Every finding on record at Harborview Rome

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Hand Hygiene, the facility failed to provide proper hand hygiene for one of nine residents (R) (R5) reviewed for infection control. This deficient practice had the potential for cross contamination and the spread of infection to staff and other residents.Findings include:Review of the facility's policy titled Hand Hygiene, revised 3/1/25, section: 6 documented The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves and the second page titled Hand Hygiene Table line 14 documented Before and after handling clean or soiled dressings, linens, etc. and line 18 When during resident care, moving from a contaminated body site to a clean body site. Review of the electronic medical record (EMR) face sheet revealed resident R5 was admitted to the facility on [DATE] with diagnoses including but was not limited to hyperlipidemia, essential primary hypertension, type two diabetes mellitus with hyperglycemia, chronic systolic congestive heart failure, presence of a cardiac pacemaker, other seasonal allergic rhinitis, generalized muscle weakness, dizziness and giddiness, unsteadiness on feet, and unspecified low back pain.Review of R5's quarterly/ annual/ significant change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12, which indicated R5 had moderate cognitive impairment. Review of section GG, functional status, revealed R5 uses [NAME] /Wheelchair and was Independent with partial/moderate assistance. Other sections include Section H, Urinary Continence (Frequently incontinent)/Bowel ([NAME] continent); Section J, Pain Management received PRN medication/received non-medication intervention for pain/has pain occasionally; Section K, Therapeutic diet; Section M, pressure ulcer/injury/Formal assessment /Clinical assessment.Review of R5's care plan dated 6/2/2025 documented under problem: Resident is at risk for/ actual pressure ulcer due to assistance required in bed mobility. Review of the physician's Order dated 11/21/2025 documented, cleanse left upper buttock with wound cleanser. Pat dry. skin prep peri wound. Thera honey [type of wound treatment] to wound bed. Cover with silicone bordered gauze dressing. Change 3 times a week and prn [as needed] for heavy soiling or dislodgment of dressing.Observation and interview on 12/3/2025 at 1:49 pm with Registered Nurse (RN) RN GG performing wound care on R5's buttocks wound revealed, RN GG applied personal protective equipment (PPE) including gown and gloves without hand hygiene. RN GG entered R5's room, she explained the procedure and asked if the procedure could be monitored by a surveyor. R5 responded granting permission for wound care to be observed. RN GG then assisted R5 to roll on her right side and removed the left side of R5's adult brief to expose R5's buttocks wound. There was no dressing observed on the wound. RN GG then moistened gauze with wound cleanser and cleaned the wound, she then removed her gloves, did not perform hand hygiene, opened the resident specific tube of Thera-Honey and squeezed some on a clean gauze. RN GG then donned clean gloves (no hand hygiene) and applied skin prep to peri wound skin and applied the Thera-Honey on the gauze pad to the wound bed. RN GG then removed her gloves (no hand hygiene) and donned clean gloves and applied the silicone bordered foam dressing to the wound. She removed her gloves, (no hand hygiene) and put her hands in her pockets feeling for a marker to mark her date, time and initials in the dressing that was already on R5 buttocks. She then donned clean gloves (no hand hygiene) and replaced the adult brief on R5. RN GG then removed her gloves and washed her hands with soap and water.Interview with RN GG on 12/3/2025 at 2:00 pm confirmed she had alcohol hand sanitizer on her wound care tray, but she did not use it or soap and water between glove changes, after going from clean to dirty during the procedure and before donning the gown and gloves at the time of entering the room. Interview with the Director of Nursing (DON) on 12/4/2025 at 9:20 am revealed that her expectations for hand hygiene include hand washing before entering a resident room, exiting a resident room, before and after donning gloves and other personal protective equipment. She stated that she also expected the medication nurses to use hand hygiene before entering a room and when exiting a resident room.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to implement the care plan for 1 of 44 sampled residents (R71). This deficient practice had the potential to prevent R71 from attaining or maintaining her highest practicable level of well being. Findings include:Review of the policy titled Comprehensive Care Plans, revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.Review of the electronic medical record (EMR) revealed R71 was admitted to the facility on [DATE], and reentered on 5/22/2025, with pertinent diagnoses including but were not limited to unspecified hypothyroidism and essential primary hypertension, residual deficits from a prior cerebral infarction, resulting in hemiplegia and hemiparesis affecting the left non dominant side accompanied by generalized muscle weakness. Review of R71's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Section B documented adequate hearing, clear speech, and the ability to make self understood and understand others. Vision was noted as adequate. Section GG indicated R71 uses a wheelchair and requires two or more person assistance for activities of daily living (ADLs).Review of R71's care plan dated 06/20/2025 indicated a problem statement identifying that R71 has a communication problem related to language. Goals included but were not limited to R71, being able to make basic needs known on a daily basis through the review date. Interventions included, but were not limited to:Anticipate and meet needs.Observe and document physical or nonverbal indicators of discomfort or distress and follow up as needed.Provide a translator, such as family, a tablet, or a phone with a language application, as necessary to communicate with R71 and R71's family.An observation with concurrent interview conducted on 12/3/2025 at 9:12 am with R71 revealed that she could not speak English. The family of R71 was present during the interaction but did not respond to the surveyor, as he also does not speak English. An interview conducted on 12/3/2025 at 9:29 am with Certified Nursing Assistant (CNA) CNA NN revealed R71 is a female stroke survivor with left-sided involvement who requires total care and two-person assistance for transfers using the Hoyer lift. She has been under CNA NN care for four years. R71 is dependent, she makes attempts to assist with her care when possible. CNA NN confirmed R71 does not speak English, and she uses the application family translateAn observation with concurrent interview conducted on 12/3/2025 at 11:24 am revealed that the surveyor attempted to have R71 and the family of R71 to read a question from a computer tablet. The family of R71 was unable to do so and immediately stated that he does not speak English. An interview conducted on 12/3/2025 at 2:10 pm with the Assistant Director of Nursing (ADON) revealed that staff communicate daily with the family of R71 who speaks limited English. The ADON stated that staff rely on gestures and family to communicate with R71. She confirmed that no staff members at the facility speak R71's primary language. The ADON further stated that the family was offered the option to use the facility's communication tablet, but they declined.An interview conducted on 12/3/2025 at 4:14 pm with the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator OO revealed the facility's care planning process, including how concerns are identified and how focus areas, goals, and interventions are developed. They confirmed that R71 does not speak English and that staff rely on the family to translate. They stated they believed staff were using the language app for communication. The DON and MDS Coordinator OO reported the facility is in the process of creating laminated communication sheets in both English and R71's primary language to keep in her room. They both confirmed that care plan interventions should be implemented as written in the care plan.

Based on interviews, record review, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to protect one of 11 Residents (R) (R1) right to be free from physical abuse perpetrated by Certified Nursing Assistant (CNA)1). Specifically, CNA1 held R1 down with her knee on his chest and flicked R1 on the face. This failure caused R1 to experience psychosocial harm and created the potential for this and other residents to experience further abuse. Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation dated 3/1/2023 indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property.Protection of the Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the (abuse) investigation.E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed. Review of R1's admission Record in the Electronic Medical Record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. The residents' diagnoses included dementia and heart disease.Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/2025 in the EMR under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident was moderately cognitively impaired.Review of R1's Progress Note, dated 7/11/2025 at 10:48 am in the EMR under the Notes tab revealed, Approx. [approximately] 7:30 am. Nurse entered room. Resident attempted to get out of bed without assistance. Bed was set in lowest position. Nurse encouraged resident to stay in bed and not to get up without assistance. 7:40 am, nurse was asked by staff to come to room. Resident had placed himself in floor. No injuries noted. Staff then assisted resident back into bed to assist with dressing and resident was then placed into w/c [wheelchair]. Resident became increasingly agitated and combative. Preceded to call staff derogatory names and racial slurs. Resident then yelled I'll get my time with yall. Resident was put in w/c and placed near nursing station. Resident refused morning medications.Review of the facility's Grievance Form dated 7/11/2025 (no time was indicated) revealed a grievance had been filed on that date by the resident's family member (F)1. The document indicated that F1 reported that R1 told her a girl had flicked his nose several times and sat on top of him. The form indicated F1 reported that R1 indicated he wanted out of the facility now due to the incident and reported he was being abused. The report further indicated that upon interview by staff after the report was received from the F1, R1 reported a girl stood over him and flicked his nose several times and had her knees in his chest. The report indicated R1 stated to the staff member conducting the interview he had been abused, and he was very upset and agitated and was saying he wanted out of this place. The report indicated F1 was at his side during the interview, and she was trying to calm/console him.Review of the facility's investigation into the above allegation of abuse revealed a thorough investigation. Staff interviews conducted during the investigation revealed three staff members (Licensed Practical Nurse (LPN1), CNA2 and CNA3 were in R1's room and directly observed the incident during which CNA1 flicked R1 in the face and held R1 down by placing her knee on his chest. The investigation revealed the incident occurred on 7/11/2025 at approximately 7:15 am and that CNA1 remained in the facility and worked providing direct care to residents until the end of her shift on 7/11/2025 at 2:00 pm. The documentation revealed CNA1 was placed on administrative leave on 7/11/2025 after she worked for her remaining shift and left the facility for the day. The Final Investigation Report related to the incident, dated 7/16/2025 revealed the facility substantiated physical abuse by CNA1 toward R1 and indicated CNA1's employment with the facility had been terminated related to the event. The documentation indicated the incident had been reported to the local police department. Documentation in the investigation file revealed a warrant had been placed for the arrest of CNA1 related to the incident on 8/20/2025 and that CNA1 had been arrested related to the incident on that date.R1 was no longer residing in the facility at the time of the survey conducted 8/26/2025 through 8/28/2025 and could not be interviewed.CNA1 could not be reached for interview.During an interview with CNA2 on 8/26/2025 at 10:05 am, she confirmed she was present on 7/11/2025 when the allegation of abuse of R1 by CNA1 occurred and confirmed she witnessed CNA1 flick R1 in the face and hold R1 down on the floor by putting her knee in his chest.During an interview with CNA3 on 8/26/2025 at 5:02 pm, she confirmed she was present on 7/11/2025 when the allegation of abuse of R1 by CNA1 occurred and confirmed she witnessed CNA1 flick R1 in the face and hold R1 down on the floor by putting her knee in his chest.During an interview with LPN1 on 8/26/2025 at 1:55 pm, she confirmed she was summoned to R1's room on 7/11/2025 at about 7:30 am by CNA3 and when she arrived in the resident's room, she observed CNA1 preparing to flick R1 in the face. LPN1 stated she told CNA1 to stop flicking the resident and she confirmed R1 appeared to be very upset by the incident.During an interview with the Administrator on 8/26/2025 at 3:00 pm, she confirmed the facility's investigation of the allegation of abuse of R1 by CNA1 had been substantiated. She stated her expectation was residents were to remain free of abuse in the facility and stated CNA1 should have been placed on administrative leave immediately after the alleged incident on 7/11/2025 to ensure protection of R1 and all residents residing in the facility from potential further abuse.

Based on interviews, record review, and review of the facility's policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure timely reporting of an allegation of physical abuse for one of 11 Residents (R) (R1) reviewed for abuse. This failure caused R1 to experience psychosocial harm and created the potential for this resident and other residents to experience further abuse. Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation dated 3/1/2023 indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property; and Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Review of R1's admission Record in the Electronic Medical Record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The residents' diagnoses included dementia and heart disease. Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/2025 in the EMR under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident was moderately cognitively impaired.Review of R1's Progress Notes dated 7/11/2025 at 10:48 am in the EMR under the Notes tab, revealed Approx. (approximately) 7:30 am. Nurse entered room. Resident attempted to get out of bed without assistance. Bed was set in lowest position. Nurse encouraged resident to stay in bed and not to get up without assistance. At 7:40 am, nurse was asked by staff to come to room. Resident had placed himself in floor. No injuries noted. Staff then assisted resident back into bed to assist with dressing and resident was then placed into w/c (wheelchair). Resident became increasingly agitated and combative. Preceded to call staff derogatory names and racial slurs. Resident then yelled, I'll get my time with yall. Resident was put in w/c and placed near nursing station. Resident has also refused morning medications.Review of the facility's investigation revealed the alleged allegation of abuse occurred at approximately on 7/11/2025 at 7:30 am and was directly observed by three staff members (Certified Nurse Aide (CNA)2, CNA3 and Licensed Practical Nurse (LPN)1) who were in the R1's room with CNA1. However, the incident was not reported by any of the three staff members who observed the incident to administration. The investigation revealed the Administration became aware of the allegation of abuse of R1 by CNA1 when the incident was reported to management by R1's family member (F)1 via the facility's grievance process on the afternoon of 7/11/2025. The incident was then reported to the Administrator, who was the facility's Abuse Coordinator on 7/11/2025 at approximately 4:30 PM. The incident was reported to the State Agency (SA), the local police department, the resident's physician, and the local Ombudsman. The incident was reported to the SA on 7/11/2025 at 6:50 pm (more than 11 hours after the incident occurred). During an interview on 08/26/25 at 10:05 AM, CNA2 confirmed she was present on 7/11/2025 when the allegation of abuse of R1 by CNA1 occurred and confirmed she did not report the abuse to anyone in facility Administration. CNA2 stated she thought LPN1 would report the incident since she was present when the incident occurred. During an interview on 8/26/2025 at 5:02 pm, CNA3 confirmed she was present on 7/11/2025 when the allegation of abuse of R1 by CNA1 occurred and confirmed she did not report the abuse to anyone in facility Administration. CNA3 stated she got busy with her duties after the incident and did not report the event.During an interview on 8/26/2025 at 1:55 pm, LPN1 confirmed she was summoned to R1's room on 7/11/2025 at 7:30 am by CNA3. When she arrived in the resident's room, she observed CNA1 preparing to flick R1 in the face. LPN1 confirmed she did not report the abuse to facility's Administration and stated she should have reported the abuse immediately to the Administrator or the nurse in charge on the day of the incident.During an interview on 8/26/2025 at 1:30 pm, Registered Nurse (RN1) confirmed she was the charge nurse in the building on the day of the alleged abuse of R1 by CNA1. RN1 confirmed the abuse had not been reported to her until R1's family member reported the incident on the afternoon of 7/11/2025. RN1 confirmed CNA2, CNA3, and LPN1 had not reported the incident of abuse to her after the event occurred and stated the incident should have been reported to her, or someone in Administration, immediately after the event occurred. During an interview on 8/26/2025 at 3:00 pm, the Administrator confirmed the abuse of R1 by CNA1 on 7/11/2025 had not been reported to her timely. She stated she did not become aware of the allegation of abuse until 7/11/2025 at about 4:30 pm or 5:00 pm when the allegation was reported to her by RN1. The Administrator confirmed CNA2, CNA3 and LPN1 had not reported the allegation abuse to anyone in administration and confirmed she learned of the abuse after it was reported by R1's F1 several hours after the incident occurred. The Administrator confirmed the alleged abuse was, in turn, not reported to the SA, local police department, or the ombudsman within the required two-hour time frame. She stated her expectation was all allegations of potential abuse were to be reported to Administration immediately and allegations of abuse were expected to be reported to the SA, local police department, and the ombudsman within the required two-hour time frame.

Based on observations, record review, and staff interviews, it was determined that the facility failed to ensure quality care and services in accordance with professional standards for one Resident (R) (R1). Specifically, the facility failed to provide timely assistance to one resident (R1) who was in respiratory distress. Findings include: Review of the admission Record for R1 revealed she was admitted to the facility with diagnoses of but not limited to dysphagia and gastro-esophageal reflux disease. Review of the resident's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was assessed as 15, which indicated cognition was intact. Section K (Swallowing and Nutritional Status) revealed R1 was assessed as having no swallowing disorder and no signs and symptoms of swallowing problems. Nutritional status triggered as an area of concern on the Care Area Assessment Summary. Review of the care plan initiated 12/17/2024 revealed that R1 is at risk for nutritional need related to a therapeutic diet. Intervention to be implemented included observe R1 for signs of dysphagia (difficulty swallowing): not limited to coughing, choking, and refusing to eat during meals. Review of the hospital Discharge summary dated [DATE] revealed the second day of hospital admission the patient (R1) had an episode of aspiration (inhaling into airway/lungs) of scrambled eggs on 12/5/2024 and required intubation (placement of a breathing tube). The patient had a diagnostic bronchoscopy and bronchoalveolar lavage (a medical procedure where a bronchoscope is used to wash the airways and collect a fluid sample from the lungs for diagnostic purposes) from right lower lobe on 12/5/2024 that revealed a remnants in the distal trachea and right lower lobe which were suctioned. The patient was extubated (breathing tube removed) on 12/6/2024 but had another aspiration event that same day and required re-intubation on 12/6/2024. The patient was able to be weaned off the ventilator on 12/8/2024. The patient after extubating had problems with swallowing. The resident (R1) was discharged from the hospital to __ facility. Review of the Medication Review Report (physician order) dated 12/16/2024 revealed: full code and Regular diet, Pureed texture, Honey consistency. Review of the Medication Review Report (physician order) dated 12/18/2024 revealed: occupational therapy (OT) clarification Order: Skilled OT 5 times a week for 30 days may include: therapeutic exercise, therapeutic activities, neuromuscular reeducation, manual therapy, self-care retraining, wheelchair management training, Orthotic (devices worn in shoes to relieve symptoms related to various foot and ankle conditions) fitting and training, Skilled instruction to resident, caregivers and staff. Review of the Medication Review Report (physician order) dated 12/26/2024 revealed Regular diet, Mechanical Soft texture, Regular/Thin consistency. Review of the Medication Review Report (physician order) dated 12/27/2024 revealed: Late entry for 12/17/2024 Clarification Orders: skilled speech therapy (ST) 5 times a week times 4 weeks for treatment of swallowing dysfunction and/or oral function for feeding, caregiver education for Dysphagia unspecified diagnosis code R13.10. Review of the Occupational Therapy (OT) note dated 1/17/2025 revealed: Self feeding TD (treatment dependent) plus: patient coughed-wet cough then was breathing through her mouth and appeared to be ready to throw up, attained basin for her to throw it up and she did not then tried to get a reading on the pulse ox (oximeter-device to measure oxygen level), unable, notified her nurse and nurse took over. Review of Nurses Note dated 1/20/2025 revealed: 1:00 pm Nurse entered room. Resident found in bed sitting upright with eyes opened and unresponsive. Nurse notified supervisor. Emergency services called. Resident transferred to __ Hospital. The family was notified at 1:15 pm. Review of R1's __ Death Certificate revealed R1 was pronounced dead on 1/17/2025. The immediate cause (final disease or condition resulting in death) hypoxic (inadequate levels of oxygen in the tissues and cells of the body) respiratory failure and aspiration of food. A phone interview on 6/6/2025 at 9:35 am with R1's family revealed the facility called on 1/17/2025 around 1:00 pm. The family was informed that mom (R1) was found unresponsive. The facility also informed the family, We worked on her and could not get her back. The family asked the caller what happened. The family was informed that R1 choked while eating lunch and was unresponsive afterwards. The family could not identify the caller but stated it was not the nurse. An interview on 6/6/2025 at 11:33 am with Licensed Practical Nurse (LPN) BB revealed around 1:00 pm Occupational Therapist AA came to the nursing station and requested that she come to R1's room because the resident wasn't looking too well. LPN BB revealed upon arriving at the room, the resident was not responding and had no pulse. LPN BB stated she left the room and went to find the Unit Manager (UM). She stated when she returned with the UM, R1 was placed in a supine (lying on one's back with face upward) position and chest compressions and ventilation were started with an Ambu bag (medical device that forces air into the lungs of patients who are not breathing or struggling to breathe) on R1. An interview on 6/6/2025 at 12:57 pm with LPN BB confirmed that she did not document the events that took place on 1/17/2025 in R1's EMR. She stated she was so overwhelmed that day and left work without charting the incident. She also revealed she spoke with the Nurse Practitioner (NP) on the phone and failed to write an order for R1 to be transferred to the hospital. An interview on 6/17/2025 at 3:05 pm, OT AA stated R1 was treated on 1/17/2025. The OT was assisting R1 with getting food from the plate to the mouth with her hand on R1's hand in a guiding motion as part of R1's therapy. She stated during the therapy session R1 began to cough (wet cough) and mouth breathing. The OT stated she attempted to get a pulse oximeter reading and was unsuccessful. The OT stated she did not stay with R1. The OT stated she left the room to get LPN BB. An interview on 6/18/2025 12:51 pm with Certified Nursing Assistant (CNA) CC revealed she has been educated on resident mealtimes and what to do if you find a resident unresponsive. She stated during mealtimes all residents' doors must remain open. She stated the reason for leaving the doors open was to listen out for residents' that may start coughing while eating. She stated if a resident became unresponsive, the staff could not leave but call out for help. She revealed that R1 was one of her assigned residents. CNA CC stated R1 did not have a suction machine in her room. An interview on 6/18/2025 1:32 pm with CNA DD revealed she has been educated by the facility on what to do if a resident became unresponsive. She stated she was educated never to leave the resident but call out for help. An interview on 6/18/2025 at 5:53 pm with the Director of Nursing (DON) revealed she was unaware that the OT was providing therapy services to R1 on 1/17/2025 when the resident became unresponsive. The DON stated the expectation of the staff was if a resident became unresponsive, the staff was educated to call out for help and not leave the room. The DON stated a staff person should always be with the resident.

Based on record review, staff and family interviews, and review of the facility policies titled, Baseline Care Plan and Care Planning-Resident Participation, the facility failed to ensure that one of two Residents (R) (R1) reviewed for participation in care plan meetings were invited to and participated in a scheduled 72-hour care plan meeting. In addition, the family representative for R1was not invited to ensure that the care plan was individualized and met R1's personal goals and preferences. Findings include: Review of the facility policy titled Baseline Care Plan revised date 3/1/2025 revealed under Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Under Policy Explanation and Compliance Guidelines: . 4. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. 5. A supervising nurse or MDS nurse/designee is responsible for providing the written summary of the baseline care plan to the resident and representative. This will be provided by completion of the comprehensive care plan. 7. If the summary was provided via telephone, the nurse shall indicate the discussion, sign the summary document, and make a copy of the written summary before mailing the summary to the resident/ representative. Review of the facility policy titled Care Planning-Resident Participation revised date 3/1/2025 revealed under Policy Explanation and Compliance Guidelines: The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan. Review of the admission Record for R1 revealed she was admitted to the facility with diagnoses of but not limited to dysphagia and gastro-esophageal reflux disease. Review of R1's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was assessed as 15, which indicated cognition was intact. Review of R1's electronic medical record (EMR) attached under the Miscellaneous Documents tab revealed a document titled Care Plan Meeting Sign Sheet dated 1/7/2025 revealed there was no indication that the resident or family were invited or attended the care plan meeting. A phone interview on 6/6/2025 at 9:35 am with R1's family revealed the family stated there was never an invitation to a care plan meeting or any type of meeting with the facility until she inquired on 1/7/2025. She stated she received a phone call from the facility on 1/7/2025 informing her that R1's therapy would be discontinued. The family stated she told the caller she had not received any phone calls about her mom (R1) or if she was progressing with therapy. The family member revaled the caller told her she was under the impression she had spoken with someone and told the family member someone would call her back. She revealed on 1/9/2025 there was a conference call with the physical therapist, occupational therapist, and speech therapist. The family member stated there were no other disciplines to her knowledge present during the telephone conference. An interview on 6/11/2025 at 1:00 pm with Resident Assessment Coordinator EE revealed the department was responsible for the resident assessment and care plans. She stated a care plan meeting should be conducted 72 hours after the resident was admitted to the facility and 14 days after a comprehensive and quarterly MDS assessment was completed. She stated the residents were invited by a visit to the residents' room. The family/responsible party were called and invited. She stated the Discharge Planner was responsible for documenting the care plan meetings. The Resident Assessment Coordinator confirmed that R1 did not have a 72-hour care plan meeting or a care plan meeting 14 days after the admission MDS assessment was completed. An interview on 6/17/2025 at 2:23 pm with the Speech-Language Pathology (SLP) revealed she did not remember having a specific care plan meeting for R1. The SLP stated she remembered discussing with the family advancing R1's diet. The SLP was asked if the information was discussed in a care plan meeting, and the SLP responded and asked the surveyor, Did the facility even hold a care plan meeting?

Based on record review, observations, resident and staff interviews, and review of the facility policy titled, Promoting Maintaining Resident Dignity, the facility failed to promote care in a manner that maintained or enhanced each resident's dignity, respect, and individuality for two of eight sampled residents (R) (R8 and R S). Specifically, staff were standing while feeding a resident. In addition, staff members did not knock or identify themselves before entering residents' rooms. Findings include: Review of the facility policy titled Promoting Maintaining Resident Dignity revised date 4/1/2024 revealed under Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Under Compliance Guidelines: .10. Respect the residents' living space. Maintain resident privacy. Review of the admission Record for R8 revealed he was admitted to the facility with a diagnosis of but not limited to dyskinesia (uncontrollable and involuntary movements) of esophagus. Review of R8's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was assessed as eight which indicated cognition was moderately impaired. Section K (Swallowing and Nutritional Status) revealed R8 was assessed as having no swallowing disorder and no signs and symptoms of swallowing problems. Nutritional status triggered as an area of concern on the Care Area Assessment Summary. Review of the care plan initiated 5/16/2025 revealed that R8 is at risk for nutritional need related to a mechanical soft diet. Intervention to be implemented included setting up each meal tray and assisting R8 as needed. Observation on 6/11/2025 at 12:43 pm revealed Certified Nursing Assistant (CNA) GG feeding R8 lunch. The resident was leaning to the left side slouched down in the bed. CNA GG was standing feeding R8. Observation on 6/11/2025 at 12:52 pm revealed Licensed Practical Nurse (LPN) HH walking into room [ROOM NUMBER] without knocking or identifying herself before entering the resident room. Observation on 6/11/2025 at 12:54 pm revealed LPN HH walking into room [ROOM NUMBER] without knocking or identifying herself before entering the resident room. Observation on 6/18/2025 at 9:02 am revealed Staffing Coordinator II walking into room [ROOM NUMBER] without knocking or identifying herself before entering the resident room. Observation on 6/11/2025 at 12:50 pm of the Treatment Nurse (TN) JJ and CNA GG repositioning R8. TN JJ or CNA GG did not pull the curtain or shut the door to provide R8 with privacy from the visitor in the room or the surveyor in the hall. Interview on 6/11/2025 with CNA GG, she stated R8 was not her assigned resident for the day, and she was helping with feeding the residents. CNA GG was asked if she always stood up to feed the residents and CNA GG answered Yes. Interview on 6/11/2025 at 12:54 pm with LPN HH revealed she did not knock when the residents' door was open. She stated, I just walk in. Interview on 6/18/2025 at 9:32 am with the Staffing Coordinator II revealed she was aware that she should knock before entering a resident's room. She stated that this was the resident's home and she should knock and announce herself before entering. Interview on 6/18/2025 at 12:28 pm with R S revealed the staff would enter the room without knocking or announcing themselves. An interview on 6/18/2025 at 5:53 pm with the Director of Nursing (DON) revealed the staff were educated on a regular basis on resident rights that included knocking on the residents' doors, announcing themselves before entering the room.

Based on observations, record review, staff interview, and the review of the facility policy titled, Oxygen (O2) Administration, the facility failed to ensure that O2 therapy was administered in accordance with the physician orders for two of 23 residents (R) (R34 and R14) receiving O2 therapy. The deficient practice had the potential to place R34 and R14 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the undated policy titled Oxygen Administration dated 1/10/204 revealed under Policy: Oxygen is administered under orders of a physician, except in the case of an emergency. Review of the electronic medical record (EMR) for R34 revealed she was admitted to the facility with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), malignant neoplasm of upper lobe, left bronchus or lung The resident's most recent Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was coded as 15, which suggests that cognition is intact. Review of Physician orders for R34 revealed Oxygen Therapy-Nasal Cannula at rate of two liters, initiated 1/24/2024. Review of the care plan initiated on 9/14/2023 and revised on 9/14/2023 revealed that R34 has diagnosis of COPD with potential for respiratory infection/exacerbation of chronic obstructive pulmonary disease (COPD). Further interventions indicate OXYGEN SETTINGS: O2 via NASAL CANNULA (NC) AS ORDERED. Observation on 7/30/2024 at 12:30 pm revealed R34's O2 concentrator (machine to converts room air into O2) set on three liters per minute (LPN), being delivered via NC. Observation on 7/31/2024 at 9:20 am and 11:20 am revealed R34's O2 concentrator flow rate set at three LPM, being delivered via NC. Observation and interview on 7/31/2024 at 11:35 with Licensed Practical Nurse (LPN) AA on the A wing confirmed that R34's O2 tank setting was on almost three LPM. LPN AA checked R34's medical orders in the facility's EMR and confirmed that the physician order was for two LPM via NC. Review of the EMR for R14 revealed she was admitted to the facility with diagnoses including but not limited to acute and chronic respiratory failure with hypoxia, respiratory disorder, post COVID-19 condition. R14's most recent MDS dated [DATE] revealed a BIMS score was coded as 14, which suggests that cognition is intact. Review of R14's Physician orders revealed Oxygen therapy - two liters via nasal canula continuous as tolerated, dated 6/7/2024. Review of the care plan for R14 initiated on 5/15/2024 revealed that resident has oxygen therapy related to Ineffective gas exchange. Further interventions indicate OXYGEN SETTINGS: O2 via NASAL CANNULA (N/C) AS ORDERED. Observation on 7/30/2024 at 12:35 pm revealed R14's O2 concentrator flow rate set at three LPM, being delivered via NC. Observation on 7/31/2024 at 9:22 am and 11:22 am revealed R14's O2 concentrator flow rate set at three LPM, being delivered via NC. Observation and interview on 7/31/2024 at 11:37 am with LPN AA on A wing confirmed that R14's O2 tank setting was on almost three LPM. LPN AA checked R14's medical orders in the facility's electronic records and confirmed that the physician order was for two LPM.

Based on observations, record review, resident and staff interviews, and review of the facility policy titled, Activities, the facility failed to ensure residents received activities to meet resident-centered and personal preferences for bed bound and dependent care residents for two of 35 sampled residents (R) (R49 and R36). Specifically, R49 and R36 were not provided with person-centered activities that would meet their individual needs. Findings Include: Review of the facility policy titled Activities last reviewed 3/1/2024 revealed under Policy: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. Under Policy Explanation and Compliance Guidelines .13. The facility will consider accommodations in schedules, supplies and timing in order to optimize a resident's ability to participate in an activity of choice. Review of R49's admission Minimum Data Set (MDS) documented the resident had been admitted to the facility with diagnoses of but not limited to end stage renal disease, dependence on renal dialysis, low back pain, type 2 diabetes, mellitus with hyperglycemia, hypertension, unspecified atrial fibrillation, hyperlipidemia, heart failure, chronic obstructive pulmonary disease, unspecified asthma, uncomplicated, gastro-esophageal reflux disease without esophagitis, benign, prostatic hyperplasia without lower urinary tract symptoms, anemia in other chronic diseases, atherosclerotic heart disease of native coronary artery without angina pectoris, gastroparesis, other intervertebral disc degeneration, lumbar region other cervical disc, degeneration, unspecified cervical region, muscle weakness, dysphagia, difficulty in walking. R49's quarterly MDS dated [DATE] revealed that R49 was assessed with a Brief Interview for Mental Status (BIMS) assessment of 12, indicating the resident has moderate cognitive deficit. Review of R49 baseline care plan dated 5/23/2024 revealed R49 prefers independent activities or spending time with my family rather than doing things in groups. The facility goal for R49 will continue participating in independent activities or things with their friends and family. R49's intervention was to assist resident in participating in their favorite activities at their highest level and invite resident to sit in during activity programs, letting them join in at their own comfort level. Observation on 7/31/2024 at 12:00 pm, R49 was observed to be asleep. Interview and observation on 7/30/2024 at 12:39 pm with R49 confirmed he would like to participate in some activities. He was observed watching television and eating lunch. Interview on 7/31/2024 at 12:39 pm with the Activities Director (AD) revealed she planned and performed activities and completed computer assessments to figure out what residents like and/or dislike. The AD confirmed she performed assessments at admission and quarterly. The AD shared she received help from the Certified Nursing Assistants (CNAs) to bring residents down to activities who were unable to ambulate. The AD confirmed she informed residents of activities by using the intercom, notifying residents by walking to rooms, or received assistance from the CNA's to help notify residents. The AD revealed today's afternoon scheduled activity was changed to bingo. The AD shared she notified residents of the change before the activity. The AD stated for residents who do not come into the activities room she would randomly do one-on-one activities. The AD confirmed she does not have a schedule for one-on-one activities with residents. The AD reviewed R49's quarterly review that revealed R49 would like to participate in bingo and musical entertainment. The AD reviewed the one-on-one log and revealed no forms were completed for the last three months for resident R49. The AD confirmed R49 had not been in any group activities in the last three months. The AD mentioned R49 had not been in activities because he was gone to dialysis or had family visits. Interview on 8/1/2024 at 2:37 pm with the Director of Nursing (DON), Administrator, and Regional Coordinator. The Administrator confirmed the role of the AD included planning and doing activities, resident council, assessment, and completing certain portion of the MDS. The Administrator confirmed for residents who were unable to enter activities were given one-on-one if they preferred, and she knew a log was done and confirmed that it was not located in the EMS but with the AD. The Administrator confirmed the MDS was completed at admission and annually. Review of R36 admission Minimum Data Set (MDS) documented the resident had been admitted to the facility with but not limited to diagnoses of fusion of spine, thoracolumbar region, spinal stenosis, thoracolumbar region, discitis, thoracolumbar region, paraplegia, incomplete, muscle weakness, paroxysmal atrial, fibrillation, benign neoplasm of pituitary gland, chronic diastolic (congestive) heart failure, essential (primary) hypertension, unspecified severe protein-calorie malnutrition, hyperlipidemia, dysphagia, unsteadiness on feet, difficulty in walking, major depressive disorder, recurrent, other lack of coordination, other malaise, chronic atrophic gastritis without bleeding, anemia, anxiety disorder, other chronic pain, polyneuropathy, unspecified osteoarthritis, insomnia, constipation, gastro-esophageal reflux disease without esophagitis, chronic kidney disease, stage, unspecified psychosis not due to a substance or known, physiological condition, acute upper respiratory infection, weakness, Parkinson's disease, without dyskinesia, without mention of fluctuations. R36 was assessed with BIMS assessment score of 10, indicating the resident has moderate cognitive deficit. Section F (Customary Routine) revealed Very Important for Activity preference. Review of R36 baseline care plan dated 10/28/2019 revealed R36 is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t [related to] Physical Limitations. The facility goal for R36 was to maintain involvement in cognitive stimulation and social activities as desired through review date. R36 intervention all staff to converse with resident while providing care. Invite the resident to scheduled activities. Provide with activities calendar. Notify resident of any changes to the calendar of activities. Thank resident for attendance at activity function. The resident needs one-on-one bedside/in-room visits and activities if unable to attend out of room events. The resident needs assistance/escort to activity functions. Observation and interview on 7/30/2024 at 12:20 pm with R 6 revealed she was not able to participate in any group activities because she cannot walk. R36 confirmed she would like to participate in activities. Interview on 7/31/2024 at 12:39 pm with the Activities Director (AD) revealed the AD reviewed R36's preference and confirmed none were offered during one-on-one activities. The AD revealed the one-on-one log she completed for R36 consisted of three dates in July; 7/4/2024, 7/11/2024, and 7/17/2024; each date activity included only conversation but on 7/4/2024 watermelon was consumed during conversation.

Based on record review and staff interview, and review of the facility policy titled, MDS (Minimum Data Set) 3.0 Completion, the facility failed to accurately assess one of 35 sampled residents (R) (R34). The deficient practice had the potential for R34 to be at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility policy titled MDS 3.0 Completion revised 1/1/2024 revealed under Policy Explanation and Compliance Guidelines: According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's function capacity, using the RAI (Resident Assessment Instrument) specified by the State. Review of the electronic medical record (EMR) revealed that R34 was admitted to the facility with but not limited to diagnoses of chronic obstructive pulmonary disease (COPD) and malignant neoplasm of upper lobe, left bronchus or lung. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/10/2024 revealed in Section O-Special Treatments, Procedures, and Programs that Oxygen (O2) Therapy was not marked as Performed while a resident of this facility and within the last 14 days. Review of R34's care plan initiated 9/14/2023 revealed the following problem: resident has COPD. Interventions included oxygen settings: O2 via nasal cannula (NC) as ordered. Review of the EMR tab Orders revealed an order dated 1/24/2024 for O2 @ 2L/NC (2 liters via cannula), PRN (as needed) as tolerated. Interview with the MDS Resident Assessment Coordinator on 8/1/2024 at 4:05 pm confirmed that resident was receiving O2 therapy, and section O (Special Treatments, Procedures, and Programs) of the MDS where question related to oxygen should be marked as yes. She stated that this MDS section was marked incorrectly as no.

Based on observations, staff interviews, record review, and review of the facility policy titled, Medication Administration, the facility failed to ensure that infection control practices were followed and adhered to by one of five nurses observed during medication administration. Findings Include: Review of the facility policy titled Medication Administration dated 6/1/2024 documented under Policy: Medications are administered by licensed nurses in accordance with professional standards of practice, in a manner to prevent contamination or infection. Under Policy Explanation and Compliance Guidelines, number 14 revealed: Remove medication from source, taking care not to touch medication with bare hand. Observation on 7/31/2024 at 8:32 am Licensed Practical Nurse (LPN) AA dropped a medication cup to the floor, bent over, picked up the cup, and placed it on a stack of clean unused medication cups. She then, with her bare hands, took medication out of a medication card and placed it in a medication cup to take to administer to a resident. Interview on 7/31/2024 at 8:48 am LPN AA verified and confirmed that she had dropped a medication cup to the floor, picked it up and placed it on a clean stack of cups. She stated she thought she had thrown it in the trash can but knew she should have thrown it out. LPN AA verified and confirmed that she had touched a medication with her bare hands and confirmed she should not have. LPN AA confirmed both were not appropriate infection control procedures. Interview on 7/31/2024 at 9:04 am the Director of Nursing (DON) confirmed that nurses should not touch any medications with bare hands. The DON confirmed that picking up a medication cup from the floor and placing it back on the clean stack was not an appropriate infection control procedure. She would expect an LPN to know the correct infection control protocols.

Based on observation, staff interview, and review of policy, the facility failed to ensure that the catheter tubing and drainage bag for one resident (#48) of 21 sampled residents were positioned to ensure that these items did not come in contact with the floor as the resident moved about the facility in her wheelchair. Findings include: Review of policy Indwelling Urinary Catheter (Foley) Care and Management last revised (MONTH) 17, (YEAR) revealed instructions for staff to keep the drainage bag below the level of the patient's bladder to prevent backflow, but to not place the drainage bag on the floor to reduce the risk of contamination and subsequent Catheter-associated Urinary Tract Infections (CAUTI). Review of the clinical records for resident (R)#48 revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS) assessment of 3/22/18 revealed the resident had an indwelling catheter with an active [DIAGNOSES REDACTED]. Review of the current physician's orders [REDACTED]. Observation on 6/13/18 at 10:35 a.m. revealed R#48 sitting just inside the doorway of her room with her catheter tubing and drainage bag hanging under her wheelchair, both touching the floor. Observation on 6/13/18 at 11:20 a.m. revealed the resident sitting in hallway outside of her room with the drainage bag and catheter tubing resting on the floor. Observation on 6/13/18 12:00 p.m. revealed the resident sitting at a table in the dining room awaiting the lunch service. The resident's drainage bag and catheter tubing hung below her wheelchair, resting on the floor. Observation on 6/14/18 at 10:26 a.m. revealed R#48 sitting in the hallway outside her room with her catheter tubing and drainage resting on the floor below her wheelchair. Observation on 6/14/18 at 10:35 a.m. revealed Licensed Practical Nurse (LPN), DD pushing R#48 into her room and closing the door. When the LPN reemerged with the resident from the room a few minutes later, the resident's catheter tubing and drainage bag was noted to be positioned closer to the bottom of the wheelchair and lifted completely off floor. During an interview on 6/14/18 at 10:43 a.m. with LPN DD revealed she noticed the resident's catheter tubing and drainage bag was hanging too low and thus she had adjusted them so they were clear of the floor. The LPN said some of the Certified Nursing Assistants (CNA were new and may not have received proper education on the appropriate placement of the drainage bag and tubing. She planned to ensure that they received such education as soon as possible. Review of a facility Training Attendance Log of 6/14/18 revealed that 27 nursing staff were just given education titled: Procedure/Placement of Catheter Bag Bed/Wheelchair. During an interview with the director of nursing (DON) on 6/14/18 at 3:05 p.m. it was revealed that staff are expected to have residents' catheter tubing and drainage bag elevated above the floor and properly anchored when they are up in their wheelchair.

Based on record review, review of the facility's Medication Administration policy, and review of the National Council of State Boards of Nursing, Georgia Practical Nurses Practice Act (Chapter 410-10) and interview, it was determined that the facility failed to ensure that services provided met professional standards. The facility failed to ensure that licensed nursing staff administered medication correctly and safely to one (1) Resident (R) (R#1) of five (5) sampled residents reviewed for medication administration. The facility census was 85 residents. Findings include: Review of the Rules and Regulations of the State of Georgia, Rule 410-10-.02 Standards of Practice for Licensed Practical Nurse addressed Rule 410-10-.03 Definition of Unprofessional Conduct to include, but not limited to: Nursing conduct failing to meet the minimal standards of acceptable and prevailing nursing practice, which could jeopardize the health, safety, and welfare of the public, shall constitute unprofessional conduct. This conduct shall include, but not be limited to the following: Using inappropriate or unsafe judgement, technical skill or interpersonal behaviors in providing nursing care and Abandoning or knowingly neglecting patients/clients requiring nursing care. Review of the facility's Medication Administration policy revealed nurses are to observe that the resident swallows oral drugs. Do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication. Continued review revealed residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the guidance for self-administration of medication. During an interview conducted on 10/30/17 at 2:14 p.m., Certified Nursing Assistant (CNA) AA revealed that on the day of the survey, 10/30/17, she observed that two pills were left on the night stand in the room of R#1. CNA AA further revealed, that she retrieved the pills and gave them to the Unit Manager, Registered Nurse (RN) DD. During an interview on 10/30/17 at 2:50 p.m. with CNA CC revealed, she found some medicine sitting on R#1's tray table on 10/30/17. CNA CC further revealed, there were two pills, one looked like an iron pill and the other was a little, tiny, white pill. CNA CC further revealed that this does happen a lot with this nurse (Licensed Practical Nurse (LPN) BB). There have been times where I will be in the room and the resident is in the restroom or something and LPN BB will come in and leave the medication on the sink. There was another occasion when I observed LPN BB come into another resident's room when I am in the room, and she'll just walk in and lay medicine down on the bedside table without watching them take it. When this occurs, I grab the medication, take it back out and give it to LPN BB. It happened this morning with R#1 and I put it the medication in the drawer and went and told the unit manager. During an interview on 10/30/17 at 4:13 p.m. with Unit Manager/RN DD revealed, My expectation is the nurses look on the computer, pull the drugs, match it with the computer, pour it in the cup. The nurse then should go to the patient's room, dispense the medication, stay with the patient while they take the medication and come back and document it. That is also the facility policy. I do not have any residents on my unit that self-administer. It is never okay to leave medications at bedside. She further revealed that she observed an over the counter multi- vitamin tablet and a Carvediol 3.125 milligram (mg) tablet in R#1's room today. I brought the medication out of the resident's room and researched what medications they were then spoke with LPN BB about it and personally gave the resident her medicines. I have not reported this situation to the Director of Nursing (DON) yet but will before leaving today. I am not aware of this occurring before with LPN BB. During an interview on 10/30/17 at 4:46 p.m. with LPN BB revealed, it is not okay to leave medications with any of the residents. She revealed that there are not resident's who are approved to self-administer medications. She stated that she was called out of the room today, before giving the medications, and forgot to go back into the room. I have always stood there and watched residents take their medication. This is the only time that I have left the room and left the medicine there and honestly I just forgot to go back. LPN BB further revealed that it is not facility policy to leave medications in a resident's room without observing them take the medicine. During an interview on 10/31/17 at 10:18 a.m., the facility Administrator revealed, her expectations are that medications are not to be left at bedside. LPN BB is aware of the facility policy on medication administration and has been counseled in relation to this incident. Record review revealed Medication Administration Records (MARs) and current physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of Brief Interview for Mental Status (BIMS) on 9/20/17 for R#1 revealed a score of five (5) indicating severe cognitive impairment. During an interview on 10/30/17 at 3:06 p.m., CNA EE revealed, that she has observed LPN BB leave medications in rooms and just walk out. I can't remember exactly when, she just leaves it on her table. I don't know if anyone told the DON about the medications. During an interview conducted on 10/30/17 at 3:30 p.m. with R#2 revealed LPN BB stays with me sometimes and sometimes she will leave them (medications) and let me take them because she knows I will take them. Review of Brief Interview for Mental Status (BIMS) on 9/25/17 for R#2 revealed a score of fifteen (15) indicating intact cognition. During an interview conducted on 10/30/17 at 3:34 p.m. R#4 revealed LPN BB will set the pills down and the resident will take them later. R#4 further added, she sets them on my tray or if I'm in the restroom she'll leave them and I will get them when I come out. Review of Brief Interview for Mental Status (BIMS) for R#4 on 9/30/17 revealed a score of fifteen (15) indicating intact cognition.

Based on record review and staff interview, the facility failed to ensure that Physician's orders were followed for medication administration for one resident (R1) of five sampled residents. Findings include: Review of the facility's Medication Administration policy revealed nurses are to observe that the resident swallows oral drugs. Do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication. Continued review revealed residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the guidance for self-administration of medication. Review of the medical record for R#1 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Medication Administration Record [REDACTED]. The resident did have Physician orders for Carvedilol tablet 3.125 milligram (mg) give 1 tab by mouth two times a day, related to [MEDICAL CONDITION] multiple Vitamin tablet give 1 tablet by mouth one time a day for supplement. An interview conducted on 10/30/17 at 2:14 p.m. with Certified Nursing Assistant (CNA) AA revealed that on the day of the survey, 10/30/17, two pills were left on the night stand in the room of R#1. CNAAA further revealed that she retrieved the pills and gave them to the Unit Manager, Registered Nurse (RN) DD. Additional interview with CNA CC on 10/30/17 at 2:50 p.m. revealed that she found some medicines sitting on R#1's tray table on 10/30/17 which were what looked like an iron pill and a tiny white pill. CNA CC further revealed that this happens a lot with this nurse, Licensed Practical Nurse BB. CNA CC revealed that there have been times that she would be in a resident's room or the resident is the restroom and LPN BB will come in a leave the resident's medications and leave the room. When this occurs, l grab the medication, take it back out and give it to her. It happened this morning with R#1 at which time I notified the Unit Manager. During an interview conducted on 10/30/17 at 3:30 p.m. with R#2 revealed LPN BB stays with me sometimes and sometimes she will leave them (medications) and let me take them because she knows I will take them. Review of Brief Interview for Mental Status (BIMS) on 9/25/17 for R#2 revealed a score of fifteen (15) indicating intact cognition. During an interview conducted on 10/30/17 at 3:34 p.m. R#4 revealed LPN BB will set the pills down and the resident will take them later. R#4 further added, she sets them on my tray or if I'm in the restroom she'll leave them and I will get them when I come out. Review of Brief Interview for Mental Status (BIMS) for R#4 on 9/30/17 revealed a score of fifteen (15) indicating intact cognition. An interview on 10/30/17 at 4:13 p.m. with Unit Manager/RN DD revealed, it is my expectation that nurses watch the resident take their medications which is also the facility policy. She further revealed that did see an over the counter multi- vitamin tablet and a Carvedilol 3.125 mg tablet in R#1's room on today. She had to research for what medications they were, then talk to LPN BB, after which she (RN DD) then administered the medications to R#1. RN DD also revealed that she had not reported this to the Director of Nurses yet but would do so before the shift ended. RN DD further revealed that this is the first time that she is aware of and doesn't know if this is common practice for LPN BB. An interview on 10/30/17 at 4:46 p.m. with LPN BB revealed that she is aware that it is not okay to leave medications with any of the residents as none of the resident's are assessed to self-administer medications. She further revealed that she had been called out of the room, left the medications in R#1's room and forgot to go back and give them. During an interview on 10/31/17 at 10:18 a.m., the facility Administrator revealed, her expectations are that medications are not to be left at bedside. LPN BB is aware of the facility policy on medication administration.

Based on observation, staff interviews and review of facility policy, the facility failed to ensure that foods were served at the appropriate temperature to prevent food borne illness for four (4) residents from a sample of nineteen (19) residents. Finding includes: On 08/25/2015 at 12:40 PM Food temperatures from the steam table were obtained by AA and FF . The individual serving bowl of Cole Slaw was fifty (50) degrees. The thermometer was recalibrated with ice water and a second Cole slaw was tested at sixty (60) degrees. 08/26/2015 at 8:00 AM an interview with FF ' Dietary manager was conducted. FF acknowledged slaw was not originally on the menu and it is not normal practice to leave Cole slaw on the counter during service, Cole slaw is usually held in the refrigerator until served. Cole slaw was an alternate item and four residents received Cole slaw.

Based on observations, medical record review, and staff interviews the facility failed to maintain clinical records in accordance with accepted professional standards and practices on two (2) residents out of a resident sample of twenty-nine (29) residents. Per Electronic Health Record (EHR) review of Resident C chart on 8/26/15 at 11:22 am, findings revealed written physician orders [REDACTED]. Review of the current monthly physician sheet in Point Click Care (PCC) revealed orders for [MEDICATION NAME] 2.5 mg by mouth daily. Review of the electronic Medication Administration Record [REDACTED]. Observation on 8/26/15 at 9:22 am revealed a prepackaged single dose pharmacy dispense packet of [MEDICATION NAME] 5 mg (one whole pill) to be given by mouth to Resident C on 08/26/15 . Licensed Practical Nurse AA administered the whole pill as prepackaged by pharmacy to Resident C. LPN AA later acknowledged she did not notice the discrepancy prior to administering the medication to the patient. Per Electronic Health Record (EHR) review of Resident D chart on 8/26/15 at 11:34 am, findings revealed written physician orders [REDACTED]. Review of the current monthly physician sheet in Point Click Care (PCC) revealed orders for [MEDICATION NAME] 5 mg by mouth daily. Review of the electronic Medication Administration Record [REDACTED]. Observation on 8/26/15 at 10:03 am revealed a prepackaged single dose pharmacy dispense packet of [MEDICATION NAME] 10 mg (one whole pill) to be given by mouth to Resident D on 08/26/15 . Licensed Practical Nurse AA administered the whole pill as prepackaged by pharmacy to Resident D. LPN AA later acknowledged she did not notice the discrepancy prior to administering the medication to the patient. Interview conducted with DON 08/26/15 at 1:30pm she stated our expectation is that each nurse follow the five rights of medication administration i.e. right patient, right dose, et. It is also our expectation that orders are transcribed appropriately When orders are written they are entered into PCC, placed on the MAR indicated [REDACTED]. Interview conducted with the Administrator on 08/26/15 at 1:40pm. Administrator acknowledged the medication errors. As a result of theses findings she arranged an immediate AdHoc Quality Assurance Performance Improvement (QAPI) meeting with key staff members and pharmacy to address the findings. The administrator stated her expectation is that all MD medication orders are transcribed appropriately, faxed in to pharmacy, and reconciliation are completed by both nursing and pharmacy. Interview conducted with Registered Pharmacist (RPh) MM on 08/27/15 at 4:30pm. RPh MM stated the MD order was entered into the facility's electronic Point Click Care (PCC) system and electronic MAR indicated [REDACTED]. The issue is the modified MD orders were not received by pharmacy on the dates the orders were entered electronically into PCC. She further stated she spoke to the General Pharmacist who stated the pharmacy department did not have a document on file showing either one of the orders had been changed on Resident C or Resident D. RPh MM reiterated we do not have an MD order on file for the current changes reflected in the charts on either of these two residents. Per her discussion with the General Pharmacist the [MEDICATION NAME] 5 mg for Resident C was dispensed based on the last orders received and they had no record of any order change. The same applied to the [MEDICATION NAME] and [MEDICATION NAME] orders for Resident D on 7/28/15.

Based on clinical record review and staff interview the facility failed to administer insulin to one (1) diabetic resident ("F") with an accucheck glucose level of two hundred seventy-nine (279) according to physician's orders [REDACTED]. Findings include: Record review for resident "F" revealed admission to the facility on [DATE] with a [DIAGNOSES REDACTED]. Further review revealed a physician's orders [REDACTED]. Interview conducted on 05/07/2015 at 9:45 AM with a family member of resident "F" revealed she was visiting the resident on 05/04/2015 at 11:30 AM. The resident's fingerstick blood sugar result was 279. The family member indicated the resident was to receive Insulin before every meal and no Insulin was given. Continued interview with the family member revealed resident "F" was leaving for a physician's appointment after lunch and was very concerned. The family member knew the resident was going to orthopedic physician appointment with a very high blood sugar and no Insulin. Review of the May 2015 Medication Administration Record [REDACTED]. The next result charted at 4:30 PM was four hundred thirty (430) and fifteen (15) units of Insulin was administered. Review of electronic MAR-Medication Administration Note indicated that on 5/04/2015 the resident's blood sugar results at 9:00 PM was three hundred seventeen (317) and she required an additional dose of 15 units of Insulin. Interview on 05/07/2015 at 4;10 PM with the Director of Nurses (DON) revealed she had received complaint from daughter of resident "F" due to not receiving a dose of Insulin at lunch time on Monday 5/4/15. The resident's blood sugar was over 200. The DON Indicated she investigated the situation and discovered that the medication nurse did not give the Insulin coverage due to an emergency with another resident and resident "F" had been picked up by the van taking her to a physician appointment before she could get back to give the resident her Insulin. The nurse had already charted that she gave the Insulin but she had not given the Insulin. The DON indicated that the facility has not had any similar issues. The DON revealed that the medication nurse should have called for assistance to make sure the resident had received her Insulin before leaving the building.

Based on record review and staff interview the facility failed to ensure that neurological (Neuro) checks were conducted following a fall for one (1) resident (#1) from a sample of three (3) residents. Review of the medical record for resident #1 revealed an admission date of [DATE] and that the resident was assessed as high risk for falls. Review of the nurses notes revealed resident fell on [DATE] at 3:00 AM. The fall resulted in bruising to the right forehead. The resident's family member was notified and refused hospital evaluation. The physician's assistant did assess the resident on 4/27/15 following the fall. Review of Neurological Assessment for the resident revealed that from 04/27/2015 at 3:00 AM until 04/27/2015 at 10:00 PM neuro checks were conducted but none were conducted after 4/27/15 at 10:00 PM. Review of facility policy revealed neurological checks are to be performed every fifteen (15) minutes for the first hour, every thirty (30) minutes for the next two (2) hours , then every hour for 2 hours , then every shift for seventy two (72) hours. Interview 05/07/2015 at 3:30 PM with Director of Nurses (DON) revealed she was aware of the facility policy. The DON further revealed there were no neurological assessments after 10:00 PM on 4/27/15 . She indicated that she had checked the nurses notes and was unable to find any further neurological assessments.

Based on record review and staff interview, it was determined that the facility failed to notify the resident and the family or legal representative, in writing, of the transfer/discharge information for two (2) residents (#1 and #2) of four (4) sampled residents. Findings include: 1. Record review for Resident #1 revealed a Progress Notes entry of 07/23/2013 at 2:42 p.m. which documented that an order had been received to send the resident to the hospital emergency room for evaluation, and that the resident had been transferred to the hospital at 12:00 p.m. on that date. A subsequent Progress Notes entry of 07/23/2013 at 7:04 p.m. documented that, upon calling the hospital to inquired about the resident's status, facility staff had been informed that the resident's family had taken the resident home. However, further record review revealed no evidence to indicate that Resident #1 and the resident's family had been notified in writing of the resident's transfer, of the reason for the transfer, of the date of the transfer, of the location to which the resident was transferred, of the right to appeal the action to the State, and of the specified contact information of the State long term care ombudsman. 2. Record review for Resident #2 revealed a Progress Notes entry of 07/26/2013 at 4:41 p.m. which documented that the physician ordered for the resident to be sent to the hospital emergency room . A subsequent Progress Notes entry of 07/27/2013 at 3:26 p.m. documented that the resident remained in the hospital. However, further record review revealed no evidence to indicate that Resident #2 and the resident's family had been notified in writing of the resident's transfer, of the reason for the transfer, of the date of the transfer, of the location to which the resident was transferred, of the right to appeal the action to the State, and of the specified contact information of the State long term care ombudsman. During interview with the Administrator and the Director of Nursing conducted on 08/06/2013 at 2:45 p.m., these staff members acknowledged that no written notices were provided upon the transfer of Resident #1 and #2, as referenced above.

Based on observations and staff interviews, the facility failed to ensure that expired floor stock medications were removed from two (2) of four (4) medication carts. Findings Include: Observation of the Front Hall "B" Medication Cart with Licensed Practical Nurse (LPN) "AA" on 2/20/13 at 12:25 PM revealed one (1) opened bottle of Vitamin E 400 International Units (IU) and one (1) opened bottle of Zinc Sulfate 220 milligrams (mg). Each medication had a manufacturer's expiration date of 1/2013 on the side of the bottle. Interview on 2/20/13 at 12:28 PM with LPN "AA" confirmed the expiration date of 1/2013 on the bottle of Vitamin E and the Zinc Sulfate. LPN "AA" revealed the expiration dates of medications were to be checked by all nurses assigned to medication administration. The expired medications are to be discarded and replaced with a new bottle. Observation of the Back Hall "B" Medication Cart with LPN, Unit Manager "BB" on 2/20/13 at 12:38 PM revealed one (1) opened bottle of Vitamin E 400 International Units (IU) with a manufacturer's expiration date of 1/2013 on the side of the bottle. Interview on 2/20/13 at 12:39 PM with LPN, Unit Manager "BB" confirmed the expiration date of 1/2013 on the opened bottle of Vitamin E 400 IU soft gels. "BB" removed the medication for disposal. "BB" revealed the expiration dates of medications were to be checked by all nurses assigned to medication administration. The expired medications were to be discarded and replaced with a new bottle.