Every finding on record at Granger Nursing & Rehabilitation Center

Based on observation, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices to ensure use of Enhanced Barrier Precautions (EBP) when required and to perform hand hygiene and infection control practices during wound care for 1 (Resident #4) of 2 residents reviewed. The facility reported a census of 52 resident. Findings include:The Minimum Data Set (MDS) for Resident #4, dated 2/6/26, includes diagnoses of peripheral vascular disease (PVD) (narrowing of blood vessels usually affecting the legs and feet) and 1 venous ulcer (wound caused by decreased blood flow). The Care Plan with initiated date 8/8/25, revealed the resident required EBP related to the presence of PVD wound to left lower leg with EBP to be instituted during completion of high contact activities. Observation on 2/23/26 at 3:07 PM, Staff A, Registered Nurse entered Resident #4's room and placed the wound treatment supplies directly on the resident's bed. Staff A applied gloves, did not apply a gown, removed the resident's left sock and leg dressing, and cleansed the scattered open wounds on the left lower leg with wound cleanser. Staff A proceeded with the same gloves on and wrapped the leg/wounds with a medicated dressing, gauze, and Coban (adhesive bandage). Staff A then removed the gloves, washed his hands, and placed wound cleanser and the medicated dressing box back in the treatment cart with other residents' supplies.Interview on 2/23/26 at 4:10 PM, Staff B, Certified Medication Aide, stated the EBP sign on the resident's door was due to wounds on his leg and staff need to wear gown and gloves with all hands-on care with the resident. Facility Enhanced Barrier Precautions policy dated 3/25/24, revealed gloves and gown are applied before performing high-contact resident care activities and an example of high-contact resident care activities requiring the use of gown and gloves included wound care. Interview on 2/26/26 at 1:31 PM, the Director of Nursing stated expectation to change gloves and complete hand hygiene when going from dirty to clean when completing a wound treatment, EBP of gown and gloves worn when completing the treatment, and to place supplies on a barrier.

Based on observation, staff interview, pharmacy recommendation, and policy review the facility failed to store and label medications properly in 1 of 2 medication carts reviewed. The facility reported a census of 52 residents. Findings include:Observation on [DATE] at 10:30 AM with Staff C, Registered Nurse (RN) in attendance, in the 100/200 hall medication cart:a. a bottle of Latanoprost eye drops (prescription medication for dry eye syndrome) for Resident #35 with the following labels: needs refrigerated, open date [DATE], and expires 42 days after open with no expired date written in. b. 4 bottles of prescribed eye drops not labeled with open date. c. 9 prescribed inhalers not labeled with open date.Interview on [DATE] at 10:35 AM, Staff C acknowledged the Latanoprost was a medication administered at bedtime which should be refrigerated and she did not know how long eye drops and inhalers were good for after opened, she would have to check. Resident #35's Medication Administration Record dated [DATE] - [DATE], documented the resident had received the Latanoprost every night [DATE] - [DATE]. Interview on [DATE] at 3:15 PM, the Director of Nursing (DON) stated the facility did not have a policy for expiration dates on medications after opening, would follow the pharmacy recommendations. The DON stated expectation for all medications to be labeled when opened with open date and expire date, and medications that are to be refrigerated to be refrigerated, not kept in the medication cart. Facility provided faxed document dated [DATE], signed by the pharmacist, revealed Latanoprost expires 42 days after opening. Facility Medication Storage Policy, not dated, instructed all medications requiring refrigeration are stored in refrigerators at each medication room.

Based on clinical record review, pharmacy record review, staff interviews, and facility policy review the facility failed to ensure accurate control and accountability of scheduled controlled narcotic medication for 1 (Resident # 34) of 3 residents reviewed. The facility reported a census of 52 residents. Findings include:The Minimum Data Set (MDS) for Resident #34, dated 11/28/25, documented diagnoses of Diabetes, depression, and primary insomnia (inability to fall or stay asleep). The MDS documented a Brief Interview of Mental Status score of 15, indicating no cognitive impairment, and the resident received a hypnotic medication. Resident #34's Medication Administration Record (MAR), dated 12/1/25 - 12/31/25, revealed a physician's order for Ambien (hypnotic medication) 5 milligrams (mg) 1 tablet at bedtime for insomnia. The MAR revealed the medication was administered 12/1/25 and 12/7/25 - 12/29/25 and the medication was not administered 12/2/25-12/6/25 and 12/30/25-12/31/25, due to the resident in the hospital. Resident #34's MAR, dated 1/1/26 - 1/31/26, revealed a physician's order for Ambien 5 mg. 1 tablet at bedtime for insomnia. The MAR revealed the medication was administered 1/2/26 - 1/12/26. Resident #34's Controlled Drug Record, Individual Patient's Narcotic Record form revealed an order for Ambien 5 mg with a quantity of 30 and dispense date of 12/12/25. The form revealed Staff F, Licensed Practical Nurse signed as date received of 12/12 and amount received appeared as 30 with a 1 marked over the 0, changing the amount received to 31. The form documented the first dose administered on 12/20/25 by Staff E, Certified Medication Aide, with 1 pill given and amount remaining of 30 pills. The form continued with the following documentation:12/21- 1 given, 29 remaining12/22 - 1 given, 28 remaining12/23 - 1 given, 27 remaining12/24 - 1 given, 26 remaining12/25 - 1 given, 25 remaining12/26 - 1 given, 24 remaining12/27 - 1given, 23 remaining12/28 - 1 given, 22 remaining12/29 - 1 given, 21 remaining1/2/26 - 1 given, 20 remaining1/3/26 - 1 given, 19 remaining1/4/26 - 1 given, 18 remaining1/5 - 1 given, 17 remaining1/6 - 1 given, 16 remaining1/7- 1 dropped and initialed by 2 staff, 15 remaining1/7- 1 given, 14 remaining1/8 at 6AM - Recount, 12 remaining1/8 at 1 PM- Recount signed by 2 staff, 12 remainingInterview on 2/24/26 at 2 PM, Staff A, Registered Nurse (RN) stated on 1/8/26 around 6 AM, he counted the narcotic medications with Staff I, Licensed Practical Nurse (LPN) who had worked the night shift and there were 1 or 2 pills missing from Resident #34's Ambien pills, not sure how many, but the count was off. Staff A stated he asked Staff I, the nurse who worked the night shift and had the medication cart keys, if Staff I had to waste any of the pills and Staff I said the pills may have popped out of the card on their own. Staff A stated that has happened before when there are a lot of narcotic cards and the drawer is full, it can push a pill out of the bubble pack and the pills can pop out if too full. Staff A stated he checked the drawer and did not find any loose pills. Staff A stated he refused to sign off for the narcotic count for the medication cart and was not going to spend time looking for a little pill that he wasn't going to find anyway. Staff A stated he reported to Staff D, RN who had worked the night shift also, that he was not going to sign for the narcotic count and walked away. Staff A stated when the narcotic count is not correct, suppose to notify the Director of Nursing (DON), but don't know if Staff D notified the DON. Staff A stated he notified the DON when the DON came into work later that day, maybe 8 AM. Staff A stated Staff I just kept stating she didn't know what happened to the medication. Staff A stated he thinks the medication cart keys were passed from Staff D to the Certified Medication Aide that was working that morning, as he did not take the keys. Staff A stated at shift change the 2 nurses count all controlled medications, the number of narcotic cards and bottles present, and sign the facility Controlled Drugs - Count Record form, and when signed the nurses are verifying the count for all medications is correct and the number of narcotic cards and bottles present. Facility Controlled Drugs-Count Record form dated January 2026, revealed on 1/8/26 at 6 AM Staff A signed as the nurse on, Staff I signed as the nurse off and comments of 31 cards and 2 bottles. The form instructed that signing acknowledges that you have counted the controlled drugs on hand and have found that the quantity of each medication counted is in agreement with the quantity stated on the Controlled Drug Administration Record and record any discrepancies or pertinent notes in comments. Interview on 2/24/26 at 2:45 PM, the DON stated he came into work later on 1/8/26. The DON stated he got a message from Staff D notifying of the discrepancy on the medication cart and nobody was willing to sign for the cart being accurate. The DON stated he notified the Assistant Director of Nursing (ADON) and she followed up to verify the medication count. The DON stated he notified the Administrator and the ADM took over from there. The DON stated he completed a verbal interview with Staff A and Staff D, but did not document the interview or have them write a statement. The DON stated he tried to call Staff I two times to figure out the medication error but she didn't answer or call back. Interview on 2/24/26 at 3:20PM, the ADON stated she was text by the DON of the medication discrepancy, went to check the med count, and found that 1 Ambien pill was unaccounted for, as when she counted the pills #13 was missing from the count sheet as the sheet had documentation of 14 pills remaining and then 12 pills remaining which meant there was only 1 pill missing. The ADON stated she recounted the Ambien pills and documented the number of 12 pills remaining on the count sheet. The ADON stated she tried to contact Staff I as Staff I was passing medications on the cart the previous night. The ADON stated she did not have a photocopy of the medication bubble pack card to verify how many pills were received, how many pills popped out, or number of pills remaining when the recount was completed. Interview on 2/24/26 at 3:35 PM, Director of Clinical Services (DCS) present during previous interview on 2/24/26 at 3:20PM and confirmed if followed the documentation of total # count of pills as documented administered, that the medication discrepancy would be 2 pills short on 1/8/26. The DCS stated it did appear on Resident #34's Controlled Drug Record, Individual Patient's Narcotic Record form for Ambien that the documented amount signed as received looked like 30 written in and then 1 marked over the 0. Interview on 2/24/26 at 3:55PM, Staff D stated the evening before the medication count was off, around 10PM, Staff I stated she dropped an Ambien. Staff D stated she observed the pill and then observed Staff I dispose of the pill in the dissolvable medication waste container. Staff D stated the next morning she did the narcotic count with Staff A and Staff I and the medication count was short by 1 pill and when she asked Staff I what happened, Staff I reported 1 pill was missing. Interview on 2/24/26 at 4:07 PM, Staff J, Pharmacist stated Zolpidem Tartrate (Ambien) 30 pills were dispensed to the facility for Resident #34 on 12/12/26 and will email a copy of the record. Facility's Shipping Manifest form from the pharmacy dated 12/12/25 documented Resident #34 Zolpidem 30 tablets and signed as received by Staff F, LPN on 12/12/25. Interview on 2/25/26 at 5:16PM, Staff F stated when she receives medication from the pharmacy delivery, she counts every card of medications, enters her name for received by and how many pills received while the pharmacy delivery person is there. Staff F stated if the count is off, she notifies the delivery person and also calls the pharmacy and notifies them if the count was not right, if there are more or less pills and the difference. Staff F acknowledged on Resident #34's Controlled Drug Record, Individual Patient's Narcotic Record form for Ambien appears a 1 is marked over the 0, to make the number 31. Staff F stated she documented 30 on the narc count record sheet, not 31 and does not know who marked 1 over the 0. Staff F stated if she needed to change the number, she would mark through the incorrect number, initial and then document the correct number, not just mark over the number. Interview on 2/26/26 at 8:30 AM, Staff E, CMA acknowledged appeared on Resident #34's Controlled Drug Record, Individual Patient's Narcotic Record form for Ambien on that 1 had been marked over the 0 to make the number 31 received Staff E stated she was the first staff to administer medication and documented 30 pills remaining after 1 given and she believes there was 30 pills remaining after she gave the medication as that is what she documented, but can't remember that far back. Staff E denied markings a 1 over the 0 for the amount received and didn't know who did or when done. Facility Controlled Substances policy revised December 2012, revealed the following:a. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record.b. If the count is correct, an individual resident controlled substance record must be made and record must include quantity received and number on hand. c. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the DON.d. The DON shall investigate any discrepancies in narcotic reconciliation to determine the cause and identify any responsibility parties, and shall give the ADM a written report of findings.

Based on observations, clinical record review, resident interviews, staff interviews and facility policy review, the facility failed to provide services and treatment to increase range of motion and to prevent further decrease in range of motion for 2 of 2 residents reviewed for limited range of motion (Resident #40 and Resident #44). The facility reported a census of 52 residents. Findings include: 1. The Minimum Data Set, dated [DATE] documented Resident #40 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had diagnoses to include stroke and hemiplegia (a form of paralysis affecting one side of the body) affecting the left side. The MDS indicated a functional limitation in range of motion in the look back period with an impairment on one side in both the upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot). The Care Plan for Resident #40, with a revision date of 8/27/24, included a problem area of resident had a history of Cerebral Vascular Accidents (CVA/stroke) with left sided weakness, with a goal of resident will be free from complications of CVA: DVT (Deep vein thrombosis), contractures (painful tightening and shortening of muscles, tendons, skin, or tissues, often replacing elastic tissue with stiff, fibrous tissue that limits joint movement), aspiration, pneumonia and dehydration through the next review date. Interventions for staff included administer medications as ordered by the physician, allow sufficient time to communicate needs and PT (physical therapy)/OT (occupational therapy)/ST (speech therapy) as ordered. During an observation 2/23/26 at 4:35 PM, Resident #40 had a contracture of her left hand, the left hand was closed with fingers curled into the palm, no padding or device was placed on or in the hand. Resident #40 demonstrated an ability to partially open her left hand with her right hand, observed indentations to the palm of the left hand from the resident's fingernails digging into the skin. During an interview 2/23/26 at 4:40 PM, Resident #40 stated she had a stroke in December of 2024, which resulted in left sided paralysis. Resident #40 stated she could not open her left hand due to contracture and stated the facility did not put anything in her hand to help keep it open or to prevent her fingernails from digging into her skin. Resident #40 stated she currently does not receive therapy for the contracture in her left hand. Resident #40 stated she has placed Kleenex in the palm of her left hand at times, for relief and to keep her fingernails from digging into her skin. During an interview and observation 2/24/26 at 9:22 AM, Resident #40 had placed some Kleenex in her left palm. Resident #40 stated placing the Kleenex into her palm felt better so her fingernails did not dig into her hand. Resident #40 stated she had to put something in the palm of her left hand and the facility did not do this, or offer this. Review of the Electronic Health Record (EHR) for Resident #40 revealed no orders or interventions in place for the contracture of the resident's left hand. During an interview 2/25/26 at 11:33 AM, Staff H, Advanced Registered Nurse Practitioner (ARNP) stated she had been a provider for Resident #40 since October of 2025. Staff H stated the resident has a left hand contracture. Staff H recommended a splint for the resident's left hand, however believed the resident's insurance would not pay for the splint. Staff H stated she talked to the resident about putting a washcloth in her hand or a foam block, however there is not an order for this. Staff H stated the contracture has not gotten worse since October of 2025, however a splint would be beneficial. The resident is currently receiving OT due to a new wheelchair, not for the splint or contracture. During an interview 2/25/26 at 12:25 PM, Staff G, Occupational Therapist (OT), stated he started working with Resident #40 recently on wheelchair safety for an electric wheelchair. Staff G stated he has not provided OT for the resident regarding her hand or contracture and has not evaluated her for a splint for the contracture for her hand. During an interview 2/25/26 at 3:45 PM, the Director of Nursing (DON), stated there is not a current order for a splint for Resident #40. The DON did not know if the resident had a splint before, or what interventions were put in place previously to address the contracture in her hand. Inquired what steps should be taken or could be taken for a resident with a contracture in their hand, the DON stated from a nursing standpoint a washcloth should be put in their hand and wash their hand twice a day. The DON stated these interventions should be in the care plan for the resident and acknowledged they are not in the care plan for the resident, or in the task section of the EHR. 2. The MDS for Resident #44, dated 2/6/26, includes diagnoses of stroke and hemiplegia (paralysis on one side of the body). The MDS identified the resident had an impairment in range of motion (ROM) for the upper and lower extremities on one side of the body and had a BIMs of 15, indicating no cognitive impairment. Observation on 2/23/26 at 1:15 PM, Resident #44's four fingers on her left hand were curled and pushing into the palm of her left hand, with her thumb remaining out, no padding between fingers and palm of hand. Interview on 2/23/26 at 1:16 PM, Resident #44 stated she had contractures of her left hand due to strokes and is unable to open her left fingers independently. Additionally, the resident stated she does sometimes use gauze under her fingers but she does not receive any restorative exercise for her hand as not able to receive therapy due to her insurance, and does not have a splint for the hand. Resident #44's Order Summary Report dated 2/25/26, revealed a physician's order dated 1/12/26, resident to be fitted for and receive a hand splint for left hand related to contracted fingers. Interview on 2/25/26 at 11:38 AM, Staff H stated she spoke with Staff G and Staff G stated insurance would not cover a splint for Resident #44. Additionally, Staff H stated the resident always has a strong offensive odor from her left hand. Interview on 2/25/2026 at 12:25 PM, Staff G stated Resident #44's insurance won't pay for an evaluation, so he has not completed an evaluation or provided any treatment for the resident and the facility has to give the go ahead that some kind of funding is in place before Staff G can do the evaluation. Interview on 2/25/26 at 2:58 PM, the DON stated was unsure what has been done since the order was received for the splint, not sure what else has been done to prevent further contracture of the resident's hand, and will have to check on it. Interview on 2/25/26 at 3:05 PM, the Director of Clinical Services stated the facility should pay for the resident's splint. Interview on 2/25/2026 at 4:00 PM, the DON stated he spoke with the Administrator (ADM) and the ADM approved for therapy to see Resident #44, was not sure why the order was not followed, and his expectation for orders to be followed. Facility Prevention of Decline in ROM policy, undated, revealed the following: a. Residents who exhibit limitations in ROM, initially and thereafter, will be referred to the therapy department for a focused assessment of ROM.b. Based on the comprehensive assessment the facility will provide intervention, exercises and/or therapy to maintain or improve ROM.c. The facility will provide treatment and care in accordance with professional standards of practice which includes appropriate services (specialized rehabilitation, restorative, maintenance), appropriate equipment (braces or splints), and assistance as needed for ROM.

Based on facility records and staff interviews, the facility failed to have a clinically qualified nutrition professional who met the required qualifications of a Certified Dietary Manager or a full time Registered Dietician. Findings Include: On 1/8/2025 at 1:46 PM, the Dietary Manager stated she did not have certification as a dietary manager. She stated she had completed courses to obtain certification, but the classes would not officially finish until 1/15/2025. An email provided by the Registered Dietician on 1/8/2025 at 2:53 PM stated she was only physically in the building one day a week. In an interview on 1/8/2025 at 2:42 PM with The Administrator, he stated the Registered Dietician is in the building one day a week. A review of facility records indicated the Dietary Manager did not hold any certifications in food safety, had not yet taken the test to be a Certified Dietary Manager, and had not been in the role of a Dietary Manager for two years or more.

Based on observations, resident interviews, staff interviews, and facility document review, the facility failed to maintain a clean environment free of hazards. The facility reported a census of 40 residents. Findings include: 1. A direct observation on 1/6/2025 at 9:58 AM of the 300 hallway revealed a baseboard heater with a bent/broken safety grate. The grate was bent in such a way that it allowed the surveyor to access the interior of the grate easily with his hand. 2. A direct observation on 1/6/2025 at 10:14 AM revealed that Resident #14's room baseboard heater cover was bent and ineffective at preventing someone from accessing the interior of the heating unit. Resident #14 commented on how it looked trashy. 3. In an interview and direct observation on 1/6/2025 at 1:07 PM with Resident #13, she stated she was unhappy with her room. When asked what she was unhappy about, the resident pointed out the state of the baseboard heater, which had a bent safety grate and appeared to be improperly secured to the unit. The heating fins were fully exposed and could be easily touched. 4. During a direct observation on 1/7/2025 at 2:37 PM of Resident #27, the surveyor noted the baseboard heater safety grate had been completely removed from the baseboard heater just below Resident #27's bed. When asked about it, Resident #27 noted it had been like that since he moved in. Review of clinical records indicated the resident admitted to the facility on [DATE]. In an interview on 1/9/2025 at 11:35 AM with Staff B, Certified Medication Aide (CMA), she stated she had been employed by the facility since approximately 2022, and the baseboard heaters have been in the same condition since she started working at the facility. In an interview on 1/9/2025 at 11:27 AM with Staff C, Registered Nurse (RN), she stated some of the baseboard heaters are in terrible shape and have been for a long time. She noted she does not have a lot of opportunity to notice the baseboard heaters in the resident rooms as she is not often performing resident cares. In an interview on 1/8/2025 at 3:56 PM with the Assistant Director of Nursing (ADON), she stated she had been employed by the facility for several years now. She further stated the baseboard heaters should have been replaced a long time ago, as the condition has worsened significantly over the last year. In an interview on 1/8/2025 at 11:30 AM with the Director of Maintenance, he revealed he has been in that role for approximately a year. He was aware that many of the baseboard heaters had broken safety shields. He has attempted to fix them as he has been made aware of them being broken, but stated he has had issues with staff members reporting the grates when they break or have worn out. He stated the building is older and a number of its systems are in need of significant repair, including the baseboard heaters. He noted the baseboard heater shrouds have been a chronic issue in the facility, and they have been in a state of disrepair since he started in the role. Review of facility provided maintenance logs documented 8 rooms that had a maintenance request placed for the state of the baseboard shrouds on 8/20/2024, with a number of the shrouds only having been repaired in December of 2024. Review of a facility provided document titled Maintenance Service, last revised in December of 2009, stated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times, including heating systems.

Based on observation, staff interview, and policy review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 40 residents. Findings include: During a direct observation on 1/6/2025 at 12:16 PM the Dietary Manager opened a package of crackers with ungloved hands. She made direct contact with the crackers before giving them to the resident. During a direct observation on 1/6/2025 at 12:18 PM the Dietary Manager served a plate of food to a resident and held the plate by the top with her thumbs. She made direct contact with ungloved hands with what appeared to be French fried potatoes on the plate. Hand hygiene was not performed after having assisted the previous resident. In a direct observation on 1/8/2025 at 12:21 PM, Staff G, Certified Nurse Aide (CNA), was seen touching the interior of a divided plate with bare hands while serving food to a resident. In a direct observation on 1/8/2025 at 12:22 PM and lasting until 12:25 PM, Staff H, Certified Medication Aide (CMA), was seen touching the tops of plates while serving food to several residents. She also unwrapped silverware for several residents, gripping the bowl of a spoon and tongs of a fork, with ungloved hands. She did not perform hand sanitation at any time during the observation. In a direct observation on 1/8/2025 at 12:24 PM, Staff I, CMA, was observed serving food to residents with her thumbs on top of the plate. In an interview on 1/8/2025 with Staff F, Dietary Cook, she explained that when serving residents during dining service staff should avoid contact with the top of the plate or interior surfaces of things like cups and bowls, they should never touch the serving ends of dining utensils, and you should wash your hands frequently when serving multiple residents and after making any direct contact with a resident. In an interview on 1/8/2025 at 1:46 PM with the Dietary Manager, she admitted she was worried she had touched the tops of the plates during dining service. She acknowledged that her expectations are that staff should never touch the tops of plates or the interior of bowls, nor should they ever touch the serving surfaces of forks and spoons. She stated staff should never make direct contact with food, and if they do the food item should be replaced. In an interview on 1/8/2025 at 3:56 PM with the Assistant Director of Nursing (ADON), she stated her expectations for Certified Nurses Aides and Certified Medication Aides who are assisting in dining service include never making direct contact with a resident's food, not touching the tops of plates or interior of items like bowls, and frequent hand hygiene. She added that staff should not touch a surface where a resident's food or mouth would make contact. Review of a facility provided document titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, last revised in November of 2022, it stated in section 6 all employees will wash hands before coming into contact with any food surfaces, as often as necessary when changing tasks, and when engaging in other activities that contaminate the hands. In section 8 it stated contact between food and bare (ungloved) hands is prohibited. Review of a facility provided document titled Dish & Utensil Handling with an unknown last reviewed date stated Fingers will not be placed in or at the lip of contact surfaces of cups, glasses, and/or flatware.

Based on resident interview, staff interview, and facility documentation, the facility failed to speak to residents with dignity and respect for 3 of 3 residents reviewed (Resident #12, #13, and #14). The facility reported a census of 40 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) for Resident #12, dated 12/12/2024, documented a brief interview for mental status (BIMS) score of 15, indicating intact cognition. A prior MDS dated [DATE] documented Resident #12 was dependent on staff members for toileting hygiene and required substantial assistance for bed mobility, transfers, and personal hygiene. It further documented her to be continent of bowel. In an interview on 1/9/2025 at 11:14 AM with Resident #12, she stated a staff member identified as Staff A, Certified Nurse's Aide (CNA), who worked night shift had a pattern of rude and unkind behavior. She stated Staff A often made her feel like she is a burden, asking her what she needs in an unkind tone and manner that makes her feel like he could care less about her. She stated he had asked her questions like What do you need now? and had sighed loudly when answering her call lights. She reported she had been made to wait so long for assistance using the restroom at night that she had soiled herself. She stated she had filed grievances with the facility in the past but felt that nothing had been done about the issue. 2. The quarterly MDS for Resident #13, dated 12/19/2024, documented the resident's BIMS score was 15, indicating intact cognition. It further documented she required moderate assistance for personal hygiene tasks. In an interview on 1/6/2025 at 1:07 PM with Resident #13, she stated she had a number of complaints about the facility, her biggest complaint is one of the night CNAs, identified as Staff A, is rude and treats her in a manner that leads her to believe he doesn't care. When she requests something at night he has entered her room asking her What does she need now?. She noted the call lights on the evening shift are also sometimes very slow when Staff A is working. She noted one call light the weekend before the surveyors entered where she waited close to an hour for assistance. She stated she accurately tells time and keeps track through use of a clock in her room. 3. The quarterly MDS for Resident #14, dated 11/1/2024, documented a BIMS score of 14, indicating intact cognition. It further documented her as requiring moderate assistance for toileting hygiene and dressing, as well as for most transfers. In an interview on 1/6/2025 at 10:14 AM with Resident #14, she stated that several staff are rude and treat her poorly. She mentioned that one gentleman in particular, identified as Staff A, makes her wait long periods of time when she requests help during the night shift. She stated he has made her feel like a piece of garbage. In an interview on 1/6/2025 at 1:24 PM, Resident #5 stated that some of the CNAs are rude to her when answering her call lights. She also stated they don't wear name tags like they're supposed to. In an interview on 1/6/2025 at 2:13 PM with Resident #1, she stated a gentleman who works the night shift is rough with cares and can be rude. In an interview on 1/9/2025 at 11:27 AM with Staff C, Registered Nurse (RN), she stated each resident prefers to be treated in their own way. She stated staff should always treat a resident with dignity and respect, which includes personalizing how you approach them to how they prefer to be addressed and treated. She stated you should assess how a resident is responding to your approach and change if the resident expresses distress or is unhappy. In an interview on 1/9/2025 at 11:35 AM with Staff B, Certified Medication Aide (CMA), stated she was trained to always greet residents in a warm and friendly manner and would never make a resident feel as if she didn't want to help them. She stated cares are expected to be as gentle as possible, and you should talk to the resident during cares to ensure they are comfortable. In an interview on 1/8/2025 at 8:24 AM with the Director of Social Services, she stated that she had received several formal grievances about rude staff and rough cares in the last several months. She stated the residents who reported these issues have a propensity to report many things. She was unsure of any actions taken regarding the grievances and stated the Administrator had the final say. Review of a facility provided document titled Resident Council Meeting, dated 12/30/2024, documented several residents had complained of the call light times on the night shift, as well as rude CNAs who had made statements such as What do you want now, why is your call light on again. Review of a Residential Grievance Form, dated 10/16/2024, documented four residents, including Resident #12 and #13, had complained that staff are rude and don't have common courtesy. It documented the follow up as the RN spoke with staff members and had them sign a customer service pledge. Review of a Residential Grievance Form, dated 12/30/2024, documented Resident #13 had complained to administration about Staff A making her wait an excessively long time for assistance, and when the call light was answered Staff A told her to take her socks off herself as it was good exercise. Resident #13's MDS documented that she required moderate assistance to remove footwear. Follow up on the grievance form failed to address how the issue was handled. Review of a Residential Grievance Form, dated 12/30/2024, documented Resident #12 had requested to be assisted to her recliner, and staff refused, stating they did not have time. The form documented staff were educated about the concern. Review of a Residential Grievance Form, dated 11/26/2024, documented Resident #12 had reported staff using inappropriate tones with her when she requested assistance. It documented a customer service pledge again as the follow up. Review of staffing files for Staff A documented the staff member had received a written warning for allowing a Resident to sit overnight in a brief that was soaked through with urine on 11/17/2024. It further documented Staff A failed to attend a mandatory nursing meeting and did not follow up with the nurse supervisor on 11/15/2024. Review of a facility provided document titled Quality of Life - Dignity, last revised in August of 2009, stated Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Section 2 defined treated with respect as the resident will be assisted in maintaining or enhancing their self worth. Section 7 stated staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. In section 11, subsection B it stated residents shall have prompt access to care for toileting assistance.

Based on clinical record review, staff interview, and instructions of CMS form 10123-NOMNC, the facility failed to provide appropriate Notice of Medicare Non Coverage (NOMNC) to 2 of 3 (Resident #7 and #142) residents reviewed for Beneficiary Notification. The facility reported a census of 40 residents. Findings include: 1. The census portion of the Electronic Health Record (EHR) of Resident #7 revealed the resident began receiving skilled care under Medicare A payer source on 8/5/24 and Medicare continued to pay for her stay through 8/23/24. The facility was unable to provide documentation of Resident #13 receiving a Notice of Medicare Non Coverage (NOMNC) form. The facility did provide a copy of the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). The SNF Beneficiary Protection Notification Review form documented the resident did not receive a NOMNC due to the resident telling therapy she was done and refused further therapy. 2. The census portion of the EHR of Resident #142 revealed the resident began receiving skilled care under Medicare A payer source on 9/13/24 and Medicare paid for her stay through 10/18/24. The facility was unable to provide documentation of Resident #13 receiving a NOMNC form. The facility did provide a copy of the SNF ABN form. The SNF Beneficiary Protection Notification Review form documented the resident did not receive a NOMNC due to the resident receiving the SNF ABN. On 1/8/25 at 12:17 pm, the Social Services Director stated she has been employed at the facility for eight months. She stated she was only trained to provide the SNF ABN form and was not trained regarding the NOMNC form. On 1/8/25 at 4:20 pm, the Administrator stated the Social Services Director had now received education on the correct forms to use when a resident's Medicare coverage is ending and future discharges will be completed following CMS guidelines. The document titled Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 directs: A Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily.

Based on clinical record review, staff interviews and facility policy review, the facility failed to revise the comprehensive Care Plan to accurately reflect the status of 2 of 16 (Resident #24 and #32) residents reviewed. The facility reported a census of 40. 1. The Minimum Data Set (MDS), dated [DATE], of Resident #24 identified a Brief Interview of Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS documented diagnoses that included depression, bipolar disorder, schizophrenia and nicotine dependence. The MDS documented a presence of an open foot lesion to her foot. The Wound Treatment Plan, dated 12/19/24, documented Resident #24 was to wear a walking boot on her right foot and a Controlled Ankle Motion (CAM) boot on her left foot (a medical device used to immobilize the foot and ankle). On 1/7/25 at 1:37 pm, Resident #24 was observed standing at the end of the hallway of the 200 hall, waiting to go outside to smoke. She was wearing a coat, a hat and gloves. She was wearing gripper socks on her feet with no shoes or boots. The State Surveyor questioned Resident #24 and she responded she was not fond of wearing her shoes. At 1:42 pm, Staff C, Registered Nurse (RN) came to join the residents to take them outside for smoking. She asked Resident #24 about her feet and the resident replied it was ok. Staff assisted Resident #24 and two other residents outside to smoke. The outside temperature was documented at 19 degrees at the time of observation. On 1/7/25 at 1:56 am, Resident #24 returned inside and the State Surveyor asked her if it was cold outside. Resident #24 replied it was not bad, and she had faced much worse when she had been homeless and had no protection from the elements except a sleeping bag. On 1/7/25 at 2:56 pm, the Director of Nursing (DON) stated smokers should wear shoes outside. He stated Resident #24 is to wear a boot for walking but has a history of being non compliant. He stated education has been given to her regarding this. The Care Plan of Resident #24 failed to reveal any documentation of Resident #24 wearing a walking boot or a CAM boot. The Care Plan additionally failed to reveal any documentation of Resident #24 being non compliant or receiving any education regarding care of her feet. 2. The MDS of Resident #32, dated 11/29/24, identified the presence of short and long-term memory impairment. The MDS coded the resident to be totally dependent for bed mobility. The MDS coded the presence of a Stage III pressure ulcer. On 1/6/25 at 10:28 am, Resident #32 was observed sleeping in bed. She had a body pillow tucked under her back, under her fitted sheet on her left side, with the resident being propped to lie on her right side. A fall mat was noted on the floor next to her. On 1/7/25 at 8:38 am, the resident was observed in bed, lying on her back. The fall mat was again observed on the floor, and the body pillow was again on the outside of the bed closest to the door, tucked under the fitted sheet. On 1/7/25 at 2:53 pm, the DON stated the body pillow is used for positioning for the resident. On 1/7/25 at 2:54 pm, the Assistant Director of Nursing (ADON) stated the resident had recently had a pressure ulcer which was now healed. She stated the body pillow was put in place as part of her repositioning schedule to assist in healing the pressure ulcer. On 1/7/25 at 3:17 pm, Staff D, Certified Nurse Aide, stated the resident had a history of rolling out of bed. She stated the pillow helped her to prevent falling but the resident still crossed her leg over it and climbed over it at times. On 1/7/25 at 3:19 pm, Staff E, RN, stated he was not really aware of why the pillow was there. He stated his assumption was to prevent falls but he said that he had seen her move the pillow in bed. He stated staff had told him the resident will still roll over the pillow at times. The Comprehensive Care Plan of Resident #32 identified a Problem Area of Fall Risk, initiated on 8/31/23. The Care Plan documented on 9/11/23 the fall mat next to the bed was removed and non skid strips were added to the floor. The Care Plan failed to document use of the body pillow for positioning. On 1/8/25 at 4:20 pm, the Administrator stated his expectation is for care plans to be kept up to date and to be comprehensive for the resident. The facility policy, Care Plans, Comprehensive Person-Centered identified the following: Point 9: Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Point 10: When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Point 11: Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. Point 12: The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, staff interview, pharmacy interview, drug manufacturer administration instructions, and policy review, the facility failed to assure a medication error rate of less than 5%. Medication errors were observed for Resident #21, Resident #22 and Resident #28. A total of 25 medications being prepared and administered were observed with 4 errors, an error rate of 16%. The facility reported a census of 40 residents. Findings include: Observation of Medication Pass began on 1/8/25 at 7:23 am. Staff B, Certified Medication Aide (CMA) was observed preparing morning medications for Resident #22. 1. Staff B prepared a total of four medications for Resident #22. Among the medications observed, Staff B prepared one tablet of Oxybutynin, (a medication to assist with overactive bladder), 5 milligrams (mg), Extended Release (medications which are modified to release at a delayed or slower rate in the digestive system). Staff B stated Resident #22 needed all of his medications crushed and she placed all of the tablet medications into a plastic sleeve and used a pill crusher to crush them into a fine powder. She mixed this with food and administered the medication to the resident at 7:34 am. 2. Staff B next prepared medications for Resident #21. She prepared eight medications for Resident #21. Among the medications observed were one capsule of Fenofibrate, 43 mg (a cholesterol medication) and one tablet of Senna, 8.6 mg (a laxative). She administered his medications at 7:54 am. When reconciling the observed medication pass against the orders for Resident #21, it was noted the Resident's order for Fenofibrate was 45 mg, rather than the 43 mg the resident received. Additionally, it was noted the resident was to have received Senna-S, a combination tablet of laxative and stool softener medication. He was given only Senna, not the combination medication prescribed. 3. On 1/8/25 at 8:00 am, the Assistant Director of Nursing (ADON) was observed administering insulin for Resident #28. The ADON performed hand hygiene and donned gloves. After verifying the correct medication for the resident, she placed an insulin pen needle on his Basaglar KwikPen insulin. She turned the dose knob of the pen to 2 units and held the pen with the needle pointing down and pushed the dose knob in. The ADON failed to follow the manufacturer instructions for the KwikPen of priming the pen with the needle facing up and noting the insulin to be at the tip of the needle. She then verified the scheduled dose and turned the dose knob to 22 units as ordered. She verified with Resident #28 where he wished for the insulin to be administered. She assisted with pulling his shirt up above his abdomen and cleansed the area with an alcohol swab. She guided the insulin needle and administered the insulin, holding the pen in place for approximately 1 second, failing to continue to hold the dose knob in and slowly counting to five before removing the needle per manufacturer instructions (this step is to ensure the full dose of insulin is delivered and doesn't leak out from the injection site immediately after insertion). A pharmacist representative from the facility's contracted pharmacy stated in an email on 1/8/25 at 9:57 am that Oxybutynin ER cannot be crushed. She also stated the incorrect dosage of Fenofibrate was entered into the computer and sent to the facility and the pharmacy would be contacting the prescriber to verify the dosage. On 1/9/25 at 10:33 am, the Director of Nursing (DON) stated it was incorrect for Resident #22's oxybutynin to be crushed. He additionally stated his expectation for staff administering medications is to triple check the medication label against the Medication Administration Record (MAR) prior to administering the medication. When asked about the expected procedure for administering insulin through an insulin pen, he stated the steps are to - Perform hand hygiene and place gloves on - Remove the cap from the pen and disinfect the top of the pen with an alcohol swab before placing a needle - Open a needle and place it on the pen - Prime the needle with 2 units of insulin - Dial the pen to the correct dosage - Disinfect the skin of the resident with an alcohol swab - Administer the insulin and hold the pen/needle in place for 10 seconds before removing. The facility policy, Administering Medications, revision date April 2019, documented the following in Point 10: The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administering the medication before giving the medication.

Based on clinical record review, observation, staff interviews, and policy review the facility failed to ensure staff changed gloves and utilized infection control techniques in order to prevent cross contamination for one of two residents reviewed for catheter care (Resident #8) and two of three residents reviewed for incontinence cares (Resident #31 and #43). The facility staff also failed to sanitize resident's glucometer after use and prior to putting the glucometer away for one of three residents reviewed for blood sugar checks (Resident #11). The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had diagnoses of septicemia, urinary tract infection (last 30 days), neurogenic bladder, diabetes, cerebral infarction (stroke), and hemiplegia (paralysis on one side). The MDS recorded the resident had an indwelling catheter. The Care Plan revised 11/13/23 revealed the resident required assistance with ADL's (activities of daily living) and had a urinary catheter due to diagnoses of urinary retention. The staff directives included to flush the catheter as per physician's order and administer medication as ordered. The order summary revealed acetic acid irrigation solution 0.25 % 60 milliliters irrigation two times a day to flush the catheter. During observation on 2/14/24 at 9:56 AM, Staff E, Licensed Practical Nurse (LPN) washed her hands, donned a pair of gloves, and placed supplies on a barrier on top of the resident's refrigerator. Resident #31 laid in bed with HOB elevated 45 degrees. Staff E placed a bedpan by the resident's groin. Staff E poured 0.25 % ascetic acid solution into a graduate container, and drew up 60 milliliters (ml) solution into a large syringe. Staff E removed the catheter from the catheter tubing, and laid the catheter tubing inside the bedpan. Staff E then connected the syringe with ascetic acid solution to the catheter and instilled the ascetic acid solution. Staff E removed the syringe, then took an alcohol swab and cleansed the end of the catheter and catheter tubing, and reconnected the catheter tubing to the end of the catheter. Staff E then removed the bedpan under the resident, and removed her gloves. Staff E rinsed the large syringe and graduate with water, and placed the bottle of ascetic acid on the counter by the sink. In an interview 2/15/24 at 9:00 AM, the Director of Nursing (DON) reported he expected staff changed gloves whenever they moved from a dirty to a clean area, and expected staff sanitized hands whenever they removed/changed gloves, as well as before, in-between, and after cares. A Urinary Catheter Care policy revised 9/2014 revealed use standard precautions whenever a catheter or catheter tubing handled or manipulated. The policy directed staff to prevent contact of the drainage spigot with a non-sterile container. A Handwashing and Hand Hygiene Policy revised 9/21/21 revealed hand hygiene considered the primary means to prevent the spread of infections. All personnel shall follow the hand hygiene procedures to help prevent the spread of infections to residents, staff and visitors. Hand hygiene performed before moved from a contaminated body site to a clean body site during resident care and after contact with bodily fluids. Glove use does not replace hand hygiene. 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had diagnoses of stroke, quadriplegia, and neurogenic bladder. The MDS indicated the resident dependent for hygiene, dressing, and toileting. The MDS revealed the resident had an indwelling catheter and had bowel incontinence. The Care Plan revised on 8/8/23 revealed the resident required assistance with activities of daily living and had incontinence. The Care Plan directed staff to check and change the resident's brief and provide peri-care with every incontinent episode. During observation on 2/13/24 at 11:39 AM, Staff G, certified nursing assistant (CNA) removed Resident #8's brief, took disposable wipes, and cleansed the groin/ penis area wiping front to back. Staff F rolled the resident onto his left side. Staff F, CNA, removed the soiled brief under the resident, then took disposable wipes and cleansed from the upper buttocks toward the scrotal area. The disposable wipe had stool present. Staff F took additional wipes and cleansed from the coccyx area toward the scrotal area. Staff G told Staff F he needed to wipe the other direction. Staff F took disposable wipes and cleansed the area front to back, then wiped the buttocks in a downward direction. Staff F placed a clean brief under the resident, rolled the resident onto his back, and attached the brief tabs. Staff F then positioned the pillow under the resident's head, touched the catheter bag, then assisted Staff G to lift the resident up in bed. Staff F failed to change gloves when moved from a dirty to a clean area or before touching other objects. In an interview 2/15/24 at 9:00 AM, the DON reported he expected staff changed gloves when they moved from a dirty to a clean area, and expected staff sanitized hands whenever they removed/changed gloves, as well as before, in-between, and after cares. A Prevention and Control of seasonal influenza policy dated 9/21/21 revealed all staff adhered to standard precautions during the care of residents. Standard precautions are the foundation for prevention of transmission of infectious agents in healthcare settings. Hand hygiene performed before and after resident contact, after contact with potentially infectious material, and donning and doffing personal protective equipment such as gloves. Hand hygiene performed after gloves removed. A Handwashing and Hand Hygiene Policy revised 9/21/21 revealed hand hygiene considered the primary means to prevent the spread of infections. All personnel shall follow the hand hygiene procedures to help prevent the spread of infections to residents, staff and visitors. Hand hygiene performed before moved from a contaminated body site to a clean body site during resident care, after contact with bodily fluids, after gloves removed, and after contact with objects in the immediate vicinity of a resident. Glove use does not replace hand hygiene. 46873 3. Continuous observation of morning medication pass began on 2/13/24 at 7:36 am. Staff A, Certified Medication Aide prepared medications for the residents of the 200 hall of the facility. On 2/13/24 at 7:55 am, Staff A, CMA, stated she needed to check a blood sugar on Resident #11. She opened the bottom drawer of the med cart and removed a small plastic box labeled with the Resident's name. She left the medication cart and walked to the resident's room and used the glucometer from the box to check the resident's blood sugar. On 2/13/24 at 7:59 am, Staff A returned to the medication cart and disposed of the lancet and other supplies in the biohazard box attached to the medication cart. She placed the box with the glucometer and other supplies back in the medication cart. She stated each resident has an individual glucometer. Staff A failed to sanitize the glucometer after use prior to putting it away. On 2/13/24 at 10:28 am, the Director of Nursing (DON) stated each diabetic resident of the facility has his or her dedicated glucometer. He stated each medication cart has sanitizing wipes in the cart and his expectation is the glucometer is to be sanitized prior to being put away for the next use. 49698 4. The MDS assessment dated [DATE] revealed Resident #43 had a BIMS score of 13, indicating cognition is intact. Resident had diagnosis of left ankle fracture, requiring assistance of 2 with a lift. Resident is dependent of care for toileting hygiene. The MDS revealed the resident is incontinent of bowel and bladder. The Care Plan dated 1/22/24, revealed the resident required assistance of two with activities of daily living and incontinence. The Care Plan directed staff to provide pericare with every incontinent episode. During observation on 2/14/24 at 1:59 PM, Staff I, CNA removed Resident #43's brief and discarded it in the trash, rolled the resident onto her right side, placed a bed pan and rolled the resident back, lying comfortably on the bed pan. Staff I, CNA, then adjusted the resident's pillow, pulled blankets up over the resident, moved call light within reach and moved bedside table in reach of the Resident. CNA did not remove soiled gloves before touching other objects. In interview on 2/15/24 at 9:00 AM, the DON reported he expected staff changed gloves when they moved from dirty to a clean area, and expected staff sanitized hands prior to putting on gloves, whenever gloves are changed, in-between and after cares.

Based on observations, resident and staff interviews, and policy review, the facility failed to provide a safe, clean, and homelike environment and keep equipment and furnishings in good repair for two of three hallways observed. The facility reported a census of 49 residents. Findings include: 1. Observations revealed the following: a. On 2/12/24 at 11:38 AM, a metal piece holding the left end of the mattress down at the foot of the bed in Resident #31's room had fallen off and was laying on the floor under the bed. b. On 2/14/24 at 10:00 AM, the front wooden piece to the top drawer of a three drawer cabinet on the left side of the sink in Resident #31's room was off, with metal staples present around the drawer edges. The metal piece for the end of the mattress was still not replaced. c. On 2/14/24 at 3:32 PM, and at 4:10 PM, the front wooden piece to the top drawer on the left side of the sink was off, with metal staples around the edges. A wooden slat under the drawer was loose and coming off, the middle and bottom drawer were not fully in their grooves and opening the drawers was difficult. d. On 2/15/24 at 8:00 AM, the drawer front is replaced, the rest of the drawers and wooden piece below the drawer is fixed, although the bottom drawer on the left side does not slide out well and is crooked. The metal bar at the foot of the bed for the mattress is replaced. The Minimum Data Set (MDS) for Resident #31, dated 1/7/24, gives a Brief Interview for Mental Status (BIMS) of 13, indicating the resident was cognitively intact. In an interview on 2/12/24 at 11:38 AM, Resident #31 stated the metal piece holding the left end of the mattress down at the foot of his bed in his bedroom came off a few days ago, the resident stated he informed maintenance of this a few days ago and it was still not fixed. In an interview on 2/14/24 at 3:32 PM, Resident #31 stated the metal piece for the end of the mattress was still not fixed. Resident #31 advised the front cover for the top drawer next to the sink came off recently when a staff member was cleaning the drawers. The resident stated he tried to fix the drawer on his own but it would not stay on the cabinet and maintenance was informed. In an interview on 2/14/24 at 4:09 PM, the Administrator advised he was not aware of any items needing fixed or replaced in Resident #31's room. In an interview on 2/14/24 at 4:10 PM, the Maintenance director advised he is fixing the front piece of the drawer right now. The Maintenance director stated he was informed today of the drawer being broken, and advised he was told a few days ago about the metal piece at the foot of Resident #31's mattress coming off; he is fixing this today as well, stating this is just a fix with placing new screws in for the metal piece to attach to the bed again, new parts did not have to be ordered to fix the metal piece. In an interview on 2/15/24 at 10:00 AM, Staff D, housekeeping, stated last week she was cleaning the drawers in Resident #31's room and the front piece to the top drawer came off; she does not remember what day exactly this was, but it was last week. Staff D advised she went to get the maintenance director and brought him down to the resident's room to show him the front of the drawer that had come off that she placed in the sink. In an interview on 2/15/24 at 10:25 AM, the Administrator stated the expectation is to fix or replace items that are broken in a resident's room as quickly as possible, the same day if they can, especially if it is a safety concern for the resident. Review of facility Maintenance Service policy, with a revision date of December of 2009, documents maintenance service shall be provided to all areas of the building, grounds and equipment. The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. Review of the facility Homelike Environment policy, with a revision date of February of 2021, documents residents are provided with a safe, clean, comfortable and homelike environment. 34817 Observations on 2/14/24 at 1:45 PM revealed the following: room [ROOM NUMBER]: a. A garbage can propped up against the door to room [ROOM NUMBER]. The door to the resident's room closed automatically. At the time, the resident reported the door closed on its own all of the time, and doesn't stay open. The resident stated the door had been that way for a long time. b. The closet door moved on the track above the door but the track appeared to be loose at the top, and the left closet framework slanted downward. c. The divider curtain track hung down and had screws exposed from the ceiling. d. The left side window had no blind or curtain. A fleece blanket partially hung over the window in the room. In an interview 2/14/24 at 1:45 PM, the resident reported the door closed on its own all of the time, and doesn't stay open. The resident stated the door had been that way for a long time. During an interview 2/15/24 at 10:15 AM, the Administrator reported he expected things fixed as quickly as can be done but sometimes they had to order parts or equipment to repair things. During an interview 2/15/24 at 10:50 AM, the Maintenance Director reported TELS system for staff to report when something needed repaired, or staff/residents told him when something needed fixed. The Maintenance Director reported he was the only maintenance person at the facility. The facility had two maintenance staff when he started working at the facility 4 years ago. A former Administrator said they would hire another person but the Administrator left, and two additional Administrators came after that but they never hired another maintenance person to help. The Maintenance Director stated he performed various checks on a daily, weekly, or monthly basis, and he kept record of, in addition to doing the repairs people told him needed done. The Maintenance Director reported he had made repairs to the door to room [ROOM NUMBER] and fixed the toilet approximately two months ago. The Maintenance Director reported the door to room [ROOM NUMBER] closed on it's own and he had it fixed but it looks like it's not fixed as the door slowly shut while talking with the surveyor. Further inspection revealed the left upper doorframe slanted downward and visually unleveled. The closet doorframe also slanted downward on the left side and the left closet door was more difficult to slide back and forth. The curtain rail nearest the sink bent down and had a screw exposed from the ceiling. The left window blind was missing and a blanket hung in front of the window. The facility's Homelike Environment policy revised 2/2021 revealed residents provided a safe, clean, comfortable and homelike environment. A Maintenance Service policy revised 12/2009 revealed the maintenance department had responsibility in maintaining the building and equipment in a safe and operable manner.

Based on clinical record review and staff interview, and instructions of CMS form 10123-NOMNC, the facility failed to provide appropriate notices of Medicare Non Coverage to 1 of 3 (Resident #16) residents reviewed and failed to provide notice within the required 2 calendar days for 1 of 3 residents reviewed (Resident #7). The facility reported a census of 49 residents. Findings include: The census portion of the Electronic Health Record (EHR) for Resident #16 revealed the Resident started skilled care under Medicare A payer source on 10/23/23 and Medicare continued to pay for his stay through 12/8/23. The facility was unable to produce evidence of Resident #13 receiving a Notice of Medicare Non Coverage (NOMNC) form. The facility did produce a copy of the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN), however it was signed on 1/17/24 with a note that verbal consent was received on 12/5/23. In an email on 2/14/24 at 3:47 pm, the Administrator stated he was unable to locate a NOMNC for Resident #13. The census portion of the EHR for Resident #7 revealed the resident admitted under Medicare A payer source on 1/24/24 and Medicare paid for his stay through 2/10/24. The facility provided a copy of the NOMNC and the SNF-ABN, uploaded to his chart on 2/14/24, which had no signature or date on it to show when the resident or resident representative received this notice. It did include a note that notice was provided on 2/7/24 and was emailed to the resident representative for a signature. When the state surveyor asked for a copy of the email for verification, the Administrator replied In an email on 2/14/24 at 4:33 pm that no email was sent. The document titled Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 directs: A Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily.

Based on observations, staff interviews and facility policy review, the facility failed to treat each resident with dignity for 3 of 6 residents reviewed for dignity (Resident #1, #11, #38). The facility reported a census of 49 residents. 1. The Minimum Data Set (MDS) of Resident #1, dated 12/22/23, identified Resident #1 to have a Brief Interview for Mental Status (BIMS) score of 13 which indicated cognition intact. The MDS recorded the resident described their pain as a 10 out of 10 on a pain scale almost constantly during the 5-day look back period. The Care Plan of Resident #1 revealed a Focus Area of Chronic pain, revision date of 9/22/23. It directed staff to administer pain medications as ordered, and to monitor/document and report any signs or symptoms of non-verbal pain including moaning or calling out. On 2/12/24 at 9:41 am, Resident #1 was heard calling out in pain from the hallway. Staff C, Certified Medication Aide was standing at the medication cart near Resident #1's doorway. Staff C did not respond to Resident #1's calls. Several minutes later another staff member checked on Resident #1 and then informed Staff C that Resident #1 was asking for pain medication. On 2/12/24 at 9:50 am, Staff C informed Resident #1 she had to wait another hour to receive any medication because it was not scheduled at this time. In review of the resident's ordered, it was documented the resident had multiple options of as needed pain medications which could have been administered prior to her next scheduled medication dose. On 2/15/23 at 3:09 pm, the Director of Nursing (DON) stated Resident #1 had previously been on hospice and had a pain management program while on hospice. She has since graduated from hospice. He stated he will inform the provider of increased pain needs to evaluate if a medication change should be made. He stated his expectation is for staff to respond to her needs. 2. The MDS of Resident #11, dated 2/3/24, identified a BIMS score of 4 which indicated severe cognitive impairment. The Care Plan of Resident #11 revealed a Focus Area of Smoking, revision date of 12/28/23. It documented the resident's preference is to be able to smoke while at the facility. It directed staff to orient the resident to the designated smoking areas. On 2/12/24 at 9:53 am, Resident #11 was observed self propelling her wheelchair in the hallway. She stopped to speak to Staff C, CMA and informed him she desired to go outside to smoke. Staff C responded that she had missed smoking time and told her to go to her room and read the smoking times listed on the sign in her room. He told her smoking was 9:30 am and she needed to wait until the next posted time. Staff C was not observed asking if any staff member was available to assist Resident #11 to grant her request to go outdoors. On 2/15/23 at 3:09 pm, the Director of Nursing (DON) stated the Certified Nursing Aides (CNAs) are aware of which residents are smokers. He stated they gather the smokers and scheduled smoking times and gather them so they can choose to attend. He stated smoking sessions are normally between 5 and 15 minutes long. He stated Resident #11 is not a regular smoker and her family has requested she not be invited to smoking times as they desire her to stop smoking. He stated she can smoke when she requests to but is not reminded of scheduled smoking times. He stated if she had missed smoking time and requested a separate time to go out, his expectation is the charge nurse would be informed and they would try to find a staff member available to accommodate her request. 3. The MDS of Resident #38, dated 11/17/23, identified no presence of memory impairment. The MDS revealed the resident required substantial/maximal assistance for upper body dressing and being totally dependent for lower body dressing. The MDS documented diagnoses that included Alzheimer's disease, anxiety, and depression. The Care Plan revealed a Focus Area of self care deficit, initiated 6/15/23. It directed staff the resident required assistance of one staff member to get dressed. On 2/13/23 at 7:43 am, Staff A, Certified Medication Aide (CMA) had prepared the morning medications for Resident #38. She knocked on the resident's closed door and entered immediately without awaiting a reply. Staff B, Certified Nurse Aide (CNA) was in the room with the resident in the process of assisting with morning cares. The resident was sitting on the side of her bed, with no clothing on from the waist up. Her nude breasts were fully exposed from the doorway when Staff A opened the door. The privacy curtain separating the resident's area of the room from the hallway was not pulled to provide privacy. Staff A then shut the door and waited for a short time and knocked again and waited for Staff B to reply it was ok to come in after she had placed clothing on the resident. On 2/13/24 at 8:47 am, Staff B, CNA stated her routine for providing morning cares is to knock on the residents door, and upon entering explain what she is in the room to do. She stated for Resident #38, she had offered her a choice of what clothing to wear that day, and after gathering supplies she had shut the door. She stated Resident #38's roommate was still on the other side of the room, and she closed the privacy curtain separating the two resident areas. She stated she was in the process of providing clothing to the resident when Staff A entered the room. On 2/13/24 at 10:28 am, the Director of Nursing (DON) stated his expectation is for staff to knock on the resident door first and wait for a reply prior to entering a room. The facility policy titled Dignity, revision date February 2021 documented: 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. 3. Individual needs and preferences of the resident are identified through the assessment process. 4. Staff are expected to knock and request permission before entering residents' rooms. 5. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on personnel file review, facility policy review, and staff interview, the facility failed to assure all employees had an Iowa criminal background check and abuse registry checks completed prior to working in the facility for 1 of 7 employees sampled (Staff G). The facility identified a census of 49 residents. Findings include: The employee new hire report dated 2/1/23 to 2/12/24 provided to the surveyors by the facility during the survey week revealed Staff G, certified nursing assistant, had a hire date of 9/11/23. Staff G's personnel file documented a hire date of 9/11/23. The single contact license and abuse registry and criminal background checks (SING) were completed 8/22/23. The criminal history background check indicated further research required, and to await DCI's (Department of Criminal Investigation) final response. A Department of Human Services (DHS) Record Check Evaluation request form was filled out and signed by Staff G on 8/22/23. Staff G's employee file lacked record of the DCI's background check and/or DHS's approval to work. The facility's Abuse Prevention, Identification, Investigation, and Reporting Policy updated 2/6/23, revealed the facility screened all potential employees for abuse, and conducted an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents prior to hire. In an interview 2/15/24 at 12:51 PM, the Dietary Manager (DM) serving as the interim human resource designee reported he checked with DHS and they have no records for Staff G. The DM stated he resubmitted the background check to DCI for Staff G. The DM reported Staff G planned to check with her former employer to see if they had a may work letter from DHS. In the interim, Staff G placed on suspension until the facility received the background check and DHS information. The DM reported he ran another SING background check on 2/15/24. The SING background check dated 2/15/24 revealed further research required and to await DCI's final response for criminal history.

Based on clinical record review, staff interview, and policy review, the facility failed to refer one resident with a Level I Preadmission Screening and Resident Review (PASARR) with a previously unknown serious mental disorder for evaluation of a Level II PASARR at the time the diagnosis was known to the facility for 1 of 2 residents reviewed for PASARR (Resident #22). The facility reported a census of 49. Findings Include: The Minimum Data Set (MDS) for Resident #22 dated 12/21/23 documented a Brief Interview for Mental Status (BIMS) of 15, indicating the resident was cognitively intact. The MDS further documented diagnoses for the resident to include medically complex conditions, anxiety disorder, depression, and post traumatic stress disorder (PTSD). The MDS reflected the resident was taking antianxiety and antidepressant medications. The Care Plan for Resident #22, with a revision date of 7/31/23, documents under the problem section the resident has the potential for and has episodes of alteration in mood as evidenced by negative statements, repetitive questions, repetitive verbalizations, persistent anger with staff or others, self-depreciation, expressions of unrealistic fears, recurrent statements, repetitive complaints and concerns, medications and bowel obsessions, sad and crying, repetitive movements, withdrawn and reduced social interactions related to diagnosis of major depression disorder. The Level I PASARR for Resident #22 was completed in October of 2019, this was the last PASARR screening completed for Resident #22. The Level I PASARR documented the resident did not have a Major Mental Illness (included in this list is Major Depression). The Level I PASARR documented the resident to have diagnoses of anxiety disorder, depression (mild or situational), and PTSD, and further documented the only psychotropic medication for the resident was Bupropion Hydrochloride for anxiety. In addition, this screening documented no further PASARR screening is required unless there is a significant change. Review of the electronic health records for Resident #22 under medical diagnoses reflects the resident had a diagnosis of Major Depressive Disorder, recurrent, with a date of 2/19/20. Review of electronic health records for Resident #22 under orders for medication administration documents the resident received psychotropic medication to include Buspirone HCI oral tablet, 15 milligrams two times as day, with a start date of 11/18/23 and Terrazzo HCI 12.5 milligrams two times a day, with a start date of 4/12/23. In an interview on 2/14/24 at 1:27 PM, the social service department head verified the last PASARR completed for Resident #22 was in October of 2019, a Level 1 screening. The social service department head acknowledged a Level II PASARR screening should have been submitted with the significant changes of the new diagnosis of major depressive disorder, psychotropic medications and behaviors. Review of the facility policy titled Behavioral Assessment, Intervention and Monitoring, with a revised date of March of 2019, documents new onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability or a related disorder will be referred for a PASARR Level II evaluation. Residents will be referred for additional PASARR Level II evaluation upon a significant change in status assessment.

Based on document review, record review, staff interviews, facility policy, and Resident Assessment Instrument (RAI) Manual the facility failed to complete 1 of 1 resident's Minimum Data Set (MDS) within 14 days of being discharged from hospital with significant changes in health status (Resident #7). The facility reported a census of 49 Residents. Findings include: Document review of Resident #7's Discharge and Transfer orders dated 1/24/24 from the hospital to the facility following Resident's surgery for a right ankle fracture. Resident ordered to be non-weight bearing and to be a two person assist with a lift (Hoyer lift). This document also indicated resident had a urinary catheter related to benign prostatic hyperplasia and urine retention diagnosis, antibiotic treatment for 30 days to treat pneumonia acquired while hospitalized , orders for skilled level of care and rehab services including physical therapy and occupational therapy. Record review of Resident #7's ENTRY Minimum Data Set (MDS) dated [DATE] documented an assessment completion date of 2/1/24. 1. In Section I of the MDS, no fracture was indicated. 2. Section H of MDS, no urinary catheter was indicated. 3. Section GG of the MDS, resident noted as one person transfer, Resident is now Hoyer lift transfers with assist of 2. 4. Section N of the MDS, failed to indicate 30 days of antibiotic treatment for pneumonia. 5. Section A of the MDS, failed to indicate resident's skilled level of care. 6. Section O of the MDS, failed to indicate resident receiving therapy. Additionally, items not listed on the MDS 1. Resident was non weight bearing 2. Splint in place to right ankle and foot. During an interview with Staff J, RN caring for Resident #7, on 02/14/24 02:26 PM, Staff J, RN confirmed that resident #7 is to be transferred by Hoyer lift as the resident is non weight bearing because of ankle fracture. Staff J, RN confirms the resident does have a catheter since returning from the hospital. Staff J, RN was asked, when staff are caring for Resident #7 how are they made aware of resident's care needs? Staff J, RN reveals a document titled Pocket Care Plan, this document indicates resident is a Hoyer lift transfer with assist of two. This document is used for CNAs to know resident's care needs, all residents in the facility are listed with their care needs. During an interview with the Director of Nursing on 02/15/24 at 9:23 AM confirmed the changes in Resident #7 status and care are accurate and were not present prior to resident's hospital transfer. DON indicated these changes would be considered a significant change in health status. DON revealed he would expect a significant change MDS to be completed within 14 days from the date identified and confirmed the significant change MDS was not completed. During an interview with Facility's remote MDS coordinator on 2/14/24 12:21 PM, MDS coordinator states schedules are set up for Resident's MDS assessments. She checks MDS dashboards for admissions and discharges. MDS coordinator states the facility will notify her if a resident is put on hospice or has had a significant change, then enters those changes to the appropriate resident's MDS. MDS Coordinator states significant changes are done whenever a resident has two or more changes in their condition that are not expected to resolve in two weeks. When discussing Resident #7's status since hospital discharge on 1/24/24, MDS coordinator states she wouldn't set up a significant change MDS until she checked the progress of the resident to determine if the significant changes would last longer than the two week period of time. The MDS coordinator did not agree the changes to Resident #7's care since hospital discharge met criteria for a significant change MDS. Facility Policy titled MDS Completion and Submission Timeframes Revised date July 2017, documented: The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. The RAI Manual dated 10/1/23 instructs facilities to complete a Significant Change Assessments MDS within 14 days after determining criteria is met.

Based on clinical record review, staff interview and facility policy review, the facility failed to revise the comprehensive care plan to accurately reflect status of 1 of 17 residents reviewed (Resident #7). The facility reported a census of 49. Findings include: The Minimum Data Set (MDS) for Resident #7, dated 1/28/24 identified a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. The MDS documented diagnoses that included fracture, urinary catheter, anxiety disorder, depression, schizophrenia/schizoaffective disorder, and Benign Prostatic Hypertrophy (BPH) with risk of urinary retention. Document review of Resident #7's Discharge and Transfer orders dated 1/24/24 from the hospital to the facility following Resident's surgery for a right ankle fracture. Resident ordered to be non-weight bearing and to be a 2 person assist with a lift (Hoyer lift). This document also indicated resident having a urinary catheter related to benign prostatic hyperplasia and urine retention diagnosis, antibiotic treatment for 30 days to treat pneumonia acquired while hospitalized , orders for skilled level of care and rehab services including physical therapy and occupational therapy. The Care Plan dated for Resident #7, dated 1/24/24 identified resident being incontinent of bowel and bladder, indicating staff to encourage toilet use every 2-3 hours or as needed. Encouragement to wear incontinence products, and perform incontinence care as per facility protocol. Resident is at risk for falls, Resident has a self-care deficit requiring assistance with ADLs, requiring a 1 person assist. The Care Plan lacked documentation of Resident's right ankle fracture, non-weight bearing with 2 person assist, urinary catheter, current antibiotic treatment for pneumonia, skilled level of care with therapies, Resident wearing a splint or monitoring for skin breakdown related to splint. During an interview with Staff J, RN caring for Resident #7, on 02/14/24 02:26 PM, Staff J, RN confirms that resident #7 is to be transferred by Hoyer lift as the resident is non weight bearing because of ankle fracture. Staff J, RN confirms the resident does have a catheter since returning from the hospital. Staff J, RN was asked, when staff are caring for Resident #7 how are they made aware of resident's care needs? Staff J, RN revealed a document titled Pocket Care Plan, this document indicates resident is a Hoyer lift transfer with assist of two. This document is used for CNAs to know resident's care needs, all residents in the facility are listed with their care needs. During an interview with the Director of Nursing on 02/15/24 at 9:23 AM confirmed the changes in Resident #7 status and care are accurate and were not present prior to resident's hospital transfer. DON indicated these changes would be considered a significant change in health status. DON revealed Care Plans for the residents in the facility are updated by himself, DON confirms this should have been completed in a timely manner and acknowledged this had not been done. The facility policy Care Plans, Comprehensive Person-Centered, revised date March 2022 documented : 1)The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (admission, Annual or Significant Change is Status), and no more than 21 days after admission. 2) Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change.

Based on record review, staff interview, and policy review the facility failed to notify the Long Term Care Ombudsman of discharge/transfer of residents as required for 3 of 4 residents reviewed who were discharged /transferred from the facility (Residents #7, #31, #34). The facility reported a census of 49 residents. Findings include: 1. Review of the Minimum Date Set (MDS) assessment dated [DATE] and the facility's computer software program used for electronic medical record documentation, revealed Resident #31 had discharged from the facility on 12/26/23 and was hospitalized until he reentered the facility on 1/3/24. The clinical record lacked documentation of notification to the Long Term Care Ombudsman that Resident #31 had been discharged to the hospital as required by federal regulation. During an interview 2/14/24 at 8:03 AM, the Social Service department head stated the facility had not notified the Ombudsman when the resident was discharged to the hospital. On 2/15/24 at 1:38 PM the Administrator advised the facility does not have a policy for Notification to the Long-Term Care Ombudsman. 49698 2. Review of the Minimum Date Set (MDS) assessment dated [DATE] and the facility's computer software program used for electronic medical record documentation, revealed Resident #7 had discharged from the facility on 1/7/24 and was hospitalized until he reentered the facility on 1/24/24. The clinical record lacked documentation of notification to the Long Term Care Ombudsman that Resident #7 had been discharged to the hospital as required by federal regulation. During an interview 2/14/24 at 8:03 AM, the Social Service department head stated the facility had not notified the Ombudsman when the resident was discharged to the hospital. On 2/15/24 at 1:38 PM the Administrator advised the facility does not have a policy for Notification to the Long-Term Care Ombudsman. 3. Review of the Minimum Date Set (MDS) assessment dated [DATE] and the facility's computer software program used for electronic medical record documentation, revealed Resident #34 had discharged from the facility on 12/11/23 and was hospitalized until he reentered the facility on 12/18/23. The clinical record lacked documentation of notification to the Long Term Care Ombudsman that Resident #34 had been discharged to the hospital as required by federal regulation. During an interview 2/14/24 at 8:03 AM, the Social Service department head stated the facility had not notified the Ombudsman when the resident was discharged to the hospital. On 2/15/24 at 1:38 PM the Administrator advised the facility does not have a policy for Notification to the Long-Term Care Ombudsman.

Based on observation, interview, record review, and policy review, the facility failed to: 1. Sanitize glucometers between uses for three (Resident (R) 43, R44, and R7) of five residents observed receiving fingerstick blood sugar (FSBS) tests and 2. perform hand hygiene for two (R45 and R39) of seven residents observed received medications, 3. during incontinent care for R38, and 4. during the tracheostomy care for R9. The failure to sanitize glucometers between residents resulted in an Immediate Jeopardy (IJ) at F880-K: Infection Control due to the increased likelihood to cause serious harm due to the potential of cross-contamination of blood-borne pathogens. On 2/2/23 at 3:53 PM, the Administrator and Director of Nursing (DON) were notified of the IJ at F880 Infection Control. The Immediate Jeopardy began on 2/1/23 when the survey team identified glucometers were not being sanitized between uses for R7, R43, and R44. The facility provided an acceptable removal plan on 2/3/23 at 10:04 AM. The removal plan included educating the DON on system management and education of staff, sanitizing all glucometers, retraining and ensuring competency of all Certified Medication Aides (CMA), Licensed Practical Nurses (LPN), and Registered Nurses (RN) on the use and sanitization of glucometers, securing hepatitis C screenings for all residents receiving FSBS tests, and updating the policy on blood sampling and glucometer sanitization to include using a manufacturer's approved sanitizing method. Through interviews with facility staff, observations of FSBS tests, review of staff in-services and facility policy, the survey team verified all elements of the facility's IJ Removal Plan and therefore removed the IJ, effective 2/3/23 at 12:49 PM; Findings include: Review of the facility's policy titled Blood Sampling - Capillary (Finger Sticks), revised September 2014, indicated, . Always ensure that blood glucose meters [glucometers] intended for reuse are cleaned and disinfected between resident uses . Review of the manual for the Assure Prism Blood Glucose Monitor System that was used by the facility revealed . The meter should be cleaned and disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed . We have validated . Super Sani-Cloth Germicidal Disposable Wipe for disinfecting the Assure Prism multi meter . Contact time 2 minutes . Review of the facility's policy titled Handwashing and Hand Hygiene, dated 9/21/21, indicated, . The facility considers hand hygiene the primary means to prevent the spread of infection . Use of an alcohol-based hand rub . for the following . Before and after direct contact with residents . Before preparing or handling medications . After contact with a resident's intact skin . After removing gloves . 1. a. R43's Admission Record, included a diagnosis of diabetes mellitus type 2. R43's Physician Order, dated 11/16/22 revealed R43 was to receive a FSBS test before every meal and before bedtime. b. R44's Admission Record, included a diagnosis of diabetes mellitus type 2. R44's Physician Order, dated 2/22/22, indicated R44 was to receive a FSBS test before every meal. c. R7's Admission Record, included a diagnosis of diabetes mellitus type 2. R7's Physician Order, dated 2/5/22 revealed R7 was to receive a FSBS test every shift. On 2/1/23 at 6:39 AM, observed two glucometers in a basket on top of the medication cart for hall 100. CMA2 obtained a glucometer from the basket and completed a FSBS test for R43 without sanitizing the glucometer. CMA2 returned to the medication cart, and without sanitizing the meter, placed the glucometer back into the basket and continued with the medication pass. - At 7:11 AM, CMA2 obtained a glucometer from the basket and completed a FSBS test for R44 without sanitizing the glucometer. CMA2 placed the glucometer on top of the medication cart and continued with the medication pass. CMA2 did not sanitize the glucometer. - At 7:17 AM, CMA2 obtained the glucometer in the basket, and without sanitizing the glucometer, completed a FSBS test for R7, returned to the medication cart, and placed the glucometer on the medication cart. CMA2 did not sanitize the glucometer. During an interview on 2/1/23 at 7:26 AM, CMA2 stated the facility's policy for cleaning glucometers before and after use was to clean the glucometers with an alcohol wipe. CMA2 verified that he did not clean the glucometers. He stated sometimes the glucometers were cleaned with sanitizing wipes. CMA2 opened the medication cart and stated there were no sanitizing wipes on the medication cart. On 2/1/23 at 7:34 AM, witnessed the MDS Coordinator (MDSC) placing a container of Super Sani-Cloth sanitizing wipes on the medication cart. The MDSC stated the wipes should have been on the cart. During an interview on 2/2/23 at 10:25 AM, the Director of Nursing (DON) stated the facility's policy on sanitizing glucometers was to use a Super Sani-Cloth wipe, clean the glucometer, and wrap the glucometer in the sanitizing cloth for three minutes between residents if the same glucometer was used on multiple residents. She stated she had a system set up so that each resident had their own meter because of infection control concerns but sometimes the CMAs would take one glucometer and complete the FSBS tests for all their assigned residents. The DON stated the CMAs should sanitize the glucometers between residents if they did that. The DON stated she had not conducted any monitoring to ensure staff were following the process she had implemented. The DON verified the CMAs worked on all halls in the facility. On 2/2/23 at 12:39 PM, the Director of Clinical Services (DCS) provided the names of all residents who received FSBS tests. R23, had a diagnosis of chronic viral hepatitis C listed. d. R23's Admission Record, included diagnoses of chronic viral hepatitis C and diabetes mellitus type 2. R23's Physician Order, dated 6/4/21 revealed R23 was to receive a fasting blood sugar test every Friday. During an interview on 2/2/23 at 1:50 PM, CMA4 stated she cleaned the glucometers with alcohol wipes between residents when she used the same glucometer. 2. On 2/1/23 at 5:32 AM, watched Registered Nurse (RN) 2 preparing an oral medication for R45. RN2 entered R45's room, administered the medication, picked up R45's water mug and assisted R45 with a drink. RN2 carried R45's water mug from the room, placed it on the medication cart, and without sanitizing her hands, began preparing an oral medication for R39. RN2 entered R39's room, administered the medication, and moved R39's water mug and soft drink container. R39 requested additional medication. RN2 left R39's room without sanitizing her hands, prepared the medication, reentered R39's room, and administered the medication. RN2 left R39's room, and without sanitizing her hands, went to the service entrance door on hall 200, opened the door, searched for a water pitcher, went to the kitchen service door, and obtained a new water pitcher. RN2 went back to the medication cart, opened the cart, and then sanitized her hands. During an interview on 2/1/23 at 6:00 AM, RN2 confirmed that she did not sanitize her hands before leaving the residents' rooms. RN2 stated it was facility policy to do so. During an interview on 2/2/23 at 10:25 AM, the DON stated staff should sanitize their hands before leaving a resident's room if a resident or their belongings had been touched during the medication pass. 3. R38's Admission Record, included a diagnosis of dementia. R38 ' s Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/11/23 revealed the resident had a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating severely impaired cognition. The MDS listed R38 as always incontinent of bladder. On 1/30/23 at 11:50 AM, observed CMA1 providing incontinent care for R38 in her room. CMA1 donned gloves without sanitizing her hands. CMA1 cleaned R38's perineal area, doffed her gloves, and rolled R38 to her right side. CMA1 removed gloves from her pocket, donned them, wiped R38's buttocks, doffed her gloves, and removed a clean incontinent brief from the bedside table. CMA1 donned new gloves, applied an ointment to R38's buttocks, doffed the glove on her right hand, and donned a new glove. CMA1 adjusted R38's briefs and clothing, removed R38's pants, doffed her gloves, and retrieved clean pants from R38's closet. CMA1 finished dressing R38, transferred her to the wheelchair, and propelled R38 to the dining room. CMA1 then propelled R24 to her room. CMA1 then sanitized her hands. During an interview on 2/3/23 at 10:00 AM, CMA1 confirmed that she did not perform hand hygiene when performing incontinent care for R38 and stated it was facility policy to perform hand hygiene before donning gloves, after doffing gloves, and before leaving a resident's room. During an interview on 2/2/23 at 10:25 AM, the DON stated per the facility's policy, staff should perform hand hygiene when entering a resident's room to perform incontinent care, if their gloves become visibly soiled during care, and when leaving the resident's room. She stated it was to help prevent cross-contamination. 28154 4. During an observation of tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing, held open by hard cannulas) and catheter care on 2/1/23 at 9:10 AM, Registered Nurse (RN) 3 completed a hand wash at Resident (R) 2's room sink at 9:12 AM that included a 15 second hand scrub (the vigorous rubbing of soaped hands together), then turned the water off and pulled paper towels to dry her hands. After completing the trach care, at 9:24 AM RN3 performed a hand wash that had a 16 second hand scrub, turned the water off and then pulled the paper towels to dry her hands. After completion of draining the urinary catheter bag, at 9:40 AM RN3 performed a hand wash that included a six second hand scrub from the pushing of the soap dispenser to the water being turned off, then the paper towel was pulled to dry her hands. During an interview on 2/3/23 at 1:29 PM, the Director of Nursing (DON) stated she expected staff to do a 15 - 20 second hand wash when entering a room, if hands become soiled, with glove changes, and wash hands when leaving the room. When asked about when the water should be turned off in the sequence, the DON stated, The water should be turned off after you dry your hands with a paper towel.

Based on clinical record review, observations, family and staff interviews, and policy review, the facility failed to prevent resident weight loss and overall health decline for one of three residents reviewed for oral cares and maintenance of nutritional status (Resident #4). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) admission assessment dated [DATE] documented Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident had a brief interview for mental status score of 0 indicating severely impaired cognition. The MDS documented the resident had no natural teeth or tooth fragment (edentulous), weighed 182 pounds (lbs), and on a mechanically altered diet. The MDS documented the resident required extensive assistance of one person for eating. The MDS assessment dated [DATE] documented Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident admitted to the facility from the hospital on 4/29/22. The MDS revealed the resident had impaired short-term and long-term memory, and severely impaired decision-making skills. The MDS recorded the resident's weight at 187 lbs, on a mechanically altered diet, and required extensive assistance for eating. The boxes under MDS Section L regarding broken or loosely fitting full or partial dentures was left blank. The MDS recorded the resident had speech therapy (ST) services 5/6 - 6/1/22. The care plan focus area revised on 6/27/22 identified the resident had altered nutrition related to a recent [CONDITION(S)], dementia, and advanced age. Staff directives included to serve a pureed diet with thin liquids, provide supplements as ordered, monitor intake and weights as directed, provide assistance of one staff for eating and oral care, and notify the physician and family with changes as needed (PRN). The care plan did not address the resident's oral status or presence or care of dentures. The admission narrative assessment dated [DATE] documented Resident #4 had a full set of dentures, and the resident had a risk for weight loss and swallowing issues. An admission/skilled nursing note dated 4/29/22 indicated the resident did not use dentures/partial. The electronic health record recorded the following weights: 6/2/22 186.2 pounds (Lbs) 6/9/22 186.8 Lbs 6/28/22 178.2 Lbs 7/1/22 178.5 Lbs 7/13/22 173.0 Lbs 7/14/22 173.4 Lbs 7/21/22 171.8 Lbs 8/1/22 171.8 Lbs 9/3/22 173.2 Lbs (note: weight loss 3.75 % over 1 month from 7/1/22 to 8/1/22, and weight loss 6.98 % in 3 months from 6/2/22 to 9/3/22). The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The order summary report revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/21/22 an order added that the resident may have mechanical soft texture as needed (PRN) with supervision, and shall remain on pureed diet for meals. A ST Evaluation and Plan of Treatment dated 5/6/22 revealed resident referred to ST after hospitalization . The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident on a pureed diet with thin liquids. Resident pocketed pureed textures and able to hold some fluids. ST recommendations included pureed diet and thin liquids and close supervision. ST Discharge Summary 6/1/22 revealed recommendations the resident remain on a pureed diet with thin liquids with staff assistance as needed. ST Evaluation and plan of treatment dated 7/28/22 revealed resident referred to ST per family request to determine if resident could consume any other kinds of foods such as a mechanical soft consistency. Prior treatment recommendations included a pureed diet. Oral motor structure and function intact. Resident initially downgraded to pureed diet after she pocketed several mechanical soft textures. The resident at risk for aspiration and further decline in function. ST notes dated 9/21/22 revealed resident seen for addressing oral function deficits. Resident seen in PM (afternoon) hours as she was upgraded to have mechanical soft textures PRN. Family had requested mechanical soft textures. ST provided new diet recommendations to nursing and kitchen staff, the resident shall remain on a pureed diet but may have mechanical soft textures with supervision. The dietary progress notes revealed the following weight change notes: a. On 6/28/2022 at 12:04 PM, monthly weight: 185.8 lbs and up 12.7% over 30 days - Weight down to 178.2# this week due to c-diff ([CONDITION(S)]) (bacteria infection) and loose stools. b. On 7/19/2022 at 12:07 PM, monthly weight: 173 lbs and down 7.4% over 30 days. Weight down due to previous c-diff and loose stools. Resident continues on [MEDICATION(S)] daily, a multivitamin, ice cream, and Hi Cal 90ml TID for increased calories and protein. Meal intakes good at this time with assistance. ST to evaluate resident for possible diet upgrade per family request. No dietary changes needed at this time. Will continue to monitor weekly for any further changes. c. On 7/26/2022 at 11:33 AM, weight 171.8 lbs and slowly trending down. Resident continues on [MEDICATION(S)] daily, a multivitamin, ice cream, and Hi Cal 90ml TID for increased calories and protein. Meal intakes good at this time with assist. ST to evaluate resident for possible diet upgrade per family request. No dietary changes needed at this time. Will continue to monitor weekly for any further changes. d. On 9/6/2022 at 11:14 AM, weight 173.2 lbs and stable at this time. Resident continues on [MEDICATION(S)] daily, a multivitamin, ice cream, and Hi Cal 90ml TID for increased calories and protein. No dietary changes needed at this time. Will continue to monitor weekly for any further changes. The progress notes lacked information regarding dentures used or missing dentures. Observations revealed: a. On 9/13/22 at 9:06 AM, the resident sat in a wheelchair in her room. A container with lower dentures sat on the counter in the room. The lid on the container was labeled unknown. b. On 9/13/22 at 12:30 PM, a CNA assisted the resident with eating a pureed diet. No dentures observed inside the resident's mouth. c. On 9/14/22 at 7:10 AM, resident wheeled in wheelchair to her room. A container with lower dentures sat on the counter by the sink. The lid on the container was labeled unknown. d. On 9/14/22 at 8:30 AM, resident sat in a wheelchair by the dining room and drank a glass of juice and fed herself a pureed entree. No dentures or teeth observed inside the resident's mouth. e. On 9/15/22 at 8:45 AM, lower dentures continued to sit in a container on the counter by the sink in the resident's room. The lid on the container had a label unknown. The resident sat in a wheelchair in the dining room and had eaten breakfast. f. On 9/19/22 at 10:15 AM lower dentures sat in a container on the counter in the resident's room. The lid on the container had a label unknown. In an interview on 9/12/22 at 5:25 PM, a family member reported a concern Resident #4's not eating much, and had lost weight. The family member expressed concern about the resident's dentures lost. The family member reported she last saw the resident with dentures on 7/17/22. Another family member visited the resident twice in 8/2022 but the resident did not have dentures at that time. The family member told the nurse when she noticed the dentures missing. A nurse told them her dentures were lost when residents got moved around during COVID-19. In an interview 9/20/22 at 3:35 PM, the social worked (SW) reported on 9/14/22, she received notice the family reported Resident #4's dentures missing. The family member wanted the facility to find them. The SW reported Resident #4 resided in the 300 hall. When the facility had a case of COVID-19, the resident got moved a couple of times. The SW stated early 8/2022 as the last COVID-19 case in the facility. The facility staff looked around and tried to find the missing dentures. A nurse reported she found bottom dentures but dentures not marked with a name or initials and when staff tried to see if they would fit, the dentures didn't fit, so she thought they were not Resident #4's dentures. The SW reported Resident #4 had a dental appointment arranged on 9/22/22 to go get refitted for new dentures. On 9/22/22 at 12:20 PM, a family member reported she took her mom to the dentist 9/22/22 to get her re-fitted for dentures because her dentures had been lost. The dentist told her they were unable to do the fitting because it had been so long since she had worn dentures they couldn't get her mouth open far enough to do the fitting. The family member stated feeling devastated because she felt the last things left for her loved one's life were the ability to eat and enjoy food. She noticed the resident didn't have dentures on 9/7/22 when she visited the resident. She asked the nurse and staff where her mom's dentures were. The nurse told her the dentures were missing for a month. She was on a mechanical soft diet but now on pureed diet. The next day, someone found some lower dentures but they weren't the resident's teeth. The nurse on dayshift on 9/8/22 said they were going to clean them up and then try to put them in her mouth to see if they would fit. She told them they were not her dentures. The (lower) dentures still sat in her room on 9/22/22 even though they don't belong to this resident. She also spoke with the SW on 9/12/22 about the missing dentures and the SW said she needed time to look for them. She gave facility a few more days to find them but then she took it upon herself and called and made a dental appointment for the resident. In an interview 9/15/22 at 3:40 PM, Staff C, LPN, stated she had worked at the facility since 8/2022. Resident #4's daughter came to her and asked about the resident's dentures. Staff C told her she didn't know the dentures were missing but would look for them. The daughter told her she reported it before, and staff reported they were looking for them. Staff C stated some dentures sat by the nurse's station, and she thought the dentures possibly could be Resident #4's but after they cleaned them up and tried to put the dentures in the resident's mouth, the dentures didn't fit. Staff C stated she looked in laundry but the dentures she found by the nurse's station were the only dentures she found that day. Staff C acknowledged Resident #4's dentures not found yet. In an email 9/22/22 at 5:29 PM, the Director of Nursing (DON) wrote: Resident #4 had a dental appointment on 9/22/22 that her daughter set up and they were unable to get the impressions completed because Resident #4 kept pushing the plates out of her mouth. The dentist tried three different times and were unsuccessful according to the staff member that accompanied her. The Social Services director also called another dental service on 9/13/22 to inquire if they could do the impressions for Resident #4's dentures. Unfortunately, the dentist had just been at the facility this month and it would be a couple months before they would be back. A follow up email 9/22/22 at 6:28 PM from the DON regarding the length of time dentures missing on Resident #4. The DON responded she believed the grievance form stated the dentures had been missing since COVID-19 outbreak. The first time Resident #4 moved to another room was 7/28/2022. In an interview 9/26/22 at 12:25 PM, Staff U, ST, reported uncertain if Resident #4 had dentures. She had never seen her wear any dentures. Staff U relayed the resident was on a mechanically altered diet when she was admitted but then her diet changed to a pureed diet when staff noticed she had trouble eating and swallowing. Staff U reported she saw Resident #4 three times a week and tried to determine the best and safest food texture for the resident. Staff U reported uncertain if the resident had weight loss, but the resident didn't appear like she had lost weight when she looked at her. A Nutrition and Hydration Policy updated 1/16/22 revealed the facility is committed to ensuring each resident maintained acceptable parameters of nutritional status and sufficient fluid intake to retain proper health, and to prevent, monitor, and intervene for undesirable weight loss for all residents. Resident weights measured at least monthly and reviewed by the Dietitian. Any negative trends in weights evaluated by multidisciplinary team to determine whether or not the criteria for significant weight change met. Interventions for undesirable weight loss shall be based on a careful consideration of resident choice and preference, nutritional needs of the resident, and functional factors that may inhibit independent eating, chewing or swallowing abnormalities and the need for diet modifications.

Based on record and policy review, observations, resident and staff interviews, the facility failed to follow up effectively when a resident threatened suicide and failed to provide the recommended psychiatric services for a resident with mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff also failed to minimize the risks of a resident who had past suicide attempts, failed to follow through with notifications to the physician and family, and failed to provide increased monitoring or securing the environment from potential hazards such as utensils (knife, fork), call light and bed control cords, TV wires, and oxygen tubing that could be used potentially to self-harm. This failure resulted in an immediate jeopardy that was removed on 10-13-21 after the facility took corrective action to assess residents' with increased depression and [CONDITION(S)], and provided staff education regarding policies and procedures for residents who had suicidal ideation/threats. These actions lowered the deficiency from a scope and severity of J to D, with the need for ongoing monitoring of hazards to maintain residents' safety. The facility reported a census of 43 residents. Findings include: The admission minimum data set (MDS) assessment dated [DATE] recorded Resident #39 admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive deficits. The MDS revealed the resident had little interest or pleasure in doing things 12-14 days, felt bad about herself 7-11 days, and felt down and depressed 12-14 days. The assessment documented Resident #39 received antianxiety medication 2 of 7 days and antidepressant medication 4 of 7 days during the look-back period. The MDS documented the resident required extensive assistance of two staff for bed mobility and hygiene, and total dependence on two staff for transfers, dressing and toileting. The 5 day MDS assessment dated [DATE] revealed Resident #39 had little interest or pleasure in doing things 12-14 days, felt bad about herself 12-14 days, and felt down and depressed 12-14 days. The MDS documented the resident took antianxiety and antidepressant medication 7 of 7 days during the look-back period. The Preadmission Screening and Resident Review (PASRR) dated 8/11/21 revealed a level I determination on 8/11/21 and approval for 30 days, and a PASRR re-evaluation required if resident expected to be in the facility longer than 30 days. The PASRR documented Resident #39 admitted on [DATE] and had a suspected mental health disability, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident took [MEDICATION(S)] and [MEDICATION(S)] for [CONDITION(S)] disorder, and [MEDICATION(S)] for anxiety. The PASRR Level II dated 9/17/21 had a short-term approval until 3/16/22, and deemed the resident required specialized services for behavioral health. Resident #39 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The PASRR documented the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A psychiatric evaluation was completed 2/2021 due to concern for depression. Triggers included changes in medical status, not feeling like others treated her with respect or respecting her preferences, major life changes, and recent marital conflict. A PHQ-9 tool dated 8/2021 used to assess depression revealed the resident scored 15 out of 27, which suggested moderate depression. The resident took [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] to help manage her health symptoms. The PASRR assessment recommended services and supports of ongoing psychiatric services for medication management and rehabilitative services based on her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] According to staff interviews and chart review, the resident was not offered these services until 10/13/21. The care plan initiated on 08/17/2021 and revised on 09/23/2021 lacked any references to the PASRR recommendations or interventions related to the mental health needs of the resident. The care plan lacked information regarding the resident receiving antidepressant and antianxiety medications, or the medication side effects. The care plan also lacked information regarding the resident's alleged suicidal thoughts and history of suicide attempts, and staff directives or interventions for keeping the resident safe. A problem area regarding the resident used antianxiety medications for anxiety disorder was added to the care plan on 10/11/21 after the surveyor spoke with Staff J, MDS Coordinator. The medication review report dated 10/1 - 10/31/21 revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] 20 milligrams (mg) every day (qd) for depression (started 8/17/21) b. [MEDICATION(S)] 0.5 mg twice a day (BID) for anxiety (started 8/26/21) c. [MEDICATION(S)] Delayed Release 500 mg x 3 tablets at bedtime (qhs) for [CONDITION(S)] disorder (started 8/16/21) d. Monitor for behaviors or acute side effects of [CONDITION(S)] medications (started 8/25/21). A PHQ-9 assessment (used to assess possible depression) completed on 8/18/21 and 9/24/21 revealed the resident scored 15 out of 27, which suggested moderate depression. A multidisciplinary care conference note recorded 8/26/21 revealed the resident had increased anxiety and had a PRN (as needed) order for antianxiety medication. The care conference note documented therapy staff had to give the resident tough love as she tried to push off standing until the following day. It took several attempts for the staff to assist the resident to stand, then anxiety and fear took over the resident and she sat herself back down into the wheelchair. The resident often required lots of cues and motivation. The progress notes revealed the following: a. On 8/16/21, resident admitted to the facility from the hospital with a fractured right ankle. b. On 8/26/21, new order for [MEDICATION(S)] 0.5 mg BID for anxiety. c. On 9/12/21 at 03:32 AM, a certified medication aide (CMA) reported to the nurse the resident told her she wanted to kill herself due to certified nurse's aides (CNAs) mean to her and mistreating her. The nurse spoke with the resident about her complaints and asked her to elaborate on what happened. The resident reported CNAs Staff EE and Staff S told her she needed to stop pushing her call light every 5 minutes, and later told the resident they would be back after the resident reported she had a BM (bowel movement). The resident stated the CNA's came back about 20 minutes later and did not do a thorough job of cleaning her. The resident told the CNA to be careful with her right lower extremity as it hurt when they bumped into it several times. The resident stated the CNA's told her she needed to stop crying about it. The resident stated I'm scared of them and I want to kill myself because the CNAs are so mean to me. d. On 9/17/21 at 06:22 AM, the resident continued to complain of anxiety at times and very anxious part of the overnight shift. e. On 10/9/2021 at 8:45 PM, CNA found a butter knife tucked under Resident #39's left calf during a brief change. The resident reported a kitchen lady brought the knife and resident told the CNA I'm going to end it all. The knife was removed from the resident's room after the nurse told the CNA to remove it. The chart lacked evidence that the resident received increased monitoring (i.e. no 15 minute checks or follow up monitoring of the resident) during this time, and the care plan lacked interventions to guide the staff in appropriate interventions to keep the resident safe. The record also lacked information regarding notification to physician or family regarding resident suicidal thoughts or threats. On 10/05/21 at 12:10 PM, Resident #39 reported some staff are mean to her but wouldn't elaborate on which staff or specific details. The resident reported it depended upon the staff who worked. On 10/11/21 at 12:05 PM, Staff J, MDS coordinator, reported the PASRR found under miscellaneous in the electronic health record (EHR). Staff J stated the social worker (SW) entered PASRR information on the resident's care plan on the EHR whenever the PASRR recommended services. On 10/11/21 at 01:00 PM, the SW reported she coordinated services and developed the care plan related to the PASRR whenever she received recommendations from the PASRR. The SW reported Resident #39 had a PASRR determination 9/17/21, but the service matters report not due until 10/22/21, so she did not list information on her care plan related to PASRR and recommended services as she was in the process of calling the insurance to determine in-network providers, and make referrals for the resident. Once she put the care plan together related to PASRR, she submitted the information to a State contracted agency for review. On 10/11/21 at 02:10 PM, Staff J, Registered Nurse (RN) reported she worked at the facility in the MDS Coordinator role since 8/8/21, and responsible for completion of care plans. Staff J reported whenever a new resident admitted to facility, they filled out the admission assessment on the EHR, which triggered certain areas for care plan. Staff J stated they reviewed the care plan with the resident or family. Staff J reported she identified concerns related to care plans not complete after she began the MDS role and she put together an action plan. Staff J reported she was in the process of updating care plans. Staff J reported care plans developed upon admission, updated at least quarterly, and for any new changes. Staff J reported she obtained information for care plans from staff, the progress notes, residents, and through her own observations whenever she worked the floor. The CAA's (care area assessment) helped her develop a resident's care plan and what she should include. Staff J reported she expected antidepressant and antianxiety medications, behaviors, and what to watch for included on the care plan. On 10/12/21 at 02:15 PM, Staff M, LPN (licensed practical nurse), reported she would call the physician and power of attorney (POA) right away if a resident had [CONDITION(S)] or stated he/she wanted to kill himself/herself. Staff M stated she would check about getting psychiatric services set up and remove any objects in the resident's room that had the potential for self-harm, do 15 minute checks on the resident and document on the form the time and location of resident, and send the resident to the hospital if needed. Staff M reported the 15 minute check form kept in a file drawer at the nurse's station, but any behaviors documented in the nurse's notes under a behavior note. On 10/12/21 at 02:25 PM, Staff Y, CNA, reported the staff CNA's documented resident behaviors in the EHR, and also filled out a Stop and Watch paper whenever she had concerns about a resident. She gave the stop and watch paper to the floor nurse and DON. Staff Y reported if a resident acted different or out of their normal behavior, or said something about harming themselves, she would redirect the resident, spend time talking with the resident, and fill out a Stop and Watch slip of paper. On 10/12/21 at 02:30 PM, the SW reported she suspected possible abuse if a resident appeared withdrawn, isolated, tearful, or refused to have a certain person care for them or be in their room. The SW stated she would report suspected abuse to the DON (Director of Nursing) and Administrator, but she would also call and report the concern as she is a mandatory reporter. The social worker stated staff let her know if a resident had suicidal thoughts or comments. If a resident had suicidal comments or ideation, she talked to the resident and asked the resident if they had a plan to threaten or self harm. Then she let the physician know and do appropriate steps such as send the resident to the hospital. The SW reported staff documented in the EHR on the hot rack charting and any behaviors in a progress note. The SW reported Resident #39 had a lot of anxiety, and needed lots of encouragement, especially whenever she worked with therapy. The SW encouraged the resident to do things so she could get better and go home. The SW reported she and the DON spoke with Resident #39 on 10/11/21 after the DON saw a note the resident may want to hurt herself. The resident laughed at the DON and SW when they spoke with her. The SW said the resident said Really? Do you really think I would do that? and then questioned how she could hurt herself with a butter knife. The SW stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She told the resident to let her know if she felt that way and asked about setting up an appointment with psychiatry service. She did not write any notes or document in the EHR after she spoke with the resident, or notes related to contacting the insurance to check benefits for psych or in-network providers, or calls made to the psychiatry office. On 10/12/21 at 02:40 PM, the DON reported she expected staff call the physician and a manager whenever a resident had suicidal comments or threatened to harm themselves. She expected staff to document 15 minute checks if they had concerns about the resident. The DON reported Resident #39 got anxious at times whenever staff got her up or whenever she had therapy. The resident had some potential suicide thoughts on the night of 10/10/21, so the DON and SW spoke with her on 10/11/21. At that time, the resident reported no plans to harm herself but had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . When she questioned the resident the resident laughed and scoffed at them as to how she could do anything with a butter knife. She discussed setting up psychiatry services and the resident agreed. The DON acknowledged she had not entered any notes about the conversation with Resident #39 but planned to enter a note in the EHR when she had time. On 10/12/21 at 02:55 PM, Staff M, reported if staff conducts 15 minute checks a resident, they place the form in the resident's chart after completed. Staff M advised a stack of papers at the nurse's station needed filed in the residents' charts. No document found regarding 15 minute checks for Resident # 39 in the pile of papers that needed filed or in the resident's paper chart. On 10/12/21 at 03:05 PM, the DON acknowledged she was unaware of Resident #39's statement on 9/12/21 she wanted to kill herself. The DON reported no 15 minute checks document found for Resident #39 for incident on 9/12/21 or 10/9/21. The DON reported she would look for a policy regarding behavioral assessment and interventions. On 10/12/21 at 04:27 PM, the DON reported she recalled going the disciplinary route with staff involved with Resident #39 on 9/20/21 because the resident told her the reason she wanted to kill herself was because staff had mistreated her and unkind to her. The DON provided the surveyor a copy of the concern/grievance form related to incident reported to her on 9/13/21. On 10/13/21 at 11:00 AM, Resident #39 had a flat affect and sad facial expression, and became tearful as she spoke to the surveyor. The resident reported a male in therapy reminded her of her dad who was really mean to her. When the male therapist spoke, it brought back negative thoughts about her dad and she just shut down. The resident reported a couple of staff who worked together were vicious and mean to her. The staff tell her she can move her fat ass and roll herself in bed. The resident stated she didn't know if she could mentally make it. The resident said a CNA saw her with a knife in her hand but she didn't even know she had a knife or was holding it. The resident stated she felt scared about her mental state and what she would do, and didn't feel safe at the facility. The resident stated she had talked to the DON and SW. Observation showed on 10/13/21 at 11:00 AM, as the surveyor spoke with the resident, a set of silverware (a knife, fork and spoon rolled in a napkin) on a bedside table, a call light cord by the bed, bed control cord on the bed, and the resident had oxygen via nasal cannula on. All of the items were within reach of the resident. On 10/13/21 at 01:35 PM, the DON confirmed no physician notification and no 15 minute checks completed on Resident #39 when the resident made comments about harming herself or when she had a knife. The DON reported she planned to follow up and address safety measures for Resident #39. On 10/14/21 at 08:59 AM, the Administrator reported no education provided to staff regarding care of residents with mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In a Behavioral Assessment, Intervention, and Monitoring policy revised 3/2019 revealed the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The policy revealed the following: a. Behavioral symptoms identified using a behavioral screening tools and comprehensive assessment. b. Behavioral health services provided by qualified staff who had the competencies and skills necessary for provision of appropriate services to the residents. c. As part of the initial assessment, the nursing staff and attending physician shall identify individuals who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . d. A level II PASRR evaluation report used for development of the care plan. e. Nursing staff identified, documented, and informed the physician about changes in an individual's mental status, behavior, and cognition, including any recent precipitating or relevant factors or triggers. A new onset or changes in behavior documented regardless of the degree or risk to the resident or others. f. Safety strategies implemented immediately to protect the resident and others from harm. g. The care plan shall include a description of the behavioral symptoms, targeted and individualized intervention for behavioral and/or psychosocial symptoms, and how staff monitored the effectiveness of the interventions. A policy for Comprehensive Person Centered Care Plans revised 12/16 revealed a comprehensive person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan will include measurable objectives and timeframes, describe the services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, incorporate identified problem area, incorporate risk factors associated with identified problems, and reflect treatment objectives. Assessments of residents are ongoing and care plans revised as information about the residents and conditions changed. According to the facility assessment updated on 10/1/21, the facility had the capacity to provide for medical conditions and services for mental health conditions such as depression, [CONDITION(S)] disorder, anxiety disorder and behaviors. The assessment revealed staff training and competencies offered for the provision of the level and types of support and care needed for these residents, as well as the identification of changes in a resident's condition, and implementation of interventions. The facility removed the IJ concerns on 10/13/21 and the IJ was lowered to a D when they implemented the following.: a. All residents had a PHQ9 assessment completed for increased depression and suicidal ideation on or before 10/13/21. Any resident who scored high on the PHQ9 or showed signs of increased depression/suicidal ideation referral to the primary care provider for further psychiatric evaluation and treatment. b. All employees received education regarding policy and procedures for suicidal ideation or threats prior to working the floor. c. Any resident who had [CONDITION(S)] or threats immediately transferred to the ER for further psychiatric review. d. Resident with suicidal ideation placed on 1:1 supervision on 10/13/21 and transferred to the ER for psychiatric evaluation. e. AD HOC meeting occurred with medical director and department management on or before 10/13/21. f. All findings will be reviewed quarterly at QA, and QAPI processes with the medical director for further system improvement, implementation and educational needs. The State Agency notified the facility of the IJ on 10-13-21.

Based on record and policy review and staff interview, the facility failed to ensure a resident received adequate nursing supervision for a resident with a history of falls for 1 of 3 residents reviewed. Resident #19 fell in his room with fracture on 4-18-21. The intervention following the fall was resident to be in the lobby area after getting up. The current care plan, and care plan in place on 4-18-21, directed staff to assist resident to lay down in-between meals or place in recliner. The resident fell again with fracture 7-29-21 after staff left him unsupervised in his room in a wheelchair. The facility reported a census of 43 residents. 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #19 with diagnoses that included: [CONDITION(S)] ([CONDITION(S)]), non-Alzheimer's dementia, [CONDITION(S)], COVID-19, and muscle weakness. The MDS indicated the resident had a Brief Interview for Mental Status score of 3, which indicated cognition severely impaired. The resident required extensive assistance of one staff for bed mobility, transfers, toileting, and ambulation in his room and the corridor. The MDS documented the resident had unsteady balance and used a walker and wheelchair, but no falls. The MDS assessment dated [DATE] revealed Resident #19 readmitted to the facility from the hospital on 8/3/21, with diagnoses of: left femur neck fracture (hip fracture), [CONDITION(S)], and difficulty walking. The MDS documented the resident had a major surgical procedure (repaired hip fracture) during the prior hospital stay and now had a surgical wound. The MDS indicated the resident required extensive assistance of two staff for bed mobility, transfers, and toileting, and no ambulation occurred during the look-back period. The MDS indicated the resident had impaired range of motion to the lower extremity, exhibited non-verbal sounds of pain, and took opioid and anticoagulant medication. The care plan initiated on 7/22/20 revealed the resident had impaired cognition, a self-care deficit requiring assistance for activities of daily living (ADLs), and a risk of falls with injury related to vascular dementia. The staff directives included the following interventions: o Encourage resident to ask for assistance if weak or tired initiated on 07/22/2020 o Low bed with fall mat initiated on 07/22/2020 o Neuro checks per facility protocol for any suspected head injury initiated on 07/22/2020 o A lipped mattress and wedge for positioning initiated 02/16/2021 o Assist resident to lay down in-between meals or place in recliner initiated 02/23/21. o Check and change and reposition resident every 2 hours and as needed initiated 04/19/2021 o Keep all follow up appointment with ortho initiated 04/19/2021 o Wear sling to left shoulder/clavicle at all times for support and healing initiated 04/19/2021, and resolved on 08/04/2021 o Dycem in recliner to prevent resident from sliding out initiated on 8/03/21 o Provide peri-care with every incontinence episode and as necessary initiated on 8/20/21 o Resident to be in recliner or bed when in room. Resident needed to be in supervised area for increased monitoring whenever in wheelchair initiated 08/03/2021 and revised on 8/30/21 The fall risk assessment dated [DATE] revealed Resident #19 had a score of 11 which indicated he had a high risk for falls. The assessment revealed the resident had diminished safety awareness and balance problem when he stood or walked. The fall risk assessment dated [DATE] revealed a score of 19 which indicated the resident had a high risk for falls. The progress notes revealed the following: a. On 2/16/21 at 12:01 AM, resident found on the mat next his bed with no apparent injuries and no signs of pain. Resident assisted back to bed with two staff. b. On 2/16/21 at 3:12 AM, resident heard chanting and found on mat on the floor next to his bed. A positioning wedge had slid out and laid on the floor next to him. The resident had no apparent injuries and moved all extremities. Resident assisted back to bed by two staff. c. On 4/18/21 at 6:20 AM, resident found lying on his left side and had a skin tear to his left elbow. Neuro checks initiated and an x-ray ordered. d. On 4/18/21 at 12:19 PM, a portable x-ray of left shoulder done. e. On 4/18/21 at 1:20 PM, nurse practitioner (NP) notified the resident had a non-displaced fracture to his distal clavicle. Resident sent to the emergency room (ER) for evaluation. Resident returned from the ER at 6:30 PM and had a sling on (L arm) for support. Resident to follow up with orthopedics physician in 5-7 days. f. On 4/20/21, NP saw the resident and ordered [MEDICATION(S)] (narcotic) four times a day (QID) for 14 days. g. On 7/29/21 at 3:36 PM, resident found on the floor behind his wheelchair at the foot of the bed around 10:00 AM. Resident assisted onto his back. Left leg appeared shortened and externally rotated. NP and 911 notified; h. On 7/29/21 at 10:09 AM, Staff KK, RN, paged to resident's room. A med aide, two CNA's, and Staff GG, RN, in room. Resident observed on floor lying flat on his back. Left lower extremity shorter in length and resident complained of pain to his left hip. Resident unable to rate his pain but observed to be shaking. Staff confirmed the fall was unwitnessed. Resident unable to effectively communicate events. POA notified and resident sent to the ER. i. On 7/30/21 at 5:05 PM, resident remains in the hospital. diagnosed with a closed left hip fracture and had hip repair surgery. j. On 8/3/21 at 3:33 PM, resident readmitted to the facility from the hospital after a left hip fracture. Resident complained of pain and had staples intact to left hip incision. An EZ stand and two staff assistance required for transfers. k. On 8/4/21 at 12:49 PM, resident yelling out in pain with any movement and seemed very uncomfortable while sitting in the wheelchair. Staff reported resident appeared to have increased pain as the day went along. Spoke with NP and received order for [MEDICATION(S)] (narcotic) three times a day for 5 days, then change [MEDICATION(S)] to every 6 hours as needed (PRN). Incident reports revealed the following: a. On 4/18/21 at 6:20 AM, Resident #19 observed lying on his left side on the floor in room. Resident unable to give description of what happened. Neuro checks initiated, ice pack applied, and x-ray notified. The intervention included resident to be in the lobby area after getting up. b. On 7/29/21 at 10:01 AM, Resident #19 found on floor in room with left lower extremity externally rotated and shorter in length. The resident complained of left hip pain and observed shaking. 911 and POA called. The staff communication book revealed Fall Interventions for Resident #19 included the bed in low position and a fall mat placed next to the bed (as of 7/28/20), resident placed in recliner or bed whenever in his room, or he needed to be placed in commons area if in his wheelchair (dated 8/3/21). The communication book lacked information regarding fall interventions after 4/18/21 fall with injury. The facility's investigation report revealed the following: a. On 7/29/21 at approximately 10 AM, Resident #19 found on the floor in his room, laying on his right side. Staff GG, RN, and Staff KK, RN, noted resident complained of left hip pain and his left leg externally rotated. 911 called and resident transferred to the ER. X-ray of bilateral hips showed a left hip intertrochanteric fracture. The resident admitted to the hospital and had surgery on 7/30/21. The facility's investigation determined the following events occurred on 7/29/21 and verified via hallway video surveillance: At 8:45 AM, resident assisted back to his room by Staff JJ, CNA. Staff JJ reported she completed pericare and assisted the resident into his recliner. His feet were elevated and he had a call light within reach. At 0940 AM, Staff II, restorative aide (RA) did restorative therapy and range of motion exercises in the resident's room. The resident was in his recliner and voiced no complaints. At 9:48 AM, Staff DD, CNA, walked past the resident's room and noted Resident #19 attempting to get out of his recliner. Staff DD assisted the resident into the wheelchair in his room. At 10:05 AM, Resident #19 found on floor in his room. It was determined the resident either attempted to get up out of the wheelchair or slid out of the wheelchair. The intervention included resident brought to common area for increased monitoring whenever in the wheelchair. If in room, resident placed in recliner or in bed, and a dycem placed in recliner to prevent the resident from sliding; An Emergency Department (ED) physician's note dated 7/29/21 documented Resident #19 presented to the ED after a fall. The resident stated his legs got caught up on his chair and he fell . Staff found the resident down around 10:00 AM. The resident had deformity, shortening, and external rotation to left leg. Left hip range of motion limited by the resident's pain. X-ray of left hip revealed an acute comminuted left intertrochanteric fracture with apex varus angulation (toward the body's midline). A major injury determination form signed by the NP on 7/30/21 revealed the resident incurred a left intertrochanteric hip fracture injury on 7/29/21 at 10 AM after the resident attempted to get up from his wheelchair and fell . Resident required assistance of one staff for all cares prior to the fall. The NP documented after reviewing circumstances, injury, and prognosis of the resident, the injury sustained was not a major injury, and believed the resident would return to his previous level of function. An internal medicine progress note dated 8/2/21 revealed the resident admitted to the hospital on 7/29/21 for a displaced comminuted left hip fracture, and underwent IM (intramedullary nail) fixation on 7/30/21. The resident had post-op [CONDITION(S)] and received packed red blood cells on 8/1 and 8/2 for hemoglobin 6.3 and 7.0. Admission hemoglobin was 13.3. The plan included anticoagulation therapy for DVT (blood clot) prophylaxis, pain, antibiotics, [CONDITION(S)], and therapies per orthopedics. On 10/7/21 at 9:00 AM, Staff DD, CNA reported she worked at the facility for 6 years, and worked the 6 AM-2 PM shift. Staff DD reported on the day in July when Resident #19 fell , she came out of the shower room and heard Resident #19 screaming out. Staff DD stated she went across the hall and saw Resident #19 trying to get up from his recliner. She asked the resident what he needed. The resident wanted to get up, so she assisted him into his wheelchair. Staff DD reported she had just completed a shower on another resident, and the resident sat in the hallway and waited for her as she moved Resident #19 into the wheelchair. She then took Resident #41 to her room. Staff DD told Staff B, CNA, Resident #19 hollered and tried to get up, so she assisted him into his wheelchair and asked Staff B to check on him. Staff DD reported she was uncertain when Staff B went back to check on Resident #19. Staff DD stated she thought the conversation with Staff B occurred around 9 AM or shortly after Staff DD went on break. Staff DD reported when she came back from break, she noticed the ambulance at the facility, and later found out Resident #19 fell . Staff DD reported Resident #19 as normally confused and hollered frequently whenever uncomfortable or incontinent. Staff DD couldn't recall if the resident experienced other falls. The resident required extensive assistance of one staff for cares and transfers at the time prior to the fall. On 10/13/21 at 10:30 AM, Staff B, CNA, reported she worked at the facility for 7 months, but only worked part-time. Staff B reported she worked on the 200 hall on the day Resident #19 fell in 4/2021. Staff B stated she transferred Resident #19 from his chair into his wheelchair. The resident said he had to go to the bathroom, so she turned to get his walker, and as she turned her back, the resident stood up and tripped over the wheelchair pedals and fell . Staff B stated this incident is when the resident broke his elbow or clavicle. Staff B reported she worked on 7/29/21. They were short staffed with 2 CNA's in the 200 hall, 1 CNA on the 100 hall, and a float, so the cna's helped in all areas. Staff B reported she was told by Staff DD the Resident #19 was in his wheelchair but Staff B stated she got busy helping other residents and didn't get back to check on him. Staff B reported this was the time Resident #19 fell and fractured his hip. On 10/7/21 at 9:20 AM, Staff GG, Registered Nurse (RN) reported she worked at the facility since 7/14/21, and worked the 6 AM- 6 PM shift. Staff GG stated she was not real familiar with residents at the time of Resident #19's fall incident because she just started in her job and in the process of learning about the residents. Staff GG reported on the day of Resident #19's fall (in July), she saw the resident lying on his right side on the floor as she walked down the hall. The resident's leg appeared externally rotated and shortened. At the time, she requested someone to call 911, and did a quick head to toe assessment. The resident complained of hip pain but unable to tell her what happened. Staff M, LPN, took over after that so Staff GG could go to a meeting. On 10/11/21 at 4:00 PM, Staff JJ, CNA, reported she worked at the facility since 11/2020, and worked the 6 AM -2 PM shift. Staff JJ reported she was uncertain whether Resident #19 tried to get out of his recliner on the day when he fell . She didn't see the resident fall. Staff JJ saw the resident in his room but couldn't recall if he was in his recliner or his bed. Staff JJ stated the resident had fallen before and hurt his collar bone but doesn't know of any other falls. Staff JJ reported the care plan interventions included the resident needed to be in his bed or recliner to prevent him from falling and knew he was not allowed to be in the wheelchair by himself in the room. Staff JJ reported no walker or chair by the resident to prevent him for trying to sit up or get up on his own. Staff JJ reported the facility had a staff communication book for staff to read about any new care plan interventions. Staff responsible for knowing the changes, and initialed the communication in the book when read. Staff JJ reported the communication book kept by the nurse's station, and she read the communication book each shift whenever she worked. On 10/7/21 at 12:08 PM, Staff HH, Agency CNA reported she worked agency only a few shifts for a month. Staff HH reported she was familiar with residents and recalled the incident when Resident #19 fell and fractured his hip. Staff HH stated Resident #19 didn't talk and staff had to assist the resident with moving. He required assistance of one staff, gait belt and a walker prior to the fall (in July). Staff HH reported after they transferred him from his recliner or his bed, she moved his walker and wheelchair out of site or he tried to get up and transfer on his own. On the day of the incident, she heard someone screaming. She found Resident #19 on the floor, lying on his back with his head toward the window and feet toward the door. Staff HH stated she didn't know where the resident was prior to the fall, or whether he was in the recliner chair or his wheelchair. The resident laid on his back, his left leg was rotated out, and he seemed to be in pain. Staff HH reported she was uncertain if the resident had had any prior falls. On 10/11/21 at 2:45 PM, Staff II, RA (restorative aide), reported she worked PRN at the facility. Staff II recalled on 7/29/21, she performed restorative range of motion exercises for Resident #19 while he laid in bed or his recliner. Staff II unable to recall exactly if Resident #19 lying in bed or his recliner on the day of his fall. Staff II reported she thought the resident was laying down because it was between meals, but he laid down in his recliner too. Staff II recalled the resident fell and fractured his hip. Staff II reported the resident had confusion, and at times, he got an idea in his head he could go to the bathroom by himself, and tried to get up. The resident had a walker which she kept out of his site so he wouldn't try to get up on his own.

Based on clinical record review and physician and staff interviews, the facility failed to appropriately intervene after a resident exhibited physical signs/symptoms of a decline in status over a two week period (#3) and failed to assure another resident received physician ordered interventions to promote wound healing (#2) of 9 total residents reviewed. The facility reported a census of 61 residents. Findings include: 1. According to the [DATE] Minimum Data Set (MDS) assessment, Resident #3 had [DIAGNOSES REDACTED]. The MDS documented the resident required the assistance of 2 staff for activities of daily living (ADLs). The [DATE] revised Care Plan identified return to the community as deemed not feasible as Resident #3 had a history of [REDACTED]. The facility's Change of Condition Process dated ,[DATE] instructed that assessment and intervention will vary depending on the extent of a change in resident's condition and the involvement of the interdisciplinary team when necessary. The nursing process of Assessment, Plan, Intervention and Evaluation will be used to ensure the optimal outcome for the resident. The process also noted that the physician's involvement is always required as is a follow-up assessment. Final test results dated [DATE] at 5:40 p.m. documented the lab notified the resident's doctor of elevated blood sodium results on [DATE] at 5:38 p.m. The physician then ordered Resident #3 to transfer to the ER (emergency room ) for evaluation and treatment of [REDACTED]. A nurse's note dated [DATE] at 6:23 p.m. documented Resident #3 transferred to the ER. A nurse's note dated [DATE] at 11:08 p.m. documented that Resident #3 admitted to the Critical Care Unit (CCU) with [DIAGNOSES REDACTED]. A nurse's note dated [DATE] at 3:15 p.m. documented Resident #3 returned to the facility from the hospital. The nurse's assessment revealed Resident #3 had a regular heart rate with diminished lung sounds and audible wheezes in his lungs. A nurse's note dated [DATE] at 11:17 a.m. documented Resident #3 was weak with irregular lung sounds throughout and an irregular, thready (weak) pulse. The nurse also noted Resident #3's skin felt cool to the touch, his left grip as being stronger than his right and he leaned more towards his right side. A nurse's note dated [DATE] at 1:52 a.m. documented Resident #3 had an irregular, thready pulse, diminished lung sounds throughout, an inability to comply with instruction to grip his hands and a respiratory rate of 24 breaths per minute. A telephone order dated [DATE] instructed staff to obtain a basic metabolic panel (BMP; a lab test) at the next lab draw. A nurse's note dated [DATE] at 3:40 a.m. documented Resident #3 with a pulse of 141, diminished lungs sounds throughout with inspiratory and expiratory wheezes. Final test results dated [DATE] at 9:40 p.m. documented lab staff notified the facility on [DATE] at 9:35 p.m. of Resident #4's elevated potassium levels. A telephone order dated [DATE] at 10:30 p.m. instructed the facility to send Resident #3 to the ER due to a critical potassium level. A nurse's note dated [DATE] at 3:55 a.m. documented that Resident #3 returned from ER. A recheck of his potassium level in ER and came back normal. A nurse's note dated [DATE] at 10:59 a.m. documented Resident #3 had diminished lung sounds throughout, an irregular and thready pulse, a pulse of 145, a blood pressure of ,[DATE], unequal grips and weak and skin cool to the touch. A nurse's note dated [DATE] at 3:03 a.m. documented Resident #3 had diminished lung sounds throughout with an irregular, thready pulse and weak, unequal grips. At 2:54 p.m. Resident #3 had diminished lung sounds throughout, an irregular, thready pulse with weak, unequal grips and skin cool to the touch. A nurse's note dated [DATE] at 3:38 a.m. documented Resident #3 had diminished lung sounds throughout, an irregular, thready pulse and weak, unequal grips. A telephone order dated [DATE] directed to check Resident #3's potassium in 1 week. A nurse's note dated [DATE] at 11:12 a.m. documented Resident #3 had diminished lung sounds throughout, an irregular, thready pulse with weak, unequal grips, skin cool to the touch and a blood pressure of ,[DATE]. A nurse's note dated [DATE] at 4:31 a.m. documented Resident #3 had a blood pressure of ,[DATE], respirations of 24 breaths per minute, pulse of 112 beats per minute, cold hands with gray nail beds. A nurse's note dated [DATE] at 4:29 a.m. documented Resident #3 had a pulse of 117. On [DATE] at 3:44 a.m. Resident #3 had a pulse of 116, respirations of 26 and gray nail beds. On [DATE] at 3:40 a.m. Resident #3's blood pressure measured ,[DATE] and he had audible inspiratory and expiratory wheezes. A nurse's note dated [DATE] at 3:40 a.m. documented Resident #3 had continued audible inspiratory and expiratory wheezes. A nurse's note dated [DATE] at 10:55 a.m. recorded Resident #3's lungs sounded diminished throughout and he had dyspnea (difficulty breathing) with activity. Final test results dated [DATE] at 8:43 p.m. noted Resident #3's potassium measured at the upper limits of the normal range (5.1). A nurse's note dated [DATE] at 6:50 a.m. recorded Resident #3 had continued diminished lung sounds throughout, a fever with a temperature of 99.1 F (Fahrenheit), a pulse of 123 and respirations of 26. At 12:16 p.m. Resident #3 continued with diminished lung sounds throughout and now had a persistent non productive cough. The nurse wrote Resident #3 sometimes had labored breathing, an irregular and tachy (fast) pulse of 126 and tended to be sleepy, even at the table while eating. On [DATE] at 3:38 p.m., nurse's notes recorded continued diminished lung sounds throughout, a persistent non-productive cough, labored breathing and an irregular, tachy pulse. The nurse also wrote that Resident #3 tended to be sleepy at the table when eating and had a pulse rate of 142. A nurse's note dated [DATE] 1:32 p.m. documented Resident #3 as being sleepy, even at meals. The nurse also documented the resident's pulse rate measured 122. A telephone order dated [DATE] documented that Resident #3 should be sent to ER for further evaluation and treatment of [REDACTED]. On [DATE] at 12:26 a.m. a nurse's note documented Resident #3 sounded awful with audible congestion heard from the doorway at about 9:00 p.m. that evening. The resident had labored breathing at rest at a rate of 38 breaths per minute. Resident #3's skin was pale, cool and diaphoretic (sweaty) to the touch. Staff contacted the on-call physician who ordered the resident to the ER for further evaluation and treatment. A Discharge summary noted that Resident #3 presented inER on [DATE] at 11:01 p.m. with an altered mental status, [MEDICAL CONDITION] (infection) with septic shock, pneumonia due to hemophilus influenza, acute kidney injury secondary to pneumonia and acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (lack of oxygen). ER notes on [DATE] at 11:10 p.m. recorded the doctor's assessment of pertinent positives including blood pressure ,[DATE], pulse 160, temperature 100.8 F, respirations 56 with severe respiratory distress, diffuse rhonchi (abnormal lung sounds) with upper airway noise, [MEDICAL CONDITION] with irregular rhythm and unresponsiveness to painful stimuli. According to an untitled document, the doctor noted he pronounced Resident #3 dead on [DATE] at 10:10 a.m. with [MEDICAL CONDITION] (abnormal heart rhythm) secondary to [MEDICAL CONDITION] (elevated potassium levels) which occurred as a result of septic shock with acute [MEDICAL CONDITION] as the direct cause of death. An interview on [DATE] at 3:50 p.m. with Staff A, RN revealed that she wanted to cry when she looked back at Resident #3's situation. Staff A said she last saw Resident #3 on [DATE]. Staff A said if you looked at his charting, you can see that he gradually got sicker and sicker. Staff A said nobody called the doctor about his signs and symptoms at any point before he got sent out and died from [MEDICAL CONDITION]. On [DATE] at 12:42 p.m., when asked if staff notified the doctor of their assessment findings between [DATE] and [DATE], the Director of Nursing (DON) stated she submitted all the doctor's notifications that she could find. The DON said she thought someone should have called the doctor about the resident's change in status and/or notified him while at the facility. An interview on [DATE] at 11:25 a.m. with Resident #3's doctor revealed he expected the facility to notify him and keep him informed if their documentation included assessments of an elevated pulse of 140 and hand grips weaker on one side. The doctor said if their assessments included an elevated pule and weak hand grips, the facility missed some opportunities to intervene sooner and should have been more vigilant in light of their findings and Resident #3's history. 2. According to the [DATE] MDS assessment, Resident #2 had [DIAGNOSES REDACTED]. The resident required the assistance of 2 with transfers, the assistance of one with dressing, toilet use and personal hygiene and did not walk during the assessment period. The MDS recorded Resident #2 had 7 venous or arterial ulcers, [MEDICAL CONDITION]/s and open lesion/s on his foot. The [DATE] Care Plan instructed Resident #'2 needs would be anticipated and met by staff every day for 90 days due to the potential for impaired cognition. The Care Plan also instructed staff to administer medication as ordered, to promote adequate nutrition and hygiene due to Resident #2's risk for impaired skin integrity and documented a right leg amputation on [DATE]. The Medication Discharge Report dated [DATE] at 7:33 a.m. documented that all necrotic wounds on Resident #2's right foot should be painted with [MEDICATION NAME], covered with gauze and woven around and between each toe every day (QD). The Patient Care Order Sheet dated [DATE] at 11:51 a.m. directed staff to place a dry dressing with Kerlix to the right lower extremity (RLE) QD. A nurse's note dated [DATE] at 1:54 p.m. recorded Resident #2 readmitted to the facility following hospitalization for a right [MEDICAL CONDITION] (BKA). Physician orders [REDACTED].#2's right leg. A cardiology note dated [DATE] recorded Resident #2 had been seen by a physician that day who ordered the incision site of the [MEDICAL CONDITION] to be cleansed with [MEDICATION NAME] and then wrapped BID (twice a day). A nurse's note dated [DATE] at 12:05 p.m. documented Resident #2 returned from a vascular appointment with a new order to paint [MEDICATION NAME] to the right leg surgical incision, wrap it with Kerlix and change it QD. A Peripheral Vascular note dated [DATE] documented the resident with lower [MEDICAL CONDITION] and a right BKA. Resident #2 had a large eschar (dead tissue) medially (inside of the leg) and a smaller one laterally (the side of the leg). After removal of the gangrenous (dead) skin, the physician identified a small amount of purulence (fluid caused by infection) medially and an old hematoma (localized collection of blood) laterally. The doctor documented the resident's middle staples as intact, but his medial and lateral incision staples had been removed in the areas where there was a wound care issue. The doctor thought the wound should heal with daily packing with wet to moist dressings and debridement (removal of unhealthy tissue) in a couple of weeks. The plan included a subsequent visit for re-debridement in 2 weeks. The (MONTH) (YEAR) TAR (Treatment Administration Record) documented staff cleansed the resident's RLE incision with an unspecified cleanser, covered it with clean 4x4s (gauze) and secured the guaze with Kerlix QD from [DATE] through [DATE], even though the [DATE] order discontinued the wound dressing to the right leg and another order had not been obtained for treatments until [DATE] with [MEDICATION NAME] BID. The TAR also documented staff cleansed the RLE incision with an unspecified cleanser, covered it with clean 4x4s (gauze) and secured with Kerlix BID from [DATE] through [DATE], despite the [DATE] order specifying that the incision should be cleansed with [MEDICATION NAME] and wrapped BID. The TAR also documented staff packed Resident #2's stump with gauze strips moistened in normal saline and wrapped with gauze BID from [DATE] through [DATE], despite the [DATE] order instructed a daily treatment instead. The Peripheral Vascular note dated [DATE] documented the 2 week follow up for [MEDICAL CONDITION] and lower right BKA. The physician recommended operative debridement to the right medial and lateral incision with necrotic tissue. The doctor also noted the need to get a handle on the infection to make sure Resident #2 did not lose his BKA stump and convert it to above the knee amputation. The doctor wrote that Resident #2 may be a candidate for a wound vac (vacuum device used to heal wounds) and at this point there is too much infection, but after a couple days of wound changes in the hospital it might be a possibility. The Vascular Discharge Summary noted that Resident #2 admitted to the hospital on [DATE] and discharged on [DATE]. The resident's had [DIAGNOSES REDACTED]. The resident had debridement of the right stump and placement of a wound vac to be utilized after being discharged . The discharge order also indicated the stump should continue to be packed with gauze strips moistened in normal saline and wrapped with roll gauze BID. The plan included a follow up appointment in 2 weeks for a wound check. A nurse's note dated [DATE] at 6:58 p.m. noted that Resident #2 readmitted to the facility after hospital stay for debridement. New orders accompanied the resident for a wound vac on 3 areas of his stump. The Peripheral Vascular recheck note of [DATE] documented a post-hospital and [DATE] debridement follow up. Resident #2 presented with a mild low-grade infection and also clotted blood on the wound surface, rendering the wound vac ineffective. The doctor ordered to discontinue the wound vac and initiate wet to dry dressings BID, to wash the wound thoroughly in the shower with water QD to keep the bacterial count down and a 2 week follow up appointment. The physician progress notes [REDACTED]. A nurse's note dated [DATE] entered late for [DATE] recorded Resident #2 had been seen for a follow up to the wound debridement. Staff received new orders to discontinue the wound vac and begin wet to dry dressings TID. The nurse's late entry lacked documentation the doctor also ordered the wound to be washed thoroughly with water in the shower every day. The (MONTH) (YEAR) TAR documented staff packed Resident #2's stump with gauze strips moistened in normal saline and wrapped with gauze BID from [DATE] through [DATE], despite the [DATE] order stipulating QD instead of BID. The TAR also documented the right stump had been treated with a wound vac on [DATE] and [DATE], although the [DATE] hospital discharge ordered use of the wound vac and also said the stump should continue to be packed with gauze strips moistened in normal saline and wrapped with roll gauze BID. Facility staff failed to clarify the order. The TAR documented staff dressed the resident's right stump with wet to dry dressings moistened with normal saline TID from [DATE] through [DATE]. The Peripheral Vascular Recheck dated [DATE] noted a 2 week follow up for a wound check as the reason for Resident #2's appointment. The doctor commented on the much improved BKA wound and ordered to continue wet to moist dressings BID (down from TID) and cleansing in the shower at least QD. The physician also ordered a 1 month follow up appointment. The physician progress notes [REDACTED]. The nurse's noted dated [DATE] at 3:48 p.m. recorded Resident #2 returned from an appointment with a new order for a wet to dry dressing to be changed BID using normal saline, despite the [DATE] order directing application of wet to moist dressings instead of wet to dry. The (MONTH) (YEAR) TAR documented staff dressed Resident #2's right stump with a wet to dry dressing moistened with normal saline TID on [DATE] through [DATE]. The TAR recorded staff dressed his right stump with a wet to dry dressing moistened with normal saline BID on [DATE] through [DATE], despite the [DATE] order for wet to moist dressing instead of wet to dry. Correspondence dated [DATE] notified Resident #2's primary care provider that Resident #2's right leg stump wound had slightly increased in size and they would continue with current wet to dry dressing and monitoring. The document also noted the next vascular appointment scheduled on [DATE]. The physician progress notes [REDACTED]. The doctor ordered wet to moist dressing to be changed BID to the right BKA wounds and a follow up appointment in 3 months. The order also recommended a rehab consult. A nurse's note dated [DATE] at 1:47 p.m. noted that Resident #2 returned from an appointment for wet to moist dressings to the right BKA twice a day, his current treatment order. Tentatively, there will be a 3 month follow up appointment. The (MONTH) (YEAR) TAR recorded staff dressed Resident #2's right stump with a wet to dry dressing moistened with normal saline BID on [DATE] through [DATE], despite the [DATE] and [DATE] orders for wet to moist dressing instead of wet to dry. During interview on [DATE] at 12:15 p.m., Staff C, LPN (Licensed Practical Nurse) recalled going into Resident #2's room one morning when he came in early as the wound nurse. Staff C noticed litter on the resident's floor that nobody cleaned up. The litter and a couple other things caused him to be irritable. He suspected Resident #2's right stump dressing had not been changed for the second time that day, so he checked on it. Staff C said his initials and date stamp were still on it from the day before, indicating it had not been done for the second time that day. Staff C said he approached the overnight nurse responsible for completing the dressing change and had her do the change before she left that morning. Staff C recalled a similar situation with another nurse. He found his own initials and date he last changed Resident #2's dressing, indicating the other nurse failed to change the dressing on his shift. Staff C said he wrote the staff member up the next morning. On [DATE] at 11:00 a.m., the DON stated the resident's (MONTH) TAR as of [DATE] stipulated that staff should cleanse Resident #2's incision site with [MEDICATION NAME] before wrapping the BKA BID. Due to a transcription error, the (MONTH) TAR simply instructed staff to cleanse the incision site, but did not stipulate what to cleanse it with. Instead of correcting the TAR to reflect the order, the DON said she expected each person to go to the chart and refer to the order. When asked if she could see how by not correcting the TAR, the potential for error increased, the DON agreed that it seemed reckless and she expected someone to notice the mistake and correct it. A subsequent interview on [DATE] at 8:15 a.m. with Staff C revealed more details about the time he discovered that a nurse failed to complete a dressing change. When asked about the possibility the offgoing nurse still had time and the intention to change the dressing before the end of the shift, Staff C said he approached the nurse about 6:05 a.m. standing at the nurse's station with her coat on and about to leave the building. Staff C said he made her take off her coat and change the dressing before she left.

Based on clinical record review and physician and staff interviews, the facility failed to administer treatments as prescribed to promote pressure ulcer healing for 1 of 3 residents sampled for wound treatments (Resident #1). The facility reported a census of 61 residents. Findings include: 1. According to the 3/9/18 Minimum Data Set (MDS) assessment, Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of 1 to 2 staff for all activities of daily living (ADLs). The assessment also noted Resident #1 had the risk for developing pressure ulcers. The MDS indicated Resident #1 received pressure ulcer care for one existing ulcer, a Stage 4 ulcer measuring 4.0 by 4.4 centimeters. The MDS identified the following descriptions of pressure ulcers: **Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. **Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured blister. **Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. **Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The 1/25/18 Care Plan recorded Resident #1 had a pressure ulcer to his right heel and treatment changes on 2/15/18, 3/8/18 and 3/29/18. The Care Plan instructed staff to promote adequate nutrition and hygiene and to report symptoms of infection to the doctor and responsible party as needed. The Care Plan also documented Resident #1 had the risk for infection related to poor nutrition and the pressure ulcer. The undated Wound Care Management policy documented the facility's standard as the promotion of healing of any wounds that are present on admission or acquired in the facility. physician's orders [REDACTED].#1's right heel, covered with gauze and secured with roll gauze and tape twice a day (BID). A telephone order dated 2/6/18 indicated that Resident #1 should be sent to ER to be evaluated. A Nurse's Note dated 2/6/18 at 5:38 p.m. documented an order to transfer Resident #1 to emergency room (ER) for fluids and an evaluation for treatment. The resident left for ER via ambulance at 4:50 p.m. A Nurse's Note dated 2/10/18 at 1:49 p.m. documented that Resident #1 returned to the facility after being hospitalized for [REDACTED]. The hospital Discharge Summary dated 2/10/18 at 4:35 p.m. recorded Resident #1 admitted on [DATE] and discharged on [DATE] with a principal problem of dehydration and a resolved acute kidney injury. The resident presented from the skilled nursing facility (SNF) with a chief complaint of dehydration. Resident #1 admitted to the hospital, received IV fluids with improvement and was cleared to go back to the SNF. The discharge orders did not include any treatments to Resident #1's wound/s. admission orders [REDACTED]. The resident's clinical did not contain an order for [REDACTED]. A physician's orders [REDACTED]. The order also instructed the wound should be covered with gauze and secured with roll gauze and tape. The (MONTH) (YEAR) TAR documented staff applied a [MEDICATION NAME] 10% solution to the resident's right heel wound, covered it with gauze wrap and secured it with roll gauze and tape BID from 2/2/18 through 2/6/18. Beginning on 2/16/18, staff documented application of [MEDICATION NAME] 10% solution to the right heel wound, covering it with gauze wrap and then secured with Kerlix and tape BID through 2/28/18. A physician's orders [REDACTED]. An Employee Counseling/Disciplinary Report dated 3/23/18 documented Staff C , LPN received a second written warning and final notice for documenting that he completed dressing changes he had not on 3/21 and 3/24/18. physician's orders [REDACTED].#1's right heel with 0.25% acetic acid and patted dry. Next, the wound surface should be painted with [MEDICATION NAME] with a piece of gauze wet with [MEDICATION NAME] the size of the wound, applied to it and changed daily (QD). The Wound Center Final Report dated 3/29/18 documented the progress notes of the Nurse Practitioner's (NP) assessment of Resident #1 and subsequent plan. The NP opened the resident's Stage 3 pressure ulcer on the right heel and obtained a culture. The NP documented her plan included applying [MEDICATION NAME] to the wound, covering it with gauze and securing it with roll gauze and tape. Skin prep should be applied to the wound margins prior to applying the wound dressing; change BID. The (MONTH) (YEAR) TAR documented staff applied [MEDICATION NAME] 10% solution to Resident #1's right heel wound, covered it with gauze wrap and secured the wrap with Kerlix and tape BID that month with the exception of treatments only being administered once on 3/12/18, 3/13/18, 3/23/18 and 3/27/18 and neither of the treatments provided on 3/26/18 and 3/29/18. The TAR indicated the treatment order had been discontinued on 3/29/18. The TAR noted a new treatment order beginning on 3/29 to cleanse Resident #1's right heel with 0.25% acetic acid, pat dry, paint the site with [MEDICATION NAME], apply a soaked gauze dressing the size of the wound and secure it with Kerlix twice a day. The (MONTH) (YEAR) Administration Record documented staff did not complete the treatments scheduled for 3/12/18 and 3/13/18 and 3/29/18 at 6:00 p.m. due to the resident being asleep. Staff did not apply the treatments on 3/26/18 and 3/27/18 at 6:00 p.m. because the resident refused. The record contained no documentation that staff re-approached the resident at a later time. The TAR documented no provision of the 6 a.m. treatment on either 3/29 or 3/31/18. physician's orders [REDACTED]. The resident's MAR indicated [REDACTED]. A nurse's note dated 4/2/18 at 1:55 p.m. noted a new order had been obtained for an antibiotic to be injected QD for 5 days for an infection to Resident #1's heel. An Employee Counseling/Disciplinary Report dated 4/17/18 recorded Staff D, RN received a written warning for not effectively doing treatments on 4/9/18 and 4/15/18. The warning documented Staff D signed for having completed treatments that he had not. The wound nurse took off the treatments from a previous day shift with the employee's initials on it when it was understood the treatments were to be done BID. A nurse's note dated 4/18/18 at 11:10 a.m. recorded Resident #1 continued to have a Stage 4 pressure wound to the bottom of his heel and the wound nurse stated it appeared to be deteriorating. A nurse's note dated 4/21/18 at 12:43 p.m. noted that Resident #1 had purulent drainage with a foul odor dripping onto the floor. Resident #1 complained of increased pain from deep inside. The nurse documented that the resident requested to go to ER and he wanted to get it cut off. Staff obtained orders to transport Resident #1 to ER via ambulance. The nurse later spoke with hospital staff and learned Resident #1 might have osteo[DIAGNOSES REDACTED] (a bone infection) according to an X-ray. An entry at 3:30 p.m. documented Resident #1 admitted to the hospital with [REDACTED]. The (MONTH) (YEAR) TAR documented the administration of the resident's right heel treatment. The treatment orders instructed to cleanse Resident #1's right heel with 0.25% acetic acid, pat it dry, paint the site with [MEDICATION NAME], apply a soaked gauze dressing the size of the wound and secure it with Kerlix - Change daily. The TAR noted that staff administered the treatment every other day, instead of daily as ordered, from 4/1/18 and 4/21/18, at which time they discontinued the treatment. The Hospitalist's Discharge Summary dated 5/7/18 at 10:26 a.m. documented that Resident #1 admitted on [DATE] and discharged on [DATE]. The summary noted the resident's principal problem as a diabetic ulcer of the ankle with the fat layer exposed. Resident #1's active problems included post above right knee amputation, heart failure, high blood pressure, diabetes, [MEDICAL CONDITION] and peripheral artery disease. Resolved problems included osteo[DIAGNOSES REDACTED] of the right foot. According to the summary, Resident #1 admitted from the facility for a non-healing right heel ulcer with increased drainage and [MEDICAL CONDITION] (bacteria) infection. An MRI (imaging test) showed heel osteo[DIAGNOSES REDACTED] and a ruptured Achilles tendon; which ultimately resulted in an above the knee amputation on 4/30/18. The doctor noted that Resident #1 was stable and ready to be discharged to skilled care. During an interview on 7/9/18 at 3:50 p.m. with Staff A, RN stated she came to work one time and saw the dressing she put on the resident 3 days before her return to work. Staff A said her initials and the date she changed it were written on the dressing. Resident #1's right heel wound definitely got worse, it went from a stable wound to one you could smell down the hallway. Staff A stated the Director of Nursing (DON) makes lists of things that show on the computer as not completed and tells them to clear the reds. When asked, Staff A said that means charting at a later time and/or date that a task was completed. Staff A stated she returned to work another time after having some days off and found 3 vials of [MEDICATION NAME] intended for Resident #1's use in the top drawer of the med cart, after the antibiotic should have been completed. Staff A told the DON about it and witnessed her throw the vials away in the trash container on the medication cart. Staff A thought it was possible that they pulled the antibiotic from the emergency medication kit, which could account for the 3 remaining vials, but she suspected the antibiotics were not given. An interview on 7/10/18 at 9:15 a.m. with the facility's Pharmacist revealed that Resident #1 had an order for [REDACTED]. An interview on 7/10/18 at 12:15 p.m. with Staff C, LPN revealed that one of his duties as a wound nurse was to track the TAR and present a list of incomplete treatments and/or dressings to the appropriate staff person and instruct them to clear the reds. Staff C said nobody ever told him they did not remember completing a task or refuse to chart a late entry. Staff C stated they just took the list and did it and he has had to reconcile things as long as 2 weeks old, but he has a good memory. Staff C mentioned seeing a dressing he put on Resident #1's foot one day, after it should have have been changed again on the evening shift that followed him. Staff C could not remember the name of the person that failed to change the dressing, but recalled they charted they did it when they did not. When asked how he knew for sure that they did not do the dressing change, Staff C said his name and the date he changed it marked the dressing. Staff C believed it was one of two people because they frequently failed to change dressings. An interview on 7/11/18 at 8:00 a.m. with the DON revealed that Resident #1 went to the hospital on [DATE] and re-admitted on [DATE] without treatment orders. As a result, the record lacked documentation to verify that staff treated Resident #1's foot between 2/11/18 and 2/15/18. The DON checked to see if the wound nurse or re-admitting nurse called about orders, but she did not find any documentation to verify that. The DON said they should have at least called the hospital to see what they wanted to do after Resident #1 discharged on [DATE], but ideally they should have called the wound clinic. Resident #1 went to the Wound Clinic on the 2/15/18 or 2/16/18 and they faxed orders after the appointment. When asked about the times in (MONTH) the TAR indicated Resident #1's treatments were not done, the DON said they write an explanation of why it was not done elsewhere. The DON said the resident refused 3 times. When asked about the lack of treatment because the resident was sleeping, the DON stated the nurse should have tried waking the resident, administered the treatment or contacted the doctor. An interview on 7/11/18 at 9:25 a.m. with the Administrator revealed that Staff C had previously been reprimanded and demoted to floor nurse because he charted he did some dressing changes, when in fact he had not. The Administrator said other staff reported the dressing they found on a resident did not have the LPN's initials and date as he documented, but another staff's initials from the dressing change they did before Staff C charted he completed it. On 7/11/18 at 9:35 a.m. the DON stated the wound clinic ordered the 3/29/18 [MEDICATION NAME] dressing change daily and the nurse entered the order incorrectly. As a result, Resident #1 received treatments every other day instead of every day. The facility has a triple check system. The receiving nurse processes the order and has another nurse double check her. The DON did not know if the receiving nurse attempted to get the second check or if the second nurse didn't contact a nurse manager for the third check like they should have. The DON said that system fell apart. An interview on 7/17/18 at 11:57 a.m. with Staff B, RN revealed the facility always tells staff to make the 'reds go away'. They get a list of things like medications, treatments or tasks that are highlighted to indicate they have not been completed during their shift. Sometimes the list might be for something missed up to a week ago. There were times she didn't know if she completed some of the things on the list or just marked it completed to make the red go away. Staff B did not know what she should actually do and did not ask for an explanation; she does it to satisfy the facility because when they give each person the list, they want each employee to make it go away. Staff B did not think it's OK to sign off on something if staff are not sure whether they did it or not. Staff B believed everyone did it the same way she did, but it was not always possible to remember what you've done after having a few days off. An interview on 7/19/18 at 1:55 p.m. with the physician that discharged Resident #1 from the hospital on [DATE] after an above the knee amputation revealed the potential for the wound to get worse if dressings are not changed as frequently as they should be or if doctor's orders are not followed as prescribed. Depending on the circumstances, the doctor said of course it could lead to amputation if the wound was not properly cared for and the condition warranted amputation. The physician said he expected staff to follow doctor's orders. He said he expected them to notify him if his orders were not followed for any reason, even if another doctor thought a different treatment should be used. An interview on 7/19/18 at 2:20 p.m. with the Wound Center Triage RN revealed that if dressing changes are not done appropriately, as frequently as they are supposed to be, or if doctor's orders are not being followed then wounds can get worse. She also said depending on the amount of drainage and if the appropriate products are not being used, surrounding tissue can macerate and break down. The RN said wounds can also get contaminated and infected without proper hand hygiene. An interview on 7/19/18 at 4:20 p.m. with the Wound Center ARNP (Advanced RN Practitioner) revealed she saw Resident #1 once on 5/16/18. The ARNP said he had circulatory issues, [MEDICAL CONDITION] and diabetes and that is why they treated him with an antimicrobial like [MEDICATION NAME]; daily treatments can be very effective. The resident had osteo[DIAGNOSES REDACTED], but could not go through an MRI (magnetic resonance imaging) due to claustrophobia. If they were not doing treatments/dressing changes daily it could have caused his wounds to get worse and caused complications. Staff should have been following orders. The ARNP concluded if they invested the resources to have him sent to us, the facility would have had a vested interest in following our orders. The orders should have been followed to promote healing. An interview on 7/24/18 at 10:09 a.m. with Wound Center Medical Director revealed that if a dressing change does not get completed as often as it should, or if doctor's orders are not followed as prescribed, a chronic wound could get infected, develop osteo[DIAGNOSES REDACTED] and ultimately require amputation if necessary.

Based on clinical record review, staff interview, physician assistant interview, and facility policy review, the facility failed to monitor anticoagulant medication by completing a lab test for [MEDICATION NAME] (blood thinning medication) as ordered by the physician for Resident #1; and subsequently failed to assess bleeding as a sign/symptom of an adverse side effect of taking [MEDICATION NAME] for Resident #1, out of 7 total residents reviewed that received [MEDICATION NAME]. Resident #1 received [MEDICATION NAME] medication from 9/1/16 to 9/27/16, with an ordered to monitor his/her [MEDICATION NAME] (PT)/INR (International Normalized Ratio) on 9/22/16. Resident #1 continued to take his/her [MEDICATION NAME] medication without monitoring until 9/28/16 when the resident was sent to the emergency room for a change in condition. While in the emergency room , Resident #1's PT/INR was elevated to high critical level of 13 (with a therapeutic PT/INR range under 2.0 to 3.0). Interviews with the Director of Nursing revealed the laboratory test did not get done as ordered and the facility did not have policy for monitoring labs/[MEDICATION NAME]. The findings constitute an immediate jeopardy to the resident's health and safety. The facility reported a census of 52 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 identified [DIAGNOSES REDACTED]. The MDS recorded the resident received anticoagulation medication on 7 out of 7 days of the assessment reference period. The resident scored 3 out of 15 possible points on the Brief Interview of Mental Status (BIMS) cognitive assessment, which identified he/she severely cognitively impaired. The resident required extensive assistance for bed mobility, transfers, dressing, toileting and personal hygiene. The care plan identified a problem onset dated 10/28/15 of a risk for adverse consequences related to chronic health conditions that included CAD ([MEDICAL CONDITION]), Fib ([MEDICAL CONDITION]), and the resident took high risk medications. The care plan directed staff to obtain the resident's labs and report to the doctor when ordered. The care plan directed staff to obtain PT/INR ([MEDICATION NAME]/International Normalized Ratio - a lab test that measures how long it takes the blood to clot). The care plan directed staff to follow [MEDICATION NAME] changes as ordered by the doctor; and monitor the resident for s/s (signs/symptoms) of bleeding and notify the doctor. The September 2016 Medication Administration Record [REDACTED]. The PT/INR Request Meter sheet dated 9/8/16 documented PT/INR results of 29.9/2.5, with new orders to continue the [MEDICATION NAME] at 3.5 mg by mouth daily and recheck the PT/INR in 2 weeks. An INR range of 2.0 to 3.0 is usually considered therapeutic range. The Departmental Notes dated 9/8/16 at 10:23 a.m. documented the resident's PT/INR checked with no new orders and to recheck the PT/INR in 2 weeks; continue to monitor. The September calendar book for the 9/22/16 date contained an entry that listed the resident's name with PT/INR. The entry had been highlighted but not crossed off and did not have any writings beside it such as initials. The [MEDICATION NAME] Flow Record documented an entry 9/8/16 of a current [MEDICATION NAME] dose of 3.5 mg with PT/INR result 28.8/2.5, the physician's assistant notified, and the date of next PT/INR 9/22/16. The next entry occurred on 10/12/16 and no entry found for 9/22/16. Review of the clinical record revealed the record lacked documentation the PT/INR lab retested [DATE] as ordered. The fax dated 9/26/16 informed the physician the resident had large amounts of blood in his/her urine and on the brief. The fax requested a UA (urinalysis) and the physician's assistant (PA) signed an okay for the order. The fax contained no information regarding monitoring of the PT/INR or assessment of the bleeding as a possible side effect of taking [MEDICATION NAME]. The Departmental Notes dated 9/26/16 at 10:22 p.m. documented the resident had a large amount of blood, dark brown in color, in his/her brief, and a fax sent out to the physician to obtain a UA for possible UTI (urinary tract infection). The Departmental Notes dated 9/27/16 at 9:38 a.m. documented the resident's temperature reading (T) at 100.1 degrees Fahrenheit (F) with continued presence of hematuria (blood in the urine). The entry recorded a new order received to obtain a UA with C&S (culture and sensitivity) if indicated. The entry documented the nurse obtained the UA and sent it to the lab. The entry did not contain an assessment of possible side effects related to taking [MEDICATION NAME]. The PA's progress note dated 9/27/16 documented an evaluation completed upon staff request for increased lethargy, decreased appetite, fever of 101 degrees F, and hematuria. The note recorded the resident complained of dysuria (painful urination) and a sample (of urine) obtained with gross (large amount) hematuria (present). The entry documented the facility staff stated symptoms had been worsening over several days and the resident on [MEDICATION NAME]. The PA wrote assessment/plan hematuria, fatigue, fever - likely UTI. The PA ordered to check UA with C&S, BMP (basic metabolic panel), CBC (complete blood count) with diff (differential), PT/INR in AM, and start [MEDICATION NAME] (an antibiotic) 1 gm (gram) IM (intramuscular) daily for 7 days. The Departmental Notes dated 9/27/16 at 12:26 p.m. documented new orders received for UA with C&S if indicated, BMP, CBC with Diff, PT/INR in the AM., and [MEDICATION NAME] 1 gm IM times 7 days for UTI. The Departmental Notes dated 9/28/16 at 3:53 a.m. documented the resident started [MEDICATION NAME] for UTI with no ASE (adverse side effects) noted. The entry recorded a temperature of 99.8 degrees F with a large amount of bright red blood still in the resident's brief. The entry did not document physician notification of the continued bleeding. The Departmental Notes dated 9/28/16 at 11:47 a.m. documented the resident's vital signs (VS) as: BP (blood pressure) 198/136, P (pulse) 98, R (Respirations) 20, T 98.0, and Pox (pulse ox) 95% RA (room air). The entry recorded the presence of some bloody discharge noted with the (brief) change, the resident lethargic, and an increased coagulation time found with the PT/INR check. The entry documented the physician's assistant notified and an order received to send the resident to the ER (emergency room ) for evaluation and treatment. The Hospitalist Discharge Summary printed 10/11/16 documented under Discharge [DIAGNOSES REDACTED]. The resident back to normal after treatment with Vitamin K (increases the blood's clotting ability); and doubted a UTI. The hospitalist recorded a belief the hematuria blamed on a UTI when it was actually due to vaginal bleeding and bladder stone with no need for antibiotics. Under the Hospital Course section, the summary documented INR greater than 13 and diffuse bruising noted. An dated/untitled facility document revealed the following: the error (medication error) was identified when the hospital called and reported to the nursing home the resident's INR was 13. We immediately went back to Resident #1's chart to identify when the INR had last been checked. It was at this time that management realized that Staff A, LPN had missed an INR. An INR was done on 9/28/16, prior to sending Resident #1 to the ER (emergency room ); and the INR machine was giving an error code that meant the INR was elevated. This was then reported to the PA and the resident was sent to the ER. The facility documented nurse management now kept track of all INRs and when they are due next. The facility added this to the nightly duties to double check all the labs were done for the current day. The Medication Error report dated 9/29/16 documented an error of the INR not drawn or reported on 9/22/16. The report documented the outcome to the resident as a delay in treatment for [REDACTED]. The report documented corrective actions of staff education, INR flowsheet for management. The report section for measures taken to prevent recurrence of similar errors documented INR flowsheet started for nurse management and changed overnight duty to check calendar nightly. The report recorded the Director of Nursing (DON) notified on 9/28/16 at 3:00 p.m. of the error and signed the report on 9/29/16. The report recorded the physician's assistant notified of the error on 9/29/16 at 9:00 a.m. Staff A, licensed practical nurse (LPN), signed the error report on 10/7/16. The Departmental Notes dated 10/11/16 at 12:17 p.m. documented the resident readmitted to the facility following discharge from the hospital. The entry recorded the resident admitted to the hospital with [REDACTED]. The entry documented the resident's INR result in theER on [DATE] found to be 13.4 In an interview on 10/26/16 at 2:35 p.m., the DON stated an incident report had been completed for a missed PT/INR lab draw scheduled for 9/22/16. The DON said the resident started [MEDICATION NAME] which affected the INR levels so the resident went to the hospital. In an interview on 10/27/16 at 9:00 a.m., the DON stated Staff A worked the day the lab missed. The DON said prior to the error, no double check system in place to check the calendar to ensure all labs done. The DON commented after the incident she or the Assistant DON (ADON) kept a [MEDICATION NAME] flowsheet to track when the next lab draws due. In an interview on 10/27/16 at 12:00 p.m., the DON stated the facility had no policy or procedure for lab draws or administration of [MEDICATION NAME]. In an interview on 10/27/16 at 12:13 p.m., the PA stated the resident had blood in the urine and with hindsight could say the INR and infection in the urine contributed to the presence of the blood. The PA commented it would be hard to say if the [MEDICATION NAME] had an effect on elevated INR. The PA recalled speaking to the facility about the error and informed the facility her routine when residents are therapeutic to check INR every 2 weeks. The PA said the facility shared with her they implemented a triple check nurse process for orders. In an interview on 10/27/16 at 3:35 p.m., Staff B, LPN, stated she had not received any new training recently. Staff B reported she had not been asked to attend any training. Staff B informed labs are crossed off on the calendar when done. In an interview on 10/27/16 at 3:45 p.m., Staff C, LPN, stated some people highlight labs in the calendar book to indicate completed and some cross off. Staff C said everyone had a different method. Staff C reported he had received training for PT/INR labs about 2 years prior with nothing recent as the process remained the same. In an interview on 10/31/16 at 11:30 a.m., Staff A stated she missed the PT/INR lab draw. Staff A said she did not normally work days but when on nights, she pulled out the [MEDICATION NAME] flowsheets and wrote the name of the residents that needed labs done the next day. Staff A commented the other nurses did not do that and she did not have any lab sheets with her hall assignments that day. Staff A stated she did not do any labs that day because she thought the system was for the night nurse to prepare sheets and that's where the error occurred. Staff A said she first became aware of the error when the DON had her sign the med error form on 10/7/16. Staff A stated she was educated on 10/28/16 the night shift check the calendar and make sure lab draws done. The Employee Counseling/Disciplinary Report signed by Staff A on 10/31/16 documented a written warning for the employee missing the INR on 9/22/16 as ordered by the physician. The report documented the corrective plan of action for the employee to follow all physician orders. In an interview on 10/31/16 at 11:45 a.m., the DON stated she thought she would split out the appointment and lab books. The DON said prior to the incident, the facility had no certain system to designate if a lab draw completed, some crossed off in the book and some highlighted. In an interview on 10/31/16 12:20 p.m., the DON acknowledged she would expect the nursing staff to at least consider [MEDICATION NAME] use or increased INR as a potential cause of bleeding when first sign of blood present on 9/26/16. In an interview on 10/27/16 at 4:00 p.m., the DON reported an all-staff facility meeting scheduled for 10/28/16 at 1:15 p.m. The DON stated no staff aware at the time of the interview about the meeting addressing PT/INR training. The DON said she wanted to educate all staff at the same time. The DON commented she waited to educate about the night nurse triple checking labs because the nurse check at night just the triple check and management doing the double check. The DON reported only Staff A had been educated. The DON stated the all-staff meeting mandatory and if staff can't come they normally tell her ahead of time. The DON said no one said they were not attending the meeting. The Nursing Meeting October 28th, 2016 documented an agenda of topics to discuss at the all-staff meeting. The agenda included an entry for INR results from the hospital and missed INR. In an interview on 10/31/16 at 9:00 a.m., the DON reported she only educated the nurses that attended the in-service. The DON provided an undated, untitled, sign-in sheet. The sign-in sheet contained signatures of 6 nurses. Of the 6 in attendance, the DON reported 4 worked nights and she had those 4 sign individual education sheets on the new night nurse duties. The DON acknowledged she had no further plans to educate the other nurses on staff at the time of the interview. On 10/31/16 at 4:30 p.m. the HR (human resources) manager provided an updated staff roster that reflected a total of 14 nurses working for the facility. The facility policy titled Guidelines for Nursing Care - [MEDICATION NAME] ([MEDICATION NAME]) Monitoring dated 11/2016 NEW, documented a new policy for monitoring [MEDICATION NAME]. The purpose recorded as to provide nursing care that optimizes the safety and effective monitoring of residents during [MEDICATION NAME] therapy. The sub-title Monitoring included the following: The procedure identified provisions for the nurse to review residents prior to admission/pre-admission/ and current residents and to record labs on PT/INR flowsheet. The policy outlined provisions for Monitoring including recommending Target levels, notification to physician if sub therapeutic or elevated from desired target range and certain medications that can affect INR; and Point 5. Monitoring for unusual or prolonged bleeding or bruising should be part of the nursing assessment on an on-going basis. This can include bleeding gums after brushing teeth and blood in the stool. Teach resident, family and nursing assistants to report such changes to the nurse. The policy listed signs of overdose that included hematuria. The facility also added a policy (dated 11/2016 New) titled [MEDICATION NAME] Monitoring with important aspects of resident reassessment to include on the SBAR with detailed provisions to include assessment, observation, vitals, reporting current medications, and notifications to physician including but not limited to: reason for [MEDICATION NAME], most two Prior INRs (if possible), current dose of [MEDICATION NAME], INR results obtained prior to administering the daily dose of [MEDICATION NAME], any signs of bleeding such as hematuria or excessing bleeding, and any fall or sustained head injury. The Facility abated the IJ on 11/1/16 when they created a policy with guidelines for monitoring residents on [MEDICATION NAME] and educated all licensed nursing staff on the verification for daily accuracy of transcription onto MARs and Lab book by DON. The facility held a meeting on 11/1/16 to evaluate and implement plan monitoring progress thereafter. These actions lowered the severity level from J severity to D severity level with going monitoring being completed by the facility.

Based on record review, observation and staff interviews, the facility failed to provide adequate supervision to ensure against hazards to self and failed to serve an appropriate diet to meet the needs of the resident (Resident #5) and failed to keep the medication cart locked when unattended. The sample consisted of 5 residents and the facility reported a census of 50 residents. Findings include: 1. Resident #5 had an MDS (Minimum Data Set) assessment with a reference date of [DATE] which identified [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance with eating. According to the MDS the resident required a mechanically altered diet. Review of the Speech Therapy Progress Note dated [DATE] through [DATE] revealed bread taken off the resident ' s diet as the resident did not tolerate this during meals and showing signs/symptoms of aspiration. Review of the Change of Diet document dated [DATE] revealed the resident should have a mechanical diet, thin liquids, fruits cut into bite sized pieces and no noodles. On [DATE] the Change of Diet document revealed the resident should not have bread. Review of the Speech Therapy Discharge Summary revealed the resident required cuing for safe intake and sat at an assisted feeding table. The Nutritional Progress Notes dated [DATE] reflected the speech therapy evaluation recommended no bread. The Nutritional assessment dated [DATE] reflected the resident with decrease in chewing and swallowing and had a mechanical soft diet with no bread. The Care Plan dated [DATE] identified the resident had a history of [REDACTED]. The care plan directed staff to provide a mechanical soft diet with no bread. Review of the Departmental Notes dated [DATE] at 8:32 PM documented the following: At 7:20 PM the resident redirected from the outer dining room where/he/she wheeling (moving in chair) from table to table grabbing food off of the tables. The resident was directed towards his/her room. At 7:25 PM kitchen staff came out of the Bistro (dining room) yelling "he/she's choking, he/she's choking". Three nurses (licensed practical nurses) and RN (registered nurse) responded instantly. The resident in obvious respiratory distress noted by poor color, weak, wrenching like chest movements, unconscious and peaches and thick white substance falling out of the resident ' s mouth. Resident quickly moved to the floor and the Heimlich Maneuver process for an unconscious individual started. Peaches and white substance removed from the mouth by finger sweep method. At 7:26 PM staff called 911. At 7:28 PM resident reassessed as unconscious, without respirations and without pulse. Chest percussions started at 7:30 PM, ambu bag (administered oxygen) per face mask. Air went into lung freely with proper positioning of the neck and head and suing the jaw thrust maneuver. Color did not improve. 7:33 PM resident reassessed to be without pulse or respiration and color very dark. Staff changed positions and CPR resumed. At 7:33 PM EMS personnel arrived and took over CPR. 7:47 PM Paramedic unit arrived. Paramedic reviewed resident's [DIAGNOSES REDACTED]. Paramedics called on call Physician. At 7:53 the on call Physician called the code (to stop) and pronounced the resident deceased . CPR stopped. On [DATE] at 5:20 PM, Staff C (licensed practical nurse) was interviewed and stated the resident had been trying to grab food in the dining room and she personally took him out of the dining room and to his/her room. The resident did not have food in his/her mouth. She brought the resident into the dining room and gave him/her a sandwich and drinks. Staff C stated she was called for help and Staff N was in with the resident. Staff N had already removed food from the resident's mouth. The resident started grinding his/her teeth and clenched. The resident went unresponsive and staff lowered him/her to the floor. Staff performed more thrusts and removed peaches. Staff continued CPR (cardiopulmonary resuscitation) and the ambulance (crew) came and took over. On [DATE] at 8:20 AM, Staff N, (licensed practical nurse) was interviewed and stated she went into the dining room to check the resident's vital signs for during medication pass (administration of medications). Resident #5 did not look quite right with poor color, sweating and panic in his/her eyes. Staff N stated she looked for food in the resident's mouth. She called for Staff C to assist. Staff could not get anything out of the resident's mouth. The resident became unresponsive and staff then removed bread. They put the resident on the floor and started CPR after removing peaches, continued CPR and bagged (used ambu bag) the resident and the airway cleared. On [DATE] at 11:15 AM Staff O (licensed practical nurse) was interviewed and stated staff called for assistance with the resident in the dining room. The resident leaned forward in the wheelchair with clenched teach. Staff put finger in mouth and pulled out sandwich with bread and peaches after the resident went unresponsive. Staff O stated we could not see any more food in the mouth. Staff put the resident on the floor, did the Heimlich Maneuver, removed peaches and then continued CPR. Note: At the time of the complaint investigation, the complaint was coded at a "J", immediate and serious jeopardy. By [DATE] the facility implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "D: level. The facility had audited all current diet orders to verify the physician's orders [REDACTED]. The facility developed a list of residents with special fluid and diet needs and placed a copy in each medication administration binder for access by licensed nurses, provided in-services to all licensed nurses regarding the special fluid and diet needs list and placed a chain on the Bistro dining room door to prevent re-entry in to the dining room after meals until tables are cleared. As of the [DATE] exit conference, the facility needed to continue to: .Finish in-servicing staff to special fluid and diet needs list .Monitor the effectiveness of the chain on the Bistro dining room door .Monitor dietary tray cards match the physician's orders [REDACTED]. 2. Observation on [DATE] at 7:50 AM revealed the medication cart in hall 1 unattended and unlocked. The cart consisted of 4 drawers containing resident medication in bubble packs and stock medication bottles. Observation revealed the narcotics drawer locked. Per the facility resident list, 17 residents reside in Hall 1. On [DATE] at 7:52 AM, Staff C was interviewed and stated she had the medication cart locked and had opened it to put insulin away but then didn't lock it. She further stated she always keeps the medication cart locked. Review of the Policy and Procedure titled Storage of Medications revised [DATE] revealed the following: a. Compartments containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. The facility identified 3 residents with wandering behaviors.

1. An admission MDS ( Minimum Data Set Assessment) with a reference date of 1/22/13, identified Resident #14 with the following [DIAGNOSES REDACTED]., traumatic brain injury, anxiety disorder, depression, dysphasia, and insomnia. The resident scored 12 out of 15 on the Brief Interview for Mental Status scale which indicated some memory and cognitive impairment present related to daily decision making skills. The MDS coded the resident with difficulty sleeping at night, and exhibited behaviors not directed toward others on an average of 1-3 days during the assessment period. The MDS reflected the resident required extensive staff assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing needs. The MDS coded the resident as frequently incontinent of both bowel and bladder function. The MDS indicated the resident sustained [REDACTED]. The MDS assessment identified the resident received anti-psychotic and anti-depressant medications each day. The resident Care Area Assessment (CAA,) related to behaviors documented the resident sustained [REDACTED]. The CAA related to falls identified the resident with a history of falls and problems with slurred speech, ataxia (poor balance resulting in an unsteady gait), and dysphagia (difficulty with chewing and/or swallowing). The resident care plan developed on 1/28/13 identified a problem of being at risk for injury related to falls due to ataxia from a cerebrovascular accident and traumatic brain injury. The care plan interventions directed staff to do the following: a. Rule out Medical Complication with increased falls, b. Notify the MD and family of falls or injuries as needed, c. Monthly medication review, d. Ensure safe environment, free of clutter, adequate lighting, clean spills promptly, e. Transfer with assist of 1 staff, f. Use 2 when hyper-ataxic, g. Uses w/c ( wheelchair) for mobility ( pedals removed due to tripping over them 1/17/13), h. On 1/18/13 tipped w/c over in resident room. not to be left in room alone unless in bed, i. On 1/20/13, found on the floor from bed; to have bed in the lowest position when in it, floor mat to side of the bed, one side of bed moved against the wall, j. Restorative program to maintain strength and ambulation per order, k. Fall assessment on admission, quarterly, and with changes, l. Ensure appropriate footwear when out of bed m. Call bell in reach, n. Provide adequate lighting, o. Physical Therapy evaluation/treatment as indicated. The initial Fall Risk Assessment, completed on 1/15/13, identified the resident with a total score of 12. A score of 7-14 indicates a moderate fall risk and a care plan is indicated. Any resident with a fall should be considered high risk until fall free for 180 days. The staff monitored the resident daily for the following behaviors of agitation and impulsiveness related to standing up, attempting to self-transfer, and grabbing at other resident wheelchairs to aide self to stand. The resident was admitted to the facility on [DATE] following a hospital stay. At the time of admission to the facility the resident received Cogentin 0.5 mg ( milligrams) daily for tremors, lorazepam 0.5 mg 1 tablet every 6 hours as needed for anxiety, Paxil 20 mg daily at bedtime for depression, and Seroquel 50 mg every night for behaviors related to dementia. The incident reports identified the following falls: On 1/17/13 at 3:40 p.m. identified the resident out in the hallway, stood up out of the wheelchair using the side rail, fell against the wall and then fell to the floor with no resulting injury. The staff 's immediate post - incident action: removed the wheelchair pedals On 1/18/13 at 9:45 p.m. identified the resident was found on the floor in the resident ' s room with the wheelchair tipped over on side. The resident received a skin tear to the left forearm area. The immediate post-incident action: Place in bed when in room. The January MAR (Medication Administration Record) documented the resident received as needed Ativan in the evening on 1/18/13 but the record failed to identify the actual time the resident received the medication. On 1/20/13 at 4:30 a.m. staff found on the floor as the CNA (Certified Nursing Assistant) did rounds. The resident received another skin tear to the right forearm. The immediate action taken following the fall - bed up against the wall with a floor mat beside the bed and the bed placed in the lowest position. On 1/22/13 the physician ordered to increase the Seroquel dose to 75 mg daily at bedtime. The physician documented on the admission History and Physical report indicated the resident has been very agitated with the staff with increased behaviors demonstrated. On 1/28/13 at 9:00 p.m. the physician ordered Haldol 5 mg/ml (milliliter, antipsychotic medication) - give 0.5 mg/0.1 ml IM (injection into the muscle tissue) for a 1 time dose only due to severe agitation and restlessness. The nursing documentation on 1/28/13 at 9:00 p.m. reflected the resident as very agitated and restless this shift. The nurse administered 0.5 mg of Ativan at 5:00 p.m. with no results. The documentation indicated the resident as calm after 30 minutes upon receiving the IM Haldol. On 1/29/13, the physician ordered to change the Ativan to 0.5 mg orally or IM every 6 hours as needed and to add Requip (medication used to decrease involuntary tremors from restless leg syndrome ) 0.125 mg orally at supper for 7 days and then increase the dose to .25 mg daily at suppertime. The physician visit report summary reflected the staff requested the physician see the resident due to increased behaviors. The resident complained of legs feeling like they needed to move all of the time and felt like ants crawling on them especially when in bed. The physician documented just had an increase in Seroquel so not enough time elapsed yet to determine if any benefit and indicated the resident with restless leg syndrome possibly the cause of the increased behaviors. The Incident Report indicated the following falls: A post fall incident report dated 1/30/13 at 5:00 a.m. revealed the resident sitting in a wheelchair at a table in the main dining room area. The resident attempted to stand up unassisted and fell to the floor. The staff's immediate post-incident action: requested a medication review. The nurse did not take any vital signs and documented them as not applicable. On 1/31/13 at 7:15 p.m., the resident sat in a chair in the main dining room. The resident attempted to stand up on own, lost balance and sat on the floor. The nurse documented recommendations to prevent further falls as administer routine Ativan every 8 hours (resident had no order for routine Ativan), offer snacks 1 to 1 as needed, assist to bed with the bed in lowest position with mat on the floor. The resident indicated at the time of the fall that he/she was looking for a bed. The MAR revealed the resident received no Ativan on the evening shift on 1/31/13. On 2/1/13 at 7:45 p.m. the resident sat in a wheelchair in the main dining room area by the nurses ' station. The resident stood up unassisted with the wheelchair brakes not locked, lost balance, and sat down on the floor. On 2/1/13 the physician ordered to discontinue the Seroquel completely without first gradually decreasing the dose and ordered Risperdal Consta (anti-psychotic medication used for the treatment of [REDACTED]. The February MAR revealed routine times assigned to the Ativan order of 2:00 a.m., 8:00 a.m., 2:00 p.m., and 8:00 p.m. and the medication given routinely at these times even though the order remained 0.5 mg orally or IM every 6 hours as needed for anxiety. The nursing note documentation dated 2/5/13 (no time noted) indicated the resident spit out evening pills when given with increased agitation and restlessness as the evening progressed but did accept the bedtime medications when given. The MAR did not reflect their refusal. Nursing documentation dated 2/6/13 at 8:13 p.m. revealed the resident agitated, anxious, combative with some cares and very confused. The documentation indicated the resident very unsteady and shaky and required the assist of 2 staff and the use of a gait belt for transfers and ambulation. The care plan on 2/4/13 indicated the resident as lethargic and on a new medication regimen. Physical and Occupational Therapies discontinued service on 2/11/13 as resident reached maximum potential. A post fall incident report dated 2/13/13 at 8:30 p.m. revealed during routine room checks; the staff observed the resident get out of bed, onto the floor mat and scooted self across the floor. On 2/14/13 the physician increased the Paxil from 20 mg to 40 mg daily at bedtime (medication used for the treatment of [REDACTED].e. tearfulness, withdrawal, decrease in eating, expressions of hopelessness or helplessness) and ordered Melatonin 2 mg at bedtime to promote sleep. A post fall incident report dated 2/16/13 at 7:15 a.m. revealed the resident seated in wheelchair in the main dining room area. The resident attempted to transfer self out of the wheelchair to ambulate out of the room and sat down on the floor. The resident did not sustain injury. A post Fall Incident Report dated 2/19/13 at 2:15 p.m. revealed the resident in the dining room attempting to self-transfer from the wheelchair to a chair and fell to the floor. The resident care plan indicated on 2/19/13 the resident's wheelchair cushion was changed to a deep seated wedge cushion. A post Fall Incident Report dated 2/20/13 at 4:00 p.m. revealed the resident again in the dining room attempting to stand up from the wheelchair using the side rail, lost balance, and fell forward hitting head on the railing and then falling to the floor. The resident received an abrasion on the right side of the forehead. A care plan intervention dated 2/20/13 indicated the resident undergoing medication adjustment. On 2/21/13 the physician changed the administration time of the Melatonin from bedtime to at suppertime, increased the Cogentin to 1 mg twice a day, and increased the Requip to 1 mg daily at suppertime. The physician progress notes [REDACTED]. The physician noted would attempt to better control restlessness with medication adjustments of Melatonin, Cogentin, and Requip and stated taking the Risperadol orally would be ideal however due to reports from the staff of inconsistent acceptance of medications, would continue with the IM route. Neither the nursing note documentation nor the MARs reflected the resident frequently refused to accept oral medications. The nursing documentation dated 2/22/13 at 10:45 p.m. indicated the resident with no increased aggression, anxiety, restlessness, or refusal of medications or acceptance of cares. The nursing documentation on 2/23/13 at 8:55 p.m. indicated the resident as combative and resistant to cares and medication acceptance on the 6:00 a.m. to 2:00 p.m. shift stating desired to just sleep as didn't sleep well the night before. The documentation described the resident as extremely sleepy. Documentation at 10:45 p.m. indicated the resident with no agitation, aggression, anxiety, or restlessness, and cooperated with medication administration and cares. A physician order [REDACTED]. According to the February MAR, the resident received no further Lorazepam (Ativan) after 2/26/13 and did not receive any Clonazepam for the rest of February. Nursing documentation on 2/27/13 and 2/28/13 described the resident as cooperative and very sleepy. A post fall incident report dated 3/4/13 at 10:30 a.m. revealed the resident seated in a wheelchair in the dining room by the water fountain and lowered self gently to the floor. The nurse documented per usual the resident with little reflex control. The DON (Director of Nursing) witnessed the resident's fall. Nursing documentation dated 3/2/13 at 9:00 p.m. revealed the resident cooperative with the staff and pleasant. A post fall incident report dated 3/4/13 at 2:15 p.m. revealed the staff responded to the resident falling from the wheelchair onto the floor as they heard his head hit the floor. The resident developed a bump to the right forehead area. The assessment did not identify any other injuries at this time. Nursing documentation on 3/4/13 (no time) revealed the resident accepted all medications crushed in applesauce and on 3/5/13 at 10:00 p.m. the nurse documented no behaviors exhibited the entire shift. The March MAR indicated the resident continued to receive the lorazepam 0.5 mg orally or IM every 6 hours as needed on 3/2/13 at 8;00 a.m. and 1:00 p.m. even though the order had been discontinued and the Clonazepam available and given to the resident on 3/4/13 and 3/5/13. A post fall incident report dated 3/7/13 at 3:45 p.m. revealed the resident seated in the dining room area. The resident slide out of the wheelchair leaning to the left. The resident fell again at 4:08 p.m. while in the dining room in the wheelchair. The resident slid to the floor. The nursing assessment described the resident with jerky/spastic movements and experiencing hallucinations. The resident again slid out of the wheelchair while seated in the dining room. The nurse practitioner observed the resident slide out of the chair onto the floor. The resident sustained [REDACTED]. The staff put the resident to bed. At 4:50 p.m. the staff observed the resident on the floor mat beside the bed with no apparent injuries noted. The physician assessed the resident on 3/7/13 as the staff reported the resident with increased weight loss and increased decline in cognitive function. The staff reported they did not feel the resident appeared to be over medicated. The physician indicated the staff may need to assist the resident to eat and drink and even though the Cogentin dose had just recently been increased to 1 mg twice daily 2 weeks ago, the dose was again increased to 1.5 mg every am and 1 mg in the evening for improved management of restlessness and extraparietal symptoms (spastic movements of legs). On 3/7/13 the interventions were added to the resident care plan which included the Dr. to see, medication review, check a urine sample, full mattress on the floor beside bed, and pressure alarm at all times. A Post Incident Fall Report dated 3/9/13 at 3:15 p.m. revealed the resident seated in the dining room in the wheelchair. The resident slid out of the wheelchair onto the floor. Two CNAs witnessed the resident fall. At 3:30 p.m. the resident sat in the wheelchair in front of the nurses ' station slid to the floor. The nursing documentation dated 3/13/13 at 8:30 a.m. revealed a large eccymotic (bleeding in skin tissue) area on the left side of the forehead measuring 9.5 cm (centimeter) by 7 cm with red color and puffiness noted to the upper left eyelid. The resident ate 75% of breakfast and vital signs and neuro (neurological) checks within normal range. The staff notified the nurse practitioner who gave an order for [REDACTED]. A Cat (Computerized Axial Tomography) Scan of the brain completed on 3/13/13 identified no evidence for bleed, mass effect or discrete mass lesions. Incidental retention cyst or polyp caudal right maxillary antrum. The resident returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident passed away at the facility on 3/23/13. An interview conducted on 4/4/13 at 9:30 a.m. with the facility DON and ADON (Assistant Director of Nursing) revealed Resident #14 was calmer generally in the mornings but toward evening demonstrated an increase in restlessness and agitation. The ADON explained the staff attempted to ambulate the resident and tried many diversionary tactics which only seemed to work for a brief period of time. The DON explained when the resident became restless, he/she attempted to stand up or crawl out of bed. The DON explained the staff tried to keep the resident in highly visible areas such as the dining room, with more staff supervision due to the numerous falls. The ADON and the DON explained they tried different wheelchair cushions however the resident managed to continue to slide out of the wheelchair. They also explained the resident had involuntary movements of the legs and the nurse practitioner continued to attempt to adjust medications or try new medications in an effort to resolve those as well. The ADON and DON stated at times the resident proved a challenge to get to take oral medications and didn't seem to comprehend when staff attempted to redirect the resident's behaviors. The ADON explained the resident presented in the very advanced stages of dementia. She stated on the day the resident was sent to the hospital, the staff noted the resident to be more lethargic and not at the normal baseline of function. She stated the resident had not exhibited any symptoms prior to this that caused concern. She stated this was why the nurse practitioner gave an order to have the resident transported to a local hospital for evaluation and treatment. 2. The MDS assessment dated [DATE] identified Resident #1 with [DIAGNOSES REDACTED]. The MDS documented Resident #1 required extensive assistance of one staff for transfers, toileting, dressing, and ambulation in his/her room and corridor. The MDS further revealed the resident as only steady with stabilization with staff assistance for walking, turning around while walking, moving on and off the toilet, and surface to surface transfers. The MDS last identified the resident used a walker as a mobility device. The Care Plan dated 08/14/12 identified Resident #1 with self-care deficit related to dementia, chronic pain, and decreased mobility. The care plan documented the following staff approaches: a. Resident uses front wheeled walker for ambulation in room and hallway with the help of one staff. b. Resident needs assistance of one staff for all his/her activities of daily living skills (ADLs). c. Resident needs one staff to walk with him/her to the dining room for meals and to manage his/her oxygen. The Care Plan dated 08/14/12 identified Resident #1 with at risk for falls related to dementia, chronic pain, and unstable gait. The care plan documented the following staff approaches: a. Educate staff on safe transfers. b. Do not leave resident in bathroom unattended. c. On 09/28/12 educated beautician on walking residents. The Nurse's Notes dated 09/27/12 documented at 1:45 p.m. the resident ambulating down 200 hallway entering small lounge area with beautician following and pushing portable oxygen tank when resident developed shuffled gait with rapid forward motion falling forward onto his/her stomach - bilateral arms bent under his/her body. Alert to self but confused per usual assisted to side lying position then onto back - assessed - has pain to left upper arm with no visible deformities, no pain to shoulder joint physician notified and order received to initiate urinary tract infection (UTI) treatment. May x-ray if develops swelling or signs and symptoms of fracture to left arm. Resident assisted from back lying position with gait belt to sitting position with left arm mobilized by staff then into standing position into wheelchair, vital signs within normal limits on graphic sheet. The Nurse's Notes dated 09/27/12 at 3:45 p.m. documented family notified of fall, portable x-ray called for x-ray of left arm. Resident unable to move left arm and complained of pain when touching left arm. Noted a 4 centimeter by 2 centimeter superficial abrasion on his/her left knee from fall. The Nurse's Notes documented at 5:00 p.m. portable x-ray at facility for resident. At 7:05 p.m. received x-ray results and revealed a transverse fracture into the humerus (upper part of arm. Call placed to physician at this time and recalled at 7:25 p.m. Received return telephone call from physician and received an order to transfer the resident to the emergency room by ambulance. A portable x-ray report dated on 09/27/12 of the left shoulder, two views revealed a transverse fracture present through the humeral neck. The fracture is very slightly impacted. Some degenerative change is present at the acromioclavicular (a joint between the clavicle and scapula). The Nurse's Notes dated 09/28/12 at 3:40 a.m. documented Resident #1 returned to the facility via ambulance with left upper arm immobilizer and ice and new order for Tramadol (pain medication) 50 milligrams one tablet every six hours as needed for pain and an ice pack to left shoulder 20 - 30 minutes every two hours for three days as needed. A physician order [REDACTED]. Do not get wet. [DIAGNOSES REDACTED]. Observation on 04/02/13 at 9:30 a.m. revealed Staff D, Certified Nurse's Aide (CNA), transferred Resident #1 from the wheelchair to bed. Observation revealed Staff D applied a gait belt around the resident's waist, observed an extensive assist of one CNA, transferred resident from the wheelchair to the edge of the bed. Staff D assisted the resident's legs from the edge of the bed into bed. Observation further revealed the resident received oxygen per nasal cannula set at 2 liters. A post incident action form dated 09/27/12 revealed an immediate post incident action as beautician education. During an interview on 04/04/13 at 2:30 p.m. the Administrator confirmed Resident #1 fell and fractured his/her left humerus. The Administrator reported the resident fell while the beautician followed the resident ambulating to main lobby. He reported the beautician was pushing/following the resident with his/her portable air tank when the resident fell forward on the floor. He reported that the beautician was not employed by the facility. The Assistant Director of Nursing (ADON) reported Resident #1 required assistance of one staff for transfers and ambulation at the time of the fall and only facility staff are to assist residents that are not independent. The ADON reported all residents that require staff assistance for transfers or ambulation require the use of a gait belt for safety.