was tested on [DATE]. The week of 1/30/22-2/5/22, R#13 was tested on [DATE]. Resident #13 tested positive for COVID-19 on 2/8/2022. Resident #13 missed a total of three tests during the current COVID-19 Outbreak period in the facility. A sample of five staff was chosen to review for the required number of testing dates, per the community transmission rate and Outbreak Status of the facility beginning December 28, 2021. 6. Review of Team Member AA's COVID-19 testing schedule for the Outbreak period beginning 12/28/21 revealed the following missing tests: The week of 1/2/21-1/8/22, Team Member AA was tested on [DATE]. missing one test. The week of 2/6-2/12/22, Team Member AA was tested on [DATE]. missing one test. Team Member AA had a total of two missing tests during the current COVID-19 Outbreak period in the facility. 7. Review of Team Member BB's COVID-19 testing schedule for the current Outbreak period revealed the following missing tests: The week of 1/9/21-1/16/22, Team Member BB tested on [DATE]. The week of 1/23/22-1/29/22, Team Member BB tested on [DATE]. The week of 1/30-2/5/22, Team Member BB was not tested . missing two tests. Team Member BB had a total of four missing tests during the current COVID-19 Outbreak period in the facility. 8. Review of Team Member CC's COVID-19 testing schedule for the current Outbreak period in the facility revealed the following missing tests: The week of 1/2/22-1/8/22, Team Member CC was tested on [DATE]. missing one test. The week of 1/23-1/30/21, Team Member CC was tested on [DATE]. missing one test. Team Member CC tested positive for COVID on 1/31/22. Team Member CC had a total of two missing tests during the current COVID-19 Outbreak period in the facility. 9. Review of Team Member PP's COVID-19 testing schedule for the current Outbreak period in the facility revealed the following missing tests: The week of 1/2/22-1/8/22, Team Member PP was tested on [DATE]. The week of 1/9/22-1/15/22, Team Member PP was not tested . The week of 1/16-1/22/22, Team Member PP was not tested . The week of 1/23-1/29/22, Team Member PP was tested on [DATE]. The week of 1/30/22-2/5/22, Team Member PP was not tested . The week of 2/6-2/12/22, Team Member PP was not tested . Team Member PP had a total of 10 missing tests during the current COVID-19 Outbreak period in the facility. 10. Review of Team Member QQ's COVID-19 testing schedule for the current Outbreak period in the facility revealed the following missing tests: The week of 1/2/22-1/8/22, Team Member QQ was tested on [DATE]. The week of 1/23/22-1/30/22, Team Member QQ was tested on [DATE]. The week of 1/30-2/5/22, Team Member QQ was tested on [DATE]. Team Member QQ had a total of six three missing tests during the current COVID-19 Outbreak period in the facility. Interview on 2/14/22 at 2:46 p.m. with the Infection Preventionist revealed that staff should be and are being tested twice a week. It was further reported that the facility remains in outbreak testing status at this time. During interview on 2/25/22 at 10:27 a.m. with the Infection Preventionist who confirmed that the sampled residents and staff were not tested appropriately.

Based on observation, record review, staff and resident interviews, facility staff failed to provide supervision and assistance for one of 11 residents reviewed for accidents. Actual harm occurred when R#2 sustained [CONDITION(S)] to his right thigh after spilling coffee on himself when he was allowed to self-transport hot coffee via wheelchair without staff assistance. Findings include: 1. Record review of the medical record for R#2 documented an admitted [DATE]. R#2 was admitted with the following diagnoses polyneuropathy diseases classified elsewhere, [CONDITION(S)] disease classified elsewhere, [NAME] Disease, hypertension. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. It also indicated R#2 required supervision for eating. Record review of a nurse note, for R#2, dated 3/24/2021 at 4:19 p.m. documented Resident went to the kitchen to get a cup of coffee. Resident got back to his room and spilled his coffee in his lap. Upon assessment resident's R (right) lateral thigh is red and resident has two blisters that have busted. Resident was told that he needed to go to hospital to get checked out. Resident refused to go out to hospital. Resident stated please just treat me here. Resident was encouraged and treated. (sic) Record review of a physician order, for R#2, dated 3/25/2021 documented Cleanse burn right lateral thigh with NS (normal saline) or wound cleanser. Pat dry. Apply [MEDICATION(S)] ([MEDICATION(S)] cream) to wound, cover with ABD pad (Highly Absorbent Dressing pad) held in place with cling (cling wrap) Daily. Record review of a nurse note, for R#2, dated 3/25/2021 at 10:56 a.m. documented Resident burn wounds measures about 17cm (centimeter) x 2.2 cm with multiple intact blisters and [CONDITION(S)]. Blister at distal aspect of burn open with pink base measures 6 cm x 3.5 cm. NO (new order) obtained to cleanse wound with NS or wound cleanse, pat dry, apply [MEDICATION(S)] to wound cover ABD held in place with cling. Dressing completed as ordered with resident tolerating well. Will continue to monitor and update as needed. Record review of physician follow up appointment for second degree burn dated 4/16/2021 documented right lateral thigh front-burn 6.00 (cm) x 13.00 (cm) x 0.10 (cm) burn. Record review of document titled, Wound Assessment Report dated 3/31/2021 documented wound identified 3/24/2021, wound type-burn, wound location-right lateral thigh front, cause-accident, burn type-scald, wound description-blisters, measurements 7.00 x 14.00 x 0.10, and date wound resolved 5/3/2021. Interview on 5/18/2021 at 12:01 p.m. with Charge Nurse, LPN CC revealed that R#2 was often observed transporting his coffee via wheelchair with the coffee mug wedged between his upper thigh in his wheelchair. LPN CC reported that she had not considered this type of behavior as a safety issue or a risk for burn. Interview on 5/18/2021 at 1:31 p.m. with the Director of Nursing (DON) revealed that she was unaware that R#2 was transporting coffee in his wheelchair. DON reported that she immediately educated the staff after R#2 sustained a second degree burn from the hot coffee. The DON stated that her expectations were for staff to immediately intervene in any situation that would result in an injury or harm to a resident. Interview on 5/19/2021 at 1:49 p.m. with the Dietary Manager (DM) revealed that any resident who desired to receive coffee in the dining area, dietary staff are to transport coffee to a table and set up the coffee for the resident. Interview on 5/20/2021 at 1:02 p.m. with DA LL confirmed that she could not recall if she was the person who gave the coffee to R#2 on 3/24/2021. However, she had given the resident coffee before without setting the coffee on the table for him. DA LL reported that she had observed R#2 transferring coffee in his wheelchair while propelling out of the kitchen area. Previously she would hand resident the coffee mug through the kitchen door and R#2 would transport the coffee in his wheelchair. DA LL stated that she did not consider R#2 transferring the coffee in his wheelchair as a safety issue until after he sustained a burn from the hot coffee spill.

Based on resident interviews, staff interviews, and review of the facility staffing/assignment sheets, review of the facility census, review of the facility 's Staffing Roster and form titled, Online Time and Attendance (Payroll detail), and review of the Facility Assessment Tool the facility failed to ensure sufficient staffing to provide quality of care to meet the needs of the residents. This deficient practice had the potential to affect all 99 residents in the facility. Findings include: Record review of the facility assessment document titled Facility Assessment Tool, the document stated The tool is organized in three parts (1). Resident profile including numbers, diseases conditions, physical and cognitive disabilities, acuity and ethnic/cultural/religious factors that impact care. 2. Services and care offered based on resident needs (includes types of care your resident population requires, (3) Facility resources needed. A facility based and community-based risk assessment . (2) Guidelines for Conducting the Assessment (2). While a facility may include input from its corporate organizations, the facility assessment must be conducted at the facility level. Responses: In house staffing needs vary by acuity and census. Facility can staff halls/unit based off census and acuity which change daily related to new admission, hospital returns and discharges., DON (Director of Nursing), Unit Manager, and/r Supervisors assess acuity needs as needed related to change of condition to resident needs and changes in the census. Record review of the facility document titled Glenvue Health & Rehabilitation Staffing Roster and form titled Online Time and Attendance (Payroll detail) documented the following assignments and insufficient coverage for Certified Nursing Assistant Staff (CNA) on the 11-7 shift for Unit 1 (adjoining halls, Hall A and Hall B) unit 2 (adjoining halls, Hall C, D, and E) and Unit 3 (adjoining halls Hall F and Hall G). 1. On 1/30/2021 there were four CNAs to cover six halls with a census of 97 residents resulting in insufficient CNA coverage on Hall A. 2. On 2/19/2021 there were four CNAs to cover six halls with a census of 97 residents with no CNA coverage on Hall A. 3. On 3/14/21 there were three CNA's to cover six halls with a census of 98 residents resulting in a lack of coverage on Hall A, Hall B, Hall C, Hall D, Hall E, Hall F, and Hall G. 4. On 5/20/2021 there were three CNA's to cover six halls with a census of 98 residents resulting in a lack of coverage on Hall A, Hall B, Hall C, Hall D, Hall E, Hall F, and Hall G. Further record review of the facility payroll dated for 1/30/2021 documented a total of only four CNAs working in the entire building with a census of 97 residents. (2). On 2/19/2021 there were no assigned CNAs to cover Hall A and Hall B (the adjoining hall) for the 11:00 p.m. to 7:00 a.m. shift. The assigned charge nurse, LPN BB was alone on the hall for a total of six hours (per an eight-hour shift) without any CNAs assistance to pass medications, monitor the safety of the residents and to provide patient care for a total of 23 residents. Record review revealed that there was a total of six residents out of the 23 residents requiring total care (repositioning, turning, transfer, incontinent care) and three newly admitted residents on quarantine on A Hall for monitoring for Covid signs and symptoms. It was also noted that R#3, a newly admitted resident required monitoring and supervision to prevent a fall due to confusion and several attempts to try to get out of bed only received a total of approximate two hours of assistance from CNAs. At 2 a.m. two CNAs (CNA DD and CNA GG) made rounds for incontinent care for approximate one hour of services and returned to their assigned halls. At 4:00 a.m. two CNAs (CNA HH and CNA QQ) made rounds for incontinent care for approximately one hour of services and returned to their assigned halls. In addition, record review revealed that there was only four CNA's working in the entire facility to cover six of six halls with a census of 97 residents. Interview on 5/18/2021 at 6:35 a.m. with CNA HH who confirmed making rounds to provide incontinent care only once during the night on Hall A and Hall B (due to no CNAs coverage on the hall) on 2/19/2021. She reported arriving on the Hall with CNA QQ at 4:00 a.m. They both stayed on the hall for approximately one hour to provide peri care and incontinent care to the residents. Interview on 5/19/2021 at 9:20 a.m. with LPN BB reported that a call was made to the Director of Nursing (DON) and was informed by DON to work with what they have. LPN BB reported that she felt the residents on Hall A and Hall B were unable to receive adequate care due to her inability to monitor the residents and ensure everyone who needed incontinent care received quality care. LPN BB further reported that it was difficult to work both A Hall behind closed doors and provide visual monitoring observation and on B Hall. Interview on 5/20/2021 at 6:44 a.m. with CNA GG who confirmed making rounds to provide incontinent care only once during the night on Hall A and Hall B (due to no CNAs coverage on the hall). She stated that she and CNA only assisted for one hour and returned to their assigned halls (Hall F and Hall G). Interview via phone on 5/26/2021 at 3:38 p.m. with CNA DD who confirmed that she and CNA GG were assigned to Hall F and Hall G. They were asked to make rounds on Hall A and Hall B (due to no CNA coverage on the hall) on 2/19/2021 to assist with providing incontinent care. They both arrived on the hall at 2:00 a.m. and only stayed on the hall for an hour. CNA DD reported that she recalls R#3 (who was on A Hall) displaying behaviors of confusion and attempting to try to get out of bed without assistant. CNA DD stated after arriving on the hall, LPN BB was coming off of A Hall and stated that there was no one on the hall to monitor B Hall. CNA DD also stated that LPN BB informed her that R#3 was trying to get out of bed, and she was trying to monitor her to prevent her from falling. CNA DD stated that she was concern that some residents may be soiled and did not receive adequate peri care and incontinent care. She recalled R#25 being completely soiled with urine that they had to change all of R#25's linen on his bed. (3). On 5/14/2021, Hall C, Hall D, and Hall E which was considered as Unit 2 assignment sheet documented only one certified nursing assistant. CNA HH was assigned to the three halls mentioned to provide care to a total census of 36 residents on the halls. In addition, payroll record review revealed that on 5/14/2021 there were only three CNAs working in the entire facility to cover six of six halls for a census of 98 residents on the 11:00 p.m. to 7:00 a.m. shift. Record review of each resident Minimum Data Set (MDS) and interview from staff interviews concluded that a total of 19 residents required ADL care with transfer, repositioning, and incontinent care. This included R# 25 and R# 26 on C Hall; R#27, R#28, R#29, R#30, R#31, R#32, R#33, R#34, and R#35 on D Hall; and R#36, R#38, R#39, R#40, R#41, R#42, R#43, and R#44 on E Hall. The MDS assessments for these residents are listed below: R#25's Quarterly MDS assessment dated [DATE] revealed extensive assistance with bed mobility and bathing requiring two-person physical assist, and total dependence with transfer and toilet use. The assessment also revealed that R#25 was always incontinent of bowel and bladder and had a Brief Interview of Mental Status (BIMS) of 12 which indicated moderately impaired cognition. R#26's Quarterly MDS assessment dated [DATE] revealed extensive assistance bed mobility, transfers, and bathing requiring two-person physical assist with total dependence needed with toilet use. The assessment revealed that R#26 was always incontinent of bowel and bladder and had a BIMS of 3 which indicated severely impaired cognition. R#27's Annual MDS assessment dated [DATE] revealed extensive assistance with bed mobility and transfer requiring two-person physical assistance and total dependence for toilet use and bathing with two-person physical assistance required. The assessment revealed that R#27 was always incontinent of bowel and bladder and had a BIMS of 3 which indicated severely impaired cognition. R#28's Admission MDS assessment dated [DATE] revealed total dependence with two-person physical assist for bed mobility, transfers, toilet use, and bathing with two-person physical assist required. The assessment also revealed that R#28 is always incontinent of bowel and bladder with inability to assess BIMS due to cognition deficit. R#29's Quarterly MDS assessment dated [DATE] revealed total dependence for transfer, toilet use, and bathing and extensive assist with bed mobility all of which requires two-person physical assist. The assessment also revealed that R#29 is always incontinent of bowel and bladder with a BIMS of 9 indicating severely impaired cognition. R#30's Quarterly MDS assessment dated [DATE] revealed extensive assist with transfer and bed mobility requiring two-person physical assist. It further revealed total dependence for toilet use with two-person physical assist required and total dependence for bathing with one-person physical assist required. R#30 was assessed as always incontinent of bowel and bladder with a BIMS of 3 indicating severely impaired cognition. R#31's Quarterly MDS dated [DATE] revealed extensive assistance with bed mobility, transfer, and toilet use with 1-person physical assistance. It further revealed physical help with bathing requiring one-person physical assist and is frequently incontinent of bowel and bladder with inability to assess BIMS due to cognition deficit. R#32 's Significant Change MDS dated [DATE] revealed extensive assistance with two-person physical assist with bed mobility. It further revealed total dependence with two-person physical assist with transfer and toilet use, with one-person physical assistance with bathing. R#32 was assessed as always incontinent of bowel and bladder R#33's Quarterly MDS assessment dated [DATE] revealed extensive assistance with transfer and bed mobility requiring two persons physical assist and total dependence for toilet use and bathing with two persons physical assist. It further revealed R#33 was assessed as always incontinent of bowel and bladder with a BIMS of 13 indicating intact cognition. R#34's Quarterly MDS assessment dated [DATE] revealed total dependence with toileting and bathing with 2-persons physical assist, extensive assistance with bed mobility and transfer with 2-persons physical assist, always incontinent of bowel and bladder, and BIMS of 15 indicating intact cognition. R#35's Annual MDS assessment dated [DATE] revealed total dependence of toilet use, transfer, and bathing requiring two-persons physical assist, extensive assistance of bed mobility with two-persons physical assist, always incontinent bowel and bladder, and BIMS of 7. R#36's Quarterly MDS assessment dated [DATE] revealed total dependence of bed mobility, transfer, and toilet use with two-persons physical assist, always incontinent bowel and bladder, and BIMS of 10 indicating moderately impaired cognition. R#38's Quarterly MDS assessment dated [DATE] revealed limited assistance with one-person physical assistance for bed mobility, extensive assistance with one-person physical assist with transfer and toilet use, total dependence with bathing with one-person physical assist, occasionally incontinent with bladder, and always continent of bowel, and BIMS of 8 indicating moderately impaired cognition. R#39's Admission MDS assessment dated [DATE] revealed extensive assistance with transfer with two-persons assist, extensive assistance with bed mobility and toilet use with one-person assist, total dependence for bathing with one-person physical assist, and BIMS of 7 indicating moderately impaired cognition. R#40's Quarterly MDS assessment dated [DATE] revealed extensive assistance of bed mobility with two persons physical assist, total dependence of transfer, toilet use, and bathing with two-person physical assist, frequently incontinent of bladder and occasionally incontinent of bowel, and a BIMS score of 15 indicating intact cognition. R#41's Quarterly MDS assessment dated [DATE] revealed total dependence for bed mobility, transfer, and bathing with two-persons physical assist, extensive assistance with toilet use with two-persons physical assist, always incontinent of bowel and bladder, and a BIMS of 8 indicating moderately impaired cognition. R#42's Admission MDS assessment dated [DATE] revealed total dependence for bed mobility, transfer, toilet use, and bathing with two-persons assist, always incontinent of bowel and bladder, and BIMS unable to assess to score due to severe impaired cognition. R#43's Annual MDS assessment dated [DATE] revealed total dependence for transfer and bathing with two-persons assist, extensive assistance for bed mobility and toilet use with two-persons assistance, always incontinent of bowel and bladder, and BIMS of 15 indicating intact cognition. R#44's Annual MDS assessment dated [DATE] revealed total dependence for toilet use and bathing with two-persons assist, extensive assistance for bed mobility with two-persons physical assist, transfer only occurred once or twice but required two-persons physical assist, always incontinent of bowel and bladder, and BIMS of 15 indicating intact cognition. Interview on 5/19/2021 at 6:45 a.m. with CNA HH who stated that it is common to work short of help for the past six to seven months. Management is telling staff that they just have to deal with it. On 3/14/2021, she worked alone on her shift without any CNAs assistance providing care to thirty-six residents. She reported being unable to provide quality care to the residents. She had a total of 18 total care residents out of 36 residents. She was not able to give baths to residents on the halls who needed bed baths due to the shortage of help. Interview on 5/19/2021 at 9:02 a.m., LPN OO reported that CNA HH worked on 5/14/2021 short of help and this has been a problem with Hall C, Hall D, and Hall E for the past seven months. Most of the time, certified nursing assistants will not show up for work. DON and on call staff will tell the charge nurse to just work with what you have. This also occurs not only on the 11 p.m. to 7 a.m. shift but the weekend 3 p.m. to 11 p.m. shift. LPN OO reported it is hard to pass medications and monitor the resident care needs with only one CNA. There are residents who required monitoring and care due to routine tube feedings. In her attempts to help the CNAs, this can sometimes drastically affect med pass times due to having to help the only CNA on the hall to turn and reposition and provide incontinent care. 4. Record review of the Minimum Data Set (MDS) and interview with random nursing and direct care service staff revealed that on 5/20/2021 there were only three CNAs to cover six halls with a census of 98. Only had one certified nurse assistant, CNA RR for Hall F and Hall G. The total hall census for Hall F and Hall G was 27 residents. A total of six residents on Hall G requiring total assist with transfer, incontinent care, and repositioning (R#14, R#57, R#6, R#7, R#18, R#9), and 11 residents (R#10, R#11, R#12, R#15, R#17, R#18, R#19, R#20, R#21, R#22, R#23) on F Hall residents requiring total assist with either all or one or more with ADL care such as transfer, repositioning, and incontinent care. Four of the residents on F Hall (R#13, R#14, R#16, R#24)) requires monitoring for either wandering/elopement risk or risk of falls. The following residents' MDS assessments are listed below: R#4's Quarterly MDS dated [DATE] documented a need for extensive assistance with bed mobility with two persons assist, total care for bath, extensive assistant for transfer and toileting with one person assist, frequently incontinent of bladder and always incontinent of bowel, and a BIMS of 12 which indicated intact cognition. R#5's Quarterly MDS dated [DATE] documented extensive assistance with bed mobility requiring one-person assist, total dependence for transfer and toileting requiring two-persons assist, always incontinent of bowel and bladder, and a BIMS of three indicating severely impaired cognition. R#6's Quarterly MDS dated [DATE] documented extensive assistance with bed mobility requiring two-persons assist, transfer-did not occur but requires two-persons assist, total dependence for toileting and bathing requiring two-persons assist, always incontinent of bowel and bladder, and a BIMS of three indicating severely impaired cognition. R#7's Admission MDS dated [DATE] documented extensive assistance with bed mobility and transfer requiring two-persons physical assist, total dependence for toileting and bathing requiring two-persons physical assist, always incontinent of bowel and bladder, and a BIMS of four indicating severely impaired cognition. R#8's Quarterly MDS dated [DATE] documented total dependence with transfer and bathing requiring two-persons physical assist, extensive assistance with bed mobility and toilet use requiring two-persons physical assist, always incontinent of bowel and bladder, and a BIMS of 12 indicating moderate cognition impairment. R#9's Quarterly MDS dated [DATE] documented extensive assistance with bed mobility requiring one-person assist, extensive assistance with transfer and toilet use requiring two-persons assist, total dependence for bathing requiring two-persons physical assist, incontinent care for catheter and always incontinent of bowel, and a BIMS of 15 indicating intact cognition. R#10's Quarterly MDS dated [DATE] documented extensive assistance with bed mobility requiring two-persons physical assist, extensive assistance with transfer and toilet use requiring one-person physical assist, total dependence for bathing requiring one-person physical assist, always incontinent of bowel and bladder, and BIMS of eight indicating moderately impaired cognition. R#11's Quarterly MDS dated [DATE] documented total dependence for transfer and bathing requiring two-persons physical assist, extensive assistance with bed mobility and toilet use requiring two-persons physical assist, always incontinent of bowel and bladder, and a BIMS of eight indicating moderately impaired cognition. R#12's Quarterly MDS dated [DATE] documented total dependence for transfer, toilet use, and bathing requiring two-persons physical assist, always incontinent of bladder and has an ostomy for bowel, and a BIMS of 12 indicating moderately impaired cognition. R#13's Admission MDS dated [DATE] documented total dependence for bathing requiring one-person physical assist, wandering behaviors requiring supervision with locomotion's on and off the unit, and a BIMS of 3 indicating severely impaired cognition. R14's Annual MDS dated [DATE] documented total dependent for transfer-2 person assist, extensive assist with bed mobility-2 person assist, extensive bath and toileting-1 person assist, always incontinent of bowel and bladder, BIMS score 14 cognitive intact, vision moderately impaired with limited vision. R15's Quarterly MDS dated [DATE] documented a BIMS score of 14 cognitive intact, total assist for transfer, bath, and toileting- 2 persons assist, extensive assist bed mobility-2 persons assist, always incontinent of bowel and bladder. R16's Quarterly MDS dated [DATE] documented extensive assist toileting-1 person assist, supervision with locomotion on and off unit, total dependent for bathing-1 person assist, frequently incontinent of bowel and bladder, (in addition R16 was assessed on Quarter MDS dated [DATE] for wandering behaviors) and a BIMS score of 12. R17'sAnnual MDS dated [DATE] documented total dependent for transfer, bathing, and toileting-2 persons assist, extensive assist for bed mobility -2 persons assist, always incontinent of bowel and bladder, and a BIMS score of 14- cognitive intact. R18's Quarterly MDS 4/5/2021 documented total dependent for transfer, bed mobility, toileting, and bath-2 persons assist, always incontinent of bowel and bladder, BIMS score -unable to assess -severely cognitive impaired, assess for Feeding tube). R19's Significant Change MDS 5/6/2021 documented total dependent for transfer, bath, and toilet use-2 persons, extensive assist bed mobility-2 persons assist, always incontinent of bowel and bladder, and a BIMS score -unable to assess severely cognitive impaired. R20's Quarterly MDS 4/12/2021 documented extensive assist for bed mobility, transfer, toileting -2 persons assist, total dependent for bath -2 persons assist, always incontinent of bowel and bladder, and a BIMS score of 5 -severely cognitive impaired. R21Quarterly MDS 4/7/2021 -Total dependent for transfer and bath-2 persons assist, extensive asst with transfer and toileting-2 person assist, always incontinent of bowel and bladder R22-Annual MDS 3/22/2021-Extensive dependent for bed mobility-2 persons assist, transfer did not occur-2 person assist, total dependent for toileting-1 person assist, total dependent for bath-2 persons assist, always incontinent of bowel and bladder, and a BIMS score of 7 -cognitive moderately impaired R23's Quarterly MDS dated [DATE] documented extensive assist with bed mobility, toileting-1 person assist, supervision with transfer-1-person, total dependent for bath-2 person assist, occasional incontinent of bladder and always incontinent of bowel, impairment with lower extremities, and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R24 's Quarterly MDS dated [DATE] documented limited assistant -1 person assist, supervision toileting-1 person assist, impairment on both sides lower extremity, obesity, walker and wheelchair use, frequently incontinent of bladder and always incontinent of bowel, and a BIMS score of 7 moderately impaired. Interview on 5/20/2021 at 4:21 p.m. with LPN MM who stated that only one certified nursing assistant, CNA RR was on duty to provide care to 28 residents on 5/20/2021. There was a total of three CNAs in the building on 5/20/2021. They were informed as always before to work with what they have. LPN MM reported that this shortage of CNA coverage has occurred often for the past eight months. Interview with R#17 on 5/21/2021 at 12:16 p.m. revealed that she wears a brief and staff is usually late changing her due to shortage of CNA coverage on the hall. She has complained to the new and former DON about the lack of care services. She stated that the CNA or the nurse will report to her when they (the CNAs) are working alone without help. Interview with the DON on 5/20/2021 at 2:15 p.m. the facility staffing practice is determined by their Facility Assessment. Hall A and Hall B staffing requirements are to staff CNAs based on the resident census. Unit Hall 2 (Halls C, D, & E) staffing requirements is two CNA's. Unit Hall # (Hall F and G) requirements are to staff two CNA's for a census of 28 residents. However, she did feel that the acuity of resident care or any resident having a fall risk as reason to staff more than one or two CNAs on a hall for 11 p.m. to 7 a.m. shift. The DON further stated that she was unaware that there was a shortage of CNA coverage on 3/14/2021 and 5/20/2021. As for 1/30/2021 and 2/19/2021, she was not serving in the position as DON and could not speak on the staffing for those days. Interview on 5/19/2021 at 11:13 a.m. with the Business Manager revealed that she was aware of the CNA shortage and call outs. She reported that she is responsible for the timecards and the time sheet payroll is a true picture of who worked the shifts. She confirmed that she has had to come in to work as a CNA on several occasions due to call outs and no coverage and she still has her CNA certification. Interview on 5/21/2021 at 1:23 p.m. with R#43, with a BIMs score of 15, reported wears brief have to wait at least over 2 hours one night and one Saturday to be changed. Interview on 5/21/21 at 1:24 p.m. with R#21 with a BIMs score of 15 on F and G Hall stated that she has to wait for care to be provided. R#21 reported that this has been mentioned in resident council meetings. R#21# also stated that she has spoken with DON, and nothing is being done. R21 reported that on more than two occasions during the month F and G Hall always have one CNA on the hall on late night shift and weekend. It was further reported that this shortage of CNAs has been occurring for a few months. Interview on 5/21/2021 at 1:25 p.m. with R#17, with a BIMs score of 15, revealed she is having to wait for assistance with incontinent care. R#17 reported that CNAs are saying they are short of help, and they will tell her that they are the only one working. R#17 reported that she has complained about not being changed timely. Interview on 5/21/21 at 1:26 p.m. with R#45, with a BIMs score of 15, revealed having to wait on meds until 11:30 at night to get meds. She reported that LPN MM always tells her that she had only one CNA and could not give meds timely because she is trying to answer the phone, help the CNA, and work as a CNA as well as a nurse. Interview on 5/21/21 at 1:27 p.m. with R#46, with a BIMs score of 12 (moderately cognitively impaired but able to answer questions appropriately) revealed that she wears briefs and is independent for toileting. She stated that she uses the bedside commode and has a [CONDITION(S)] bag. R#46 stated that sometimes due to shortage on evening and night shift there is no help with emptying her [CONDITION(S)] bag. R#46 reported that if her call light is not answered and she is not feeling weak, she changes it for herself. Interview on 5/21/21 at 1:33 p.m. with R#15, with a BIMs score of 14 revealed that she has received her medications late and has to wait a long time to receive medications. She has spoken with the Unit Manager and DON on several occasions. She reported that it sometimes times takes hours for the nurse to bring her as needed (PRN) medications when requested. She reported that one night she asked for the med and had to wait to after 11 pm to get her meds. She also stated that her roommate has to wait long periods of time to be changed. They both had to sit in urine for a long time one night (last night 5/20/2021) because only had one CNA working. She thinks that they have filed written complaints (facility grievances) in the past. Interview on 5/21/2021 at 2:13 p.m. with the Administrator who confirmed being unaware of the certified nursing assistant shortage. The Administrator reported that his expectations are to have staff coverage for all halls based on the Facility Assessment Staffing procedures. He did state that a few months ago, the facility had posted a hiring advertisement for the surrounding areas for nurses and CNA's. Interview on 5/22/2021 at 3:01 p.m. with CNA RR who verified that she was the only CNA working on the hall. She could not provide timely care to all the residents who required incontinent care. The nurse could not assist as much. This has happened on several occasions. CNA further stated that on call supervisor was contacted and staff were informed to work with what they have. Interview with 6/18/2021 at 11:30 a.m. with CNA UU who stated that still have to pull a double shift to keep from having short coverage now and work on 11p.m. to 7 a.m. shift at times and other weekend shifts. They were informed to help out with other shifts especially the night shift. The new CNAs who were hired have quit and they are still short for coverage. She feels that the lack of certified nursing assistant coverage does impact her ability to provide quality care to the resident. CNA UU reported that there is no way you can change all those resident every 2 hours and reposition residents. Interview 6/29/2021 at 10:01 a.m. with CNA VV who stated that she is still helping out on her off days when they are short. Staff is calling out on the weekend and nightshift. CNA VV reported that she has not seen any new CNA staff working. Interview on 6/29/2021 at 12:03 p.m. with LPN PP who stated the facility still has a shortage of CNA coverage on all shifts. Interview on 6/29/2021 at 1:00 p.m. with the Administrator who stated that the facility attended another job fair this month. They have hired four new CNAs and two nurses. The facility has acknowledged the CNA shortages by hiring new CNAs. This will be ongoing until the coverage for certified nursing assistants is met for all shifts.

Based on record review, staff interview, observation, and facility policy review entitled Administering Medications and facility policy Self-Administration of Medications the facility failed to ensure the medication error rate was less than 5%. There were 19 errors with 34 opportunities for two of four residents (R#8, R#9) for a medication error rate of 55.88%. Findings: Review of the facility policy titled Administering through an Enteral Tube revised November 2018, revealed under general guidelines number three Administer each medication separately and flush between medications. Continued review of policy located under steps and procedures number thirteen states If administering more than one medication, flush with 15 ml warm purified water (or prescribed amount) between medications. 1. Record review of R#8 Medication Administration Record [REDACTED]. Observation of medicatio admininstration on 8/11/2020 at 8:45 a.m pass revealed LPN EE charge nurse on F Hall preparing medication for R#8 which included the following medications: [REDACTED]. LPN EE prepared R#8 medications for [DEVICE] administration, medication was taken to the residents' room. Observation revealed taht LPN EE checked rthe [DEVICE] for placement and residual which was 20 ml, LPN EE continued with administration of medications in different medication cups with 5ml of water in each cup for medication dilution. First medication was poured into R#8 G- tube via 60 ml syringe. LPN EE continued administering medications one after the other with no flushes between each individual medication administered. After completion of medication administration [DEVICE] was flushed with 30 ml of water. LPN EE administered 30 ml of water before medication administration and after completion of medication administration no water was administered between each medication as order specifies. Interview on 8/11/2020 at 9:00 a.m. with LPN EE revealed that R#8 was to receive 30 ml of water per tube before and after medication administration. Continued interview also revealed that the procedure for [DEVICE] medication administration according to LPN EE was to check for placement before medication administration, then residual is checked and if there was more than 100 ml of stomach contents the medication would be held and she would return later to administer medications after residual was less than 100 ml. 2. Record review of page three the MAR for R#9 revealed [MEDICATION NAME] powder mix one scoopful (4mg) with 60 ml water and stir until completely mixed: Give by mouth. Also noted in R#9 record medication was ordered to be given by mouth not by [DEVICE] according to MAR. Medication observation on 8/12/2020 at 9:35 a.m. with LPN FF revealed LPN FF pulled /prepared the following medication for R#9 : Folic acid 1mg tab (1 tab); Zen pep DR (3 capsules); Vitamin C 500mg (1 tab); Zinc sulfate 220mg (1 tab); [MEDICATION NAME] liquid 15 ml; Potassium Chloride 20MEQ/15ml (15ml); [MEDICATION NAME] Sodium 100mg (1 tab); [MEDICATION NAME] 30mg capsule (1 tab); [MEDICATION NAME] 0.5mg (1 tab); [MEDICATION NAME] 1.5 cal ( (1)-8fl oz carton); B-1 100mg (1 tab); [MEDICATION NAME] powder mix 1pk (4GM) in 60ml of water. Observed nurse wash her hands, placed each pill in a separate 30 ml cup. LPN FF then crushed each pill separately and opened capsules and poured into 30 ml cup. LPN FF stated she was pouring 5 ml of water into each cup because it was the facility's policy to add 5 ml to each medication. Residual was checked and medication administration began using [DEVICE] syringe. LPN FF was observed pouring water in syringe after each medication was given without measuring. LPN FF stated she was pouring about 3-5 ml of water between medications to help it (the medications) go down. [MEDICATION NAME] powder was not mixed in a cup, she took the syringe and attempted to mix the powder with syringe just before [DEVICE] administration to R#9. After administration of Zen pep and [MEDICATION NAME], there were some beaded medication left in the cup. There was no attempt to extract this medications from the base of the cup. After administration of the [MEDICATION NAME] powder, obseervation revealed that most of the medication remained at the base of the cup. LPN FF discarded cups without ensuring that all of the medications were administered. Observation of medication given to R#9 revealed that medication was not mixed completely as evidence by medication powder remained in the base of the cup after [DEVICE] administration and the amount of flush between each medication was not measured. Interview on 8/17/2020 at 5:00 p.m. with the Director of Nursing (DON) revealed that her expectations for medication administration for [DEVICE]s is that the nurses administer the residents' medication in its entirety. Continued interview revealed that the facility has no policy to her knowledge of what to do when there is medication left in the bottom the administration cup.

Based on observation, record review, and staff interview, the facility failed to follow the care plan related to related to [DEVICE] medication administration as ordered for two residents of nine (R) R#8, and R#9 residents receiving medications through a Gastric tube ([DEVICE]). The deficient practice had the potential to affect nine of twelve residents receiving medications through [DEVICE]. Facility census 115 Findings include: 1. Record review of the care plan for R#8 care plan problem on set date of 9/27/2019 last updated 6/18/2020 revealed R#8 is at risk for alteration in nutrition and risk for dehydration, resident receives all nutrition and hydration via [DEVICE], approaches are to administer supplements/nutrition and flushes as ordered at room temperature. Record review of R#8 the Medication Administration Record [REDACTED]. Observation and interview on 8/11/2020 at 9:00 a.m. with LPN EE revealed that LPN EE administered 30 ml of water before medication administration and after completion of medication administration no water was administered between each medication as order specifies. Interview with LPN EE revealed that R#8 was to receive 30 milliters (ml) of water per tube before and after medication administration. Continued interview also revealed that the procedure for [DEVICE] medication administration according to LPN EE was to check for placement before medication administration, then residual is checked and if there was more than 100 ml of stomach contents the medication would be held and she would return later to administer medications after residual was less than 100 ml. 2. Review of the care plans for R#9 revealed a care plan with an onset date of 3/30/2020 that was updated on 7/3/2020 that documented the following: at risk for alteration in nutrition and risk for dehydration. Resident is NPO (nothing orally), receives all nutrition and hydration via [DEVICE]. Approaches for R#9 was to administer medication as ordered. Record review of page three of the MAR for R#9 revealed [MEDICATION NAME] powder mix one scoopful (4mg) with 60 ml water and stir until completely mixed: Give by mouth. Observation of medication given to R#9 revealed that medication was not mixed completely as evidence by medication powder remained in the base of the cup after [DEVICE] administration. Also noted in R#9 record medication was ordered to be given by mouth not by [DEVICE] according to MAR. Cross-reference to F 759

Based on record review, staff interview, observation, and review of the facility policy titled, Administering Medications and facility policy titled Self-Administration of Medications the facility failed to follow physician order to administer medications as ordered for two of four residents observed for medication administration through [DEVICE], Resident (R) R#8, R#9. The deficient practice had the potential to affect nine of twelve residents receiving medications through [DEVICE] administration. Facility census was 115. Findings include: Review of the facility policy titled Administering through an Enteral Tube revised November 2018, revealed under general guidelines number three Administer each medication separately and flush between medications. Continued review of policy located under steps and procedures number thirteen states If administering more than one medication, flush with 15 ml warm purified water (or prescribed amount) between medications. 1. Record review of R#8 Medication Administration Record [REDACTED]. Observation of medicatio admininstration on 8/11/2020 at 8:45 a.m pass revealed LPN EE charge nurse on F Hall preparing medication for R#8 which included the following medications: [REDACTED]. LPN EE prepared R#8 medications for [DEVICE] administration, medication was taken to the residents' room. Observation revealed taht LPN EE checked rthe [DEVICE] for placement and residual which was 20 ml, LPN EE continued with administration of medications in different medication cups with 5ml of water in each cup for medication dilution. First medication was poured into R#8 G- tube via 60 ml syringe. LPN EE continued administering medications one after the other with no flushes between each individual medication administered. After completion of medication administration [DEVICE] was flushed with 30 ml of water. LPN EE administered 30 ml of water before medication administration and after completion of medication administration no water was administered between each medication as order specifies. Interview on 8/11/2020 at 9:00 a.m. with LPN EE revealed that R#8 was to receive 30 ml of water per tube before and after medication administration. Continued interview also revealed that the procedure for [DEVICE] medication administration according to LPN EE was to check for placement before medication administration, then residual is checked and if there was more than 100 ml of stomach contents the medication would be held and she would return later to administer medications after residual was less than 100 ml. 2. Record review of page three the MAR for R#9 revealed [MEDICATION NAME] powder mix one scoopful (4mg) with 60 ml water and stir until completely mixed: Give by mouth. Also noted in R#9 record medication was ordered to be given by mouth not by [DEVICE] according to MAR. Medication observation on 8/12/2020 at 9:35 a.m. with LPN FF revealed LPN FF pulled /prepared the following medication for R#9 : Folic acid 1mg tab (1 tab); Zen pep DR (3 capsules); Vitamin C 500mg (1 tab); Zinc sulfate 220mg (1 tab); [MEDICATION NAME] liquid 15 ml; Potassium Chloride 20MEQ/15ml (15ml); [MEDICATION NAME] Sodium 100mg (1 tab); [MEDICATION NAME] 30mg capsule (1 tab); [MEDICATION NAME] 0.5mg (1 tab); [MEDICATION NAME] 1.5 cal ( (1)-8fl oz carton); B-1 100mg (1 tab); [MEDICATION NAME] powder mix 1pk (4GM) in 60ml of water. Observed nurse wash her hands, placed each pill in a separate 30 ml cup. LPN FF then crushed each pill separately and opened capsules and poured into 30 ml cup. LPN FF stated she was pouring 5 ml of water into each cup because it was the facility's policy to add 5 ml to each medication. Residual was checked and medication administration began using [DEVICE] syringe. LPN FF was observed pouring water in syringe after each medication was given without measuring. LPN FF stated she was pouring about 3-5 ml of water between medications to help it (the medications) go down. [MEDICATION NAME] powder was not mixed in a cup, she took the syringe and attempted to mix the powder with syringe just before [DEVICE] administration to R#9. After administration of Zen pep and [MEDICATION NAME], there were some beaded medication left in the cup there was no attempt to extract left over medications from the base of the cup. After administration of the [MEDICATION NAME] powder, most of the medication remained at the base of the cup. LPN FF discarded cups without ensuring that all of the medications were administered. Observation of medication given to R#9 revealed that medication was not mixed completely as evidence by medication powder remained in the base of the cup after [DEVICE] administration.

Based on observation, staff interview , and facility policy review titled How to Properly store foodthe facility failed to ensure that expired foods in the dried foods pantry, kitchen up right cooler, and milk cooler, in the main kitchen were discarded. The facility also failed to ensure that kitchen steamer, food warmer, and steam table were clean and maintained. The deficient practice had the potential to affect 106 of 115 residents receiving an oral diet. Findings: Observation on [DATE] at 9:50 a.m. of the facility kitchen revealed the steamer located behind the steam table had noted buildup of white streaks streaming down the front of steamer as well as the stand in which the steamers rested on had debris noted. Further observation of steamer revealed that the inside base had dark brown substance noted as well. Observations were confirmed by Dietary Manager (DM) at the time of observation. Observation on [DATE] at 9:55 a.m. of kitchen steam table revealed the base of the steam table tray is covered with brown substance to all tray inserts. The substance was from the base to the sides of noted trays on all trays observed which was confirmed by DM. Interview on [DATE] at 10:00 a.m. with DM revealed that the substance in question was lime build up and that the staff has not had a chance to clean them. Continued interview with DM revealed that she would have the staff to remove steam table pans and have them to soak them over night to remove the build up that has accumulated. DM was unable to express the last time that steam table pans have been cleaned for lime build-up. Observation on [DATE] at 10:15 a.m. of the milk cooler located in the first room to the right revealed four half gallons (1.89L) of buttermilk with the expiration date noted of [DATE] DM confirmed that milk was expired and still inside milk cooler. Observation of first cooler located in the back of the kitchen revealed a quart sized covered container labeled green lima beans was dated [DATE] Interview with DM revealed that container should have been discarded on [DATE] per facility policy that states leftover foods are be discarded after 72 hours if not used. Observation on [DATE] at 10:30 a.m. of the dried food storage revealed three four-pound bags of new potatoes that were spoiled and had brown liquid puddled under each bag and small flies flying around the box they were stored in with a foul smell noted. DM confirmed that potatoes were rotten and removed them from the pantry area. Further observation on [DATE] at 10:35 a.m. revealed that the freezer door was frozen shut and DM was unable to open the door. DM revealed that the door often freezes shut and maintenance is notified, and they come and fix the issue. Interview on [DATE] at 10:40 a.m. with DM revealed that the head cook is responsible for making sure that all expired foods are discarded and properly rotated out daily as needed. Further interview also revealed that a daily cleaning schedule is posted for the staff to follow and that the expectation is that the schedule is completed and followed daily. Review of facility kitchen Daily cleaning schedule dated Aug. ,[DATE], 2020 revealed the tray line cleaning had been completed four of seven days, blender/food processor two of seven days, knife rack two of seven days, can opener two of seven days, refrigerator three of seven days, grill zero of seven days, steam table three of seven days, garbage cans and lids three of seven days, Ice machine - scoop three of seven days, tray carts- wiped and sanitized two of seven days, floors zero of seven days, steamer was to be cleaned weekly there was no documentation of cleaning for the week, the last noted date for cleaning and organizing refrigerator was documented on [DATE]. Interview on [DATE] at 4:20 p.m. with Administrator revealed that she is aware of the freezer door malfunction, and further states that the door had been freezing since a sprinkler head was added inside of the freezer. Continued interview also revealed that the time when the door is freezing shut is when it is held open for a period for staff to unload food when supplies are delivered. Administrator also acknowledge that there was also an issue with the food steamer located in the kitchen and revealed that the door has an issue with staying closed and sealed.

Based on observation, record review, staff interview, and review of the policy titled, Important Dietary Instruction Guide: Labeling and Dating, the facility failed to ensure opened and canned food items in the dry storage area were properly labeled and dated. This had the potential to affect 111 out of 120 residents receiving an oral diet. Findings include: 1. Review of the facility policy titled Important Dietary Instruction Guide: Labeling and Dating, revealed All Foods Must Have a Date Grocery truck opened times: Any items that have been opened but will be used again. During the initial tour on 01/27/2020 at 11:10 a.m. with the Dietary Manager revealed the following: (3) gallon-sized cans of ketchup not labeled for receiving date, (2) gallon-sized cans of whole kernel corn not labeled for receiving date, (7) gallon-sized cans of beets not labeled for receiving date, (1) gallon-sized can of apple sauce not labeled for receiving date, (1) 16 oz. bag of marshmallows opened with no opening date, (1) 16 oz. container of All Spice Seasoning opened with no opening date, and (1) 16 oz. container of Pumpkin Pie Spice opened with no opening date. An interview with the Dietary Manager on 12/17/19 at 8:15 a.m. revealed that that it is the expectations of everyone to label all food items with date item was received, opened, and expires. The DM explained that they receive supplies each week and supplies are to be labeled upon arrival.

Based on observation, staff interview, and review of the facility policy titled, Ice Machine and Ice Storage Chests the facility failed to provide a sanitary ice scoop for an ice machine serving five of five halls and failed to ensure a soap dispenser was working in one of three shower rooms. Findings include: Review of the Ice Machine and Ice Storage Chests policy dated (MONTH) 2012 revealed to keep ice scoop/bin in a covered container when not in use. During an interview on 1/30/2020 with the Maintenance Assistant he reported that the ice scoop should be kept on the outside of the ice machine. During an observation on 1/27/2020 at 11:20 a.m. of the ice machine on the F hall there was a blue scoop inside of the ice machine. During an observation on 1/27/2020 at 11:57 a.m. in the shower room on F hall the hand soap dispenser was not functioning. During an observation and interview on 1/30/202 at 11:45 a.m. Licensed Practical Nurse DD confirmed there was a scoop hanging in the ice machine. LPN DD also revealed that the ice scoop should be kept in the ice machine to keep residents from getting it. LPN DD reported that she is unsure of who is responsible for cleaning the ice machine or how frequently the ice machine is cleaned. During an observation and interview on 1/30/2020 at 12:04 p.m. Certified Nursing Assistant (CNA) FF was present at the ice machine on the F hall and was filling cooler with ice. CNA FF revealed that the ice scoop should be kept inside of the ice machine. During an interview and observation with the Maintenance Director on 1/30/2020 at 12:12 p.m. who confirmed that the scoop was in the ice machine. The Maintenance Director reported that the scoop should be stored on the outside of the ice machine.

Based on observation, record review, and staff interviews the facility failed to follow the care plan for two of 24 residents (R#82, R#21) reviewed for care plans. Findings include: 1. Record review revealed that R#82 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the Physician Orders for R#82 revealed an order for [REDACTED]. A review of the care plan revealed that R#82 was at risk for ineffective breathing pattern related to requiring oxygen with an intervention to follow the physician orders. An observation on 1/27/2020 at 11:51 a.m. revealed that portable oxygen for resident (R)#82 was set at 2 liters per minute (LPM) and the resident was up in a wheelchair. The observation revealed that the oxygen concentrator was also on and was set at 2.5 LPM. An observation on 1/28/2020 at 10:03 a.m. revealed that R#82 was in bed with oxygen on. The oxygen concentrator was set at 2.5 LPM. An observation on 1/29/2020 at 12:49 p.m. revealed that R#82 was in bed with oxygen on and the oxygen concentrator was set at 2.5 LPM. An interview and observation on 1/29/2020 at 2:16 p.m. with the Licensed Practical Nurse (LPN) AA of R#82 in Room B5-A confirmed the oxygen concentrator was set at 2.5 LPM. LPN AA also confirmed that the Physician Order documented the oxygen was to be set at 3 LPM. An interview on 1/29/2020 at 2:36 p.m. with the Director of Nursing (DON) revealed that her expectation was that oxygen was to be administered as ordered by the Physician. The DON confirmed that the oxygen for R#82 was ordered at 3 LPM. An interview on 1/30/2020 at 2:58 p.m. with the DON confirmed that R#82 and R#21 both have interventions on their care plan to administer oxygen as ordered and that her expectation was that the care plan was to be followed. An interview on 1/30/20 at 3:06 p.m. with the Nurse Consultant revealed that the facility used the RAI guidelines as their care plan policy. 2. Review of medical record for R#21 revealed [DIAGNOSES REDACTED]. The Minimum Data Set annual assessment dated [DATE] section O revealed oxygen therapy. Record review of the medical record revealed a care plan for R#21 being at risk for ineffective breathing due to [MEDICAL CONDITION] and acute chronic [MEDICAL CONDITION] with an intervention that included oxygen as ordered. There was no Physician's order for oxygen. During observations on 1/27/2020 at 3:17 p.m., 1/28/2020 at 4:28 p.m., and 1/29/2020 at 8:45 a.m. R# 21 was observed wearing oxygen. During an interview with Licensed Practical Nurse (LPN) CC on 1/29/2020 at 1:40 p.m. she confirmed that R#21 wears oxygen but was unable to find the orders for oxygen.

Based on closed record review and staff interview, it was determined that the facility failed to thoroughly assess and document wound descriptions timely for two residents( #119 and #125) and failed to provide pressure relieving devices to promote healing of a current pressure sore and/or prevent the development of additional pressure sores for two residents (#119 and #125) in a review of two closed records in an active sample of three residents with pressure sores in a total sample of 36 residents. This failure resulted in actual harm for resident #119 and #125 who developed additional pressure sores after admission to the facility. Findings include: 1. Review of the closed record for resident #119 revealed that he/she was admitted on [DATE] without any pressure sores (ulcers). The resident had [DIAGNOSES REDACTED]. However, according to the record, the resident had developed pressure sore on both of his/her heels prior to discharge on 11/11/11. Licensed staff completed an admission Minimum Data Set (MDS) assessment on 10/24/11. Nursing staff coded the resident as requiring extensive assistance with bed mobility, transferring, dressing and toileting. Licensed nursing staff assessed and coded the resident as being at high risk for the development of pressure sores. The resident's 10/31/11 care plan addressed his/her potential risk for skin impairment related to his/her impaired mobility and fragile skin. On 10/29/11, there was a handwritten note on the care plan about a blister on the resident's left heel and interventions for nursing staff to apply a heel lift boot on his/her left lower extremity. On 11/3/11, there was a handwritten note on the care plan about a suspected deep tissue injury to the resident's left and right heels. At that time, interventions were documented as (applying) heel lift boots to his/her lower extremities and for staff to monitor the resident's heels and feet for new signs and symptoms of skin breakdown. Review of the resident's closed record revealed nursing staff's documentation on 10/29/11 that identified the development of a stage II pressure ulcer on the resident's left heel and the initial care plan intervention for nursing staff to apply a heel lift boot on his/her left heel. Although, nursing staff identified that pressure ulcer on 10/29/11, they failed to thoroughly assess and document a complete description of it that included its size until 11/3/11. Additionally, there was not any documentation that nursing staff had promptly applied the heel lift boot to relieve pressure from it. Nursing staff did not apply that heel lift boot until 11/2/11. Review of nursing staff's documentation on the 11/3/11 "Wound Assessment" form revealed that the resident had developed a 1.5 centimeter (cm) by 1.5 cm suspected deep tissue injury on his/her right heel which was described as a purple area. Nursing staff documented on 11/9/11 that pressure sore had declined and was a 2 cm by 2.5 cm unstageable pressure ulcer. During an interview on 2/16/12 at 9:30 a.m., the Director of Nursing (DON) was unable to provide any other documentation about the resident's pressure sores. The DON confirmed that staff had not thoroughly assessed the pressure ulcer on resident's left heel when, it was initially identified on 10/29/11. The DON also confirmed that nursing staff did not document a complete description of it until 11/3/11. 2. Review of the closed record for resident #125 revealed that he/she was admitted to the facility on [DATE]. He/She had [DIAGNOSES REDACTED]. On the 11/30/11 "Continence Assessment " form nursing staff documented that the resident had an unstageable pressure ulcer on his/her right heel. Licensed staff completed the admission MDS assessment on 12/01/11 and coded the resident as having an unstageable pressure ulcer. Nursing staff's documentation on the 12/01/11 "Nursing Assessment" form noted that the resident had a 4 centimeter (cm) by 3 cm unstageable pressure ulcer on his/her right heel. However, there was not any documentation that nursing staff had throughly assessed that pressure ulcer. During an interview on 2/16/12 at 9:30 a.m., the DON was unable to provide any additional documentation about the unstageable pressure ulcer on the resident's her right heel. Although the resident was described in the "Nursing Assessment" of 12/1/11 as having an unstageable pressure sore on his/her right heel, on the 12/5/11 weekly skin assessment form, licensed nursing staff incorrectly described the skin on the resident's feet and heels as "normal". Nursing staff also noted on that assessment that the had developed a new, open blister on his/her left inner buttocks. On the 12/16/11 "Daily Wound Rounds" form, nursing staff documented that the stage 2 pressure ulcer on the resident's left inner buttocks was "worse" but, they failed to include any measurements about the size of the area. The resident was discharged home on[DATE].