Every finding on record at Harborview Satilla

Based on staff interviews, record review, and review of the facility's policy titled, Safe Resident Handling/Transfer, Facility A failed to ensure safe transfer to a shower chair for one of 68 sampled residents (R) (R112). Actual harm occurred on 12/5/2025 when Certified Nurse Assistant (CNA) LL failed to transfer R112 using two people to assist, which resulted in a left humerus fracture.Review of the facility's policy titled, Safe Resident Handling/Transfer, dated 1/1/2026, under the Policy section stated, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk of injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines.Review of the quarterly Minimum Data Set (MDS) assessment for R112, dated 11/29/2025, revealed that Section C (Cognitive Patterns) documented that R112 had a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented that a chair-to-bed-to-chair transfer and a tub or shower transfer were not attempted due to medical condition or safety concerns. Section I (Active Diagnoses) documented diagnoses of, but not all inclusive, dementia, muscle weakness, congestive heart failure, osteoarthritis, and hypertension.Review of the Progress Notes for R112 revealed an entry dated 12/7/2025 of Bruising observed under resident's left axilla. Resident reported tenderness to the affected area. MD [medical doctor] notified; received order to obtain an X-ray.Review of a Radiology Results Report, dated 12/7/2025, for R112 revealed that the procedure was left humerus, 2+ views, and the findings were a fracture of the proximal humerus (upper bone of the arm).Review of a Facility Incident Report Form, dated 12/7/2025, revealed R112 complained of pain to left shoulder post transfer to the shower chair. Resident noted to have bruising under left axilla and left arm. X-ray results showed fractured left proximal humerus.In an interview on 2/12/2026 at 5:15 PM, Certified Nurse Aide (CNA) LL confirmed that R112 required a mechanical lift transfer with two people. She reported that on 12/5/2025, R112 was insistent on getting a shower to wash her hair, but all the mechanical lift pads were in use. She confirmed that she transferred R112 without assistance. CNA LL stated that another CNA was there to hold the shower chair during the transfer, but did not touch R112. She reported that R112 complained of pain during the last round at approximately 12/5/2025 at 5:30 PM. She states she reported it to the nurse.In an interview on 2/12/2026 at 5:29 PM, CNA MM confirmed that she held the shower chair while CNA LL transferred R112 without using the mechanical lift. She confirmed that R112 required two staff during transferring with the Hoyer lift. CNA MM stated that she did not physically transfer the resident, and that CNA LL picked the resident up under the resident's arms for the transfer.In an interview on 2/12/2026 at 4:53 PM, the Administrator revealed that the incident happened on 12/5/2025, and on 12/7/2025, the Director of Nursing (DON) notified the Administrator when bruising was identified under R112's left axilla.In an interview on 2/12/2026 at 4:59 PM, the National Director of Risk Management confirmed that R112 was a two-person assist for transfer using a mechanical lift. He stated he was unsure who the other person was who assisted the CNA.In an interview on 2/12/2026 at 5:02 PM, the Administrator confirmed that there should have been a second CNA. She confirmed that R112 required two-person assistance with transfers.

Based on staff interviews, record review, and review of the facility's policy titled, Comprehensive Care Plans, Facility A failed to implement the comprehensive care plan for one of 63 sampled Residents (R) (R112). Actual harm occurred on 12/5/2025 when Certified Nurse Assistant (CNA) LL failed to transfer R112 using two people to assist, which resulted in a left humerus fracture.Findings include:Review of the facility's policy titled, Comprehensive Care Plans, dated 1/1/2023 under the Policy section revealed, It is the policy of this facility to develop and implement comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a residents' medical, nursing, mental, and psychosocial needs and all services that are identified in the residents' assessment.Review of the quarterly Minimum Data Set (MDS) assessment for R112, dated 11/29/2025, revealed that Section C (Cognitive Patterns) documented that R112 had a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented that a chair-to-bed-to-chair transfer and a tub or shower transfer were not attempted due to medical condition or safety concerns. Section I (Active Diagnoses) documented diagnoses of, but not all inclusive, dementia, muscle weakness, congestive heart failure, osteoarthritis, and hypertension.Review of the care plan for R122, date initiated 6/8/2022 and revised 2/7/2024, revealed that R112 needed assistance with grooming, bathing, and personal hygiene related to mobility impairment and self-care impairment, and required two people at all times when giving care. Interventions included bathing assistance of two people, must have two people for all care provided, and transfer assistance of two people with a mechanical lift.Review of a Facility Incident Report Form, dated 12/7/2025, revealed R112 complained of pain to left shoulder post transfer to the shower chair. Resident noted to have bruising under left axilla and left arm. X-ray results showed fractured left proximal humerus.In an interview on 2/12/2026 at 5:15 PM, Certified Nurse Aide (CNA) LL confirmed that R112 required a mechanical lift transfer with two people. She reported that on 12/5/2025, she transferred R112 without assistance. She reported that R112 complained of pain during the last round at approximately 12/5/2025 at 5:30 PM. In an interview on 2/12/2026 at 4:59 PM, the National Director of Risk Management confirmed that the care plan interventions for R112 documented the resident required two-person assistance with a mechanical lift for transfers.In an interview on 2/12/2026 at 5:02 PM, the Administrator confirmed the care plan documented R112 required two persons assistance with a mechanical lift for transfers. Cross-Reference F-689

Based on observations, staff interviews, record review, and review of facility's policy titled, Date Marketing for Food Safety Policy, Facility A failed to ensure food was stored, sealed, and labeled correctly. This deficient practice affected the facility kitchen and had the potential to cause food contamination and foodborne illness among all residents consuming facility-prepared food. Facility A had 75 sampled residents that received an oral diet from the kitchen.Findings include:A review of the facility's policy titled, Date Marketing for Food Safety Policy, dated 1/1/2026, revealed that the facility adheres to a date marketing system to ensure the safety of ready-to-eat, time/temperature control for safety food.During an observation and walk through of the kitchen on 2/10/2026 at 10:20 AM with the Dietary Manager (DM) revealed the following:1. In the walk-in freezer a bag of filet fish was observed freezer burned, undated, and unlabeled.2. In the walk-in freezer sweet potato waffle fries were observed unsealed and unlabeled. 3. In the walk-in freezer a bag of chicken fingers was observed opened, unsealed, and undated. 4. In the walk-in freezer a bag of chicken fingers was observed opened, unsealed, and undated.Interview on 2/10/2026 at 1:50 PM with the DM confirmed the findings and stated that moving forward he and the kitchen staff would routinely monitor the dates and labels of all foods stored in the walk-in freezer.-in freezer.

Based on observation, record review, and review of the facility's policy titled, Disposal of Garbage and Refuse, Facility A failed to ensure trash and garbage refuse for one of two dumpsters was maintained in a sanitary manner, creating a potential of harboring pest and insects. The facility's census was 75 residents. Findings include:Review of the facility's policy titled, [Name of Facility] Disposal of Garbage and Refuse Procedure revealed containers shall be durable, cleanable, and free from cracks or leaks and covered when not in use.Observation on 2/12/2026 at 2:15 PM with the Dietary Manager revealed that the dumpster lid was open with no staff observed in the area.Interview on 2/12/2026 at 2:25 PM with the Dietary Manager confirmed the findings and acknowledged that the dumpster lid should be closed when not in use.Interview on 2/12/2026 at 5:50 PM with the Administrator confirmed the findings and acknowledged that the dumpster lid should be closed when not in use.

Based on staff interviews, record review, and review of the facility's policy titled, Abuse Neglect and Exploitation, Facility A failed to protect the residents' right to be free from resident-to-resident abuse for one of two residents (R) ( R151) reviewed for abuse. Specifically, R119 touched R151 on the breast. This deficient practice had the potential to affect other residents at the facility.Findings include:Review of the facility's policy titled Abuse Neglect and Exploitation, dated 7/15/2025 under Policy revealed, 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 resident property. VI. Protection of 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 investigation. Examples include but are not limited to:1.Responding immediately to protect the alleged victim and integrity of the investigation.2. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed.1. Review of the Electronic Medical Records (EMR) revealed R151 had diagnoses that included but not limited to down syndrome, mild neurocognitive disorder due to known physiological condition without behavioral disturbance, and mild neurocognitive disorder due to known physiological condition with behavioral disturbance.Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed that R151 had a Brief Interview for Mental Status (BIMS) of three, which indicated the resident had severe cognitive impairment.Review of R151's care plan included a focus area initiated on 2/12/2025, that indicated difficulty with making daily decisions (related to) r/t: down syndrome, and mild neurocognitive D/O (disorder).Review of R151's Progress Notes, revealed the following:On 1/2/2026 at 2:22 pm A staff member reported that upon returning from his break, he saw another resident ( R119) touch this resident's (R151) left breast over her clothing while she was seated in a common area. Staff members quickly stepped in and redirected the residents away from the other individual. The involved resident was tearful but denied pain or injury when assessed. No redness, bruising, or marks noted to left breast. Both residents were separated and safety measures were reinforced. Administrator notified per facility policy. Voicemail left for RP (responsible party) to return call back. [Name] Police Department notified. Medical Doctor notified via on-call service. Awaiting call back from Medical Doctor at this time.On 1/2/2026 at 3:12 pm Family notified of state reportable filed today. She stated that she would notify the other siblings.2. Review of the EMR revealed R119 had diagnoses that included but not limited to, Alzheimer's disease, dementia, unspecified severity, with other behavioral disturbances.Review of the Quarterly MDS assessment dated [DATE], revealed R119 had a Brief Interview for Mental Status (BIMS) of 0, which indicated the resident had severe cognitive impairment. Review of R119's care plan included a focus area initiated on 7/14/2025, that indicated R119 displayed behaviors which included urinating in floor and other inappropriate areas. Further review indicated wandering, walking in hallway naked and going into other residents' rooms. Touched a female resident's breast (State reportable filed). Appropriate interventions in place. Revision completed on: 1/5/2026.Review of the police report dated 1/2/2026 at 1:00 pm indicated the officer responded to [Name] Nursing Home, in reference to R119 touching the breast of R151. The report further revealed when the officer arrived and spoke with Licensed Practical Nurse (LPN) FF. LPN FF revealed R119, who has a diagnosis of dementia and Alzheimer's disease, was rubbing the stomach of R151, who has a diagnosis of down syndrome. Staff at the nursing home told R119 to stop rubbing the stomach of R151, his hand rubbed across the outer clothing of her breast area as he was moving it away. LPN FF revealed R151 became upset and she needed the incident reported. LPN FF was unsure if R119 touched R151's breast on accident or not. A case card was given.Review of orders for R119 revealed an order dated 2/5/2026 for medroxyprogesterone Acetate Oral Tablet 10 MG (Medroxyprogesterone Acetate); give one tablet by mouth two times a day related to high-risk heterosexual behavior. During an interview on 2/10/2026 at 11:13 am with R151 confirmed that she knew R119 and that she does not like it when he comes into her room. She confirmed that R119 touched her, saying, Bad touch, and pointed to her right breast. Interview on 2/12/2026 at 3:00 pm with R100 revealed that she has been R151 roommate since her admission to the facility and has become her big sister. She revealed that R119 did touch R151's breasts, but she was not around when it happened. She further revealed, R119 wanders all the time and it seems like no one can control his wandering and that staff make excuses for him due to his diagnoses.Interview on 2/12/2026 at 9:00 am with LPN FF revealed that she worked with both residents (R119 and R151). She revealed that R151's communication was like a child but she was able communicate her needs, likes, and dislikes in her own way. She further revealed R119 touched her while in wheelchair by nurses' station. She stated that R119 was redirected and they were both separated LPN FF revealed that R119 was a very sweet touchy person when he talks to you and that was his character and he does not mean any harm. She stated R119 began to console R151 because she was complaining about her knee and patted her on the shoulder and then her breast while saying it's going to be alright.Interview on 2/12/2026 at 11:45 am with the Administrator confirmed R119 did touch R151 on her breast but feels that the resident did not mean it sexually. The Administrator further revealed, R151 was crying and that R119 told her she was going to be alright patting her on her shoulder first and then breast. R119 was redirected and both residents were separated and it was immediately reported to the State. Both residents' family was contacted. The physician was contacted and ordered skin assessments which were completed.

Based on observation, staff interviews, record review and review of the facility's policy titled Promoting/Maintaining Residents Dignity, Facility A failed to provide one of 59 sampled Residents (R) (R22) privacy during wound care. This deficient practice had the potential to place R22 at risk of diminished quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.Findings Include:Review of the facility's policy titled, Promoting/Maintaining Residents Dignity, dated 1/1/2026 under the Policy section revealed that it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity 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.Review of the significant change Minimum Data Set (MDS) assessment for R22, dated 12/23/2025, for Section C (Cognitive Patterns) revealed, R22 had a Brief Interview for Mental Status (BIMS) score of 10 (indicating moderate cognitive impairment). Section I (Active Diagnosis) documented diagnosis of, but not all inclusive, Alzheimer's disease, stage three sacral pressure sore, psychotic disturbances, and malignant neoplasm of stomach.Review of the care plan for R22, dated 12/9/2025, revealed that R22 had a pressure ulcer due to needing assistance with bed mobility, bowel and bladder incontinence.Observation on 2/11/2026 at 10:30 AM revealed the Wound Care Nurse, knocked on the R22's door, introduced herself, and explained the procedure to R22. She returned to obtain supplies. Further observation revealed, R22 in a private room with blinds open. Certified Nursing Assistant (CNA) EE, who was assisting the Wound Care Nurse proceeded to remove and change R22's soiled brief while the blinds remained opened, exposing R22 during the wound care.In an interview on 2/11/2026 at 11:03 AM, the Wound Care Nurse confirmed that the blind was open and that she should have closed the blind for the residents' privacy. In an interview on 2/11/2026 at 11:05 AM, CNA EE confirmed that the open blinds were exposing R22 during the entire care.In an interview on 2/12/2026 at 10:00 AM, the Unit Supervisor FF stated that the staff were to close blinds and pull curtains when providing care to residents to provide privacy.In an interview on 2/12/2026 at 12:36 PM, the Director of Nursing (DON) confirmed that when staff provide care to include wound care the blinds should be closed and curtains pulled.

Based on record review, staff interviews, and review of the facility's policy titled, MDS 3.0 Completion, Facility B failed to complete and transmit a Minimum Data Set (MDS) discharge assessment to the Center for Medicaid Services (CMS) for one of two residents (R) (R137) reviewed for discharge.Finding include:Review of the Electronic Medical Record (EMR) revealed that R137 was admitted to the facility on [DATE] with diagnoses that included but was not limited to streptococcal sepsis, cellulitis of right lower limb, and chronic obstructive pulmonary disease.Review of the EMR under the progress notes section revealed, a progress note dated 11/14/2025 that indicated R137 discharged home.Review of the EMR under the MDS section revealed, a discharge assessment had not been completed for R137. Review of the care plan dated 10/26/2025 for R137 revealed a focus of R137 wishes to discharge on ce antibiotic therapy is completed. Interventions included but not limited to Contact MD for discharge orders prior to anticipated discharge, make arrangement with required community resources to support independence post discharge. (i.e. home health, PT, OT, MD, wound nurse), review all meds and (Medical Doctor) MD Orders prior to discharge with resident and family.Interview on 2/12/2026 at 4:58 pm with the MDS/Resident Assessment Director revealed she sends the transmittal as soon as the discharge was completed. She confirmed that R137 was discharged on 11/14/2025 but the discharge assessment was not completed. She revealed that typically when she know that a resident was going to discharge, she would complete a paper that organizes them by payor source however she was unsure why the discharge assessment was not completed.Interview on 2/12/2026 at 5:15 pm with the Administrator revealed that she was unsure of why the discharge had not been completed because of all of the steps the MDS department goes through.

Based on observation, staff interview, record review, and review of the facility's policy titled Medication Administration via Enteral Tube, Facility A failed to ensure services provided met the professional standards of quality care for one of five Residents (R) (R 124) with gastrostomy tubes. This deficient practice had the potential to result in an adverse drug reaction, ineffective treatment, and medical complications.Findings include:Review of the facility's policy titled, Medication Administration via Enteral Tube, date reviewed 3/1/2025 under the Policy revealed, It is the policy of this facility to ensure the safe and effective administration of medication via enteral feeding by tubes utilizing best practices. Under Policy Explanation and Compliance Guidelines revealed, 6. Each medication will be administered separately, not combined or added to an enteral feeding formula.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed, R156 had a Brief Interview for Mental Status (BIMS) score of 13 indicating minimum to no cognitive impairment; Section I (Active Diagnoses) revealed diagnoses that included but not limited to psoriasis and hip fracture; Section GG (Functional Abilities and Goals) revealed that R156 was totally dependent on staff for activities of daily living (ADLs) with two persons-assist.A review of the Quarterly MDS assessment dated [DATE] revealed that R124 had a BIMS score of nine, indicating moderate cognitive impairment; that R124 had diagnoses of, but not limited to, cerebral palsy, asthma, protein-calorie malnutrition, gastrostomy tube, and dysphagia; and that R124 required maximal assistance from staff for ADL care with one person assistance.Review of the physician order dated 4/10/2023 for R124 revealed a diet order for nothing by mouth. An additional order on 4/10/2023 revealed that residents were to receive 60 milliliters (ml) of water before and after each medication pass.Observation on 2/11/2026 at 8:37 AM revealed that LPN CC crushed all R124 medications in the medication pouch. After flushing the tube with 100 ml of water, she administered the crushed medications in the tube. During the interview, LPN CC confirmed that she crushed all the medications together and administered them. She acknowledged that she should have crushed and administered them separately.An interview with the Director of Nursing (DON) on 2/11/2026 at 3:25 PM revealed that nurses were to crush each medication separately and administer them separately through a feeding tube.

Based on observations, staff interviews, record review, and review of the facility's policies titled, Medication Storage and Controlled Substance Administration & Accountability, Facility A failed to ensure that three of three medication carts ([NAME] Hall, Sunflower Hall, and Dogwood Trail) did not have expired, unlabeled, and discontinued medications stored on the medication carts. The deficient practice had the potential to place residents at risk of receiving expired medications.Findings include:Review of the facility's policy titled, Medication Storage, dated 3/1/2025 revealed, all medications housed on premises will be stored in pharmacy or medication rooms according to the manufacturer's recommendations.Review of the facility's policy titled, Controlled Substance Administration & Accountability, dated 5/1/2025 under the Policy section revealed, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure.1. An observation and concurrent interview with Licensed Practical Nurse (LPN) AA on 2/11/2026 at 12:22 PM revealed, on the [NAME] Hall medication cart had a bottle of (Name) eye drops that had expired on 1/18/2026. In addition, there was a Lantus pen that was not labeled with a resident's name. LPN AA confirmed that the eye drops were expired and the Lantus pen was not labeled and did not have a resident name on it. She revealed that Lantus pen came from emergency box.2. An observation and concurrent interview with LPN AA on 2/11/2026 at 2:30 PM of the Sunflower Hall medication cart revealed that Insulin Aspartate had been opened on 1/10/2026 and expired on 2/7/2026. LPN AA confirmed that the insulin was expired.3. An observation and interview with LPN AA on 2/11/2026 at 2:49 PM of the Dogwood Trail medication cart revealed, morphine liquid, tramadol, and lorazepam in the third drawer lock box for a resident that had expired on 1/26/2026.Interview with Pharmacist Consultant (PC) on 2/12/2026 at 1:32 PM revealed that his last visit was on 1/15/2026 to the facility. The PC revealed that medication should be labeled with open and expiration dates. He revealed that insulin aspart was good for 28 days after it was opened stated that insulin from the emergency kit should be labeled with an open date, expiration date, patient's name, and room. He further revealed eye drops were good for 30 days after opening and that Narcotics were to be turned in immediately to the DON after the resident expired. The PC explained, narcotics that had been discontinued should not be left in medication cart.

Based on observations, staff interviews, and review of the facility's policy titled, Enhanced Barrier Precautions, Facility A failed to ensure infection control practices were followed for one of two sampled Residents (R) (R22) reviewed for pressure ulcers. This deficient practice had the potential to place R22 at risk of infection due to cross-contamination and exposure.Findings include:Review of the facility's policy titled, Enhanced Barrier Precautions, dated 3/1/2025 under the Policy Explanation and Compliance Guidelines section revealed, an order for enhanced barrier precautions (EBP) will be obtained for residents with wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous statis ulcers) and /or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO (multi-drug resistant organism). Implementation of EBP included making gowns and gloves available immediately near or outside of the resident's room, is only necessary when performing high-contact care activities.Review of the Significant Change Minimum Data Set (MDS) for R22 dated 12/23/2025 for Section C (Cognitive Patterns) revealed, R1 had a Brief Interview for Mental Status (BIMS) score of 10 (indicating moderate cognitive impairment); Section I (Active Diagnosis) revealed diagnoses that included Alzheimer's disease, stage three sacral pressure sore, psychotic disturbances, and malignant neoplasm of the stomach.Review of the care plan for R22 dated 12/9/2025 revealed, that R22 had a pressure ulcer due to assistance needed with bed mobility, bowel and bladder incontinence.Review of physician order dated 1/26/2026 revealed, that R22 had an order for enhanced barrier precautions r/t (related to) wound every shift.Observation on 2/11/2026 at 10:30 AM revealed, the Wound Care Nurse knocked on the resident's door, introduced herself, and explained the procedure to R22. She cleaned the bedside table then she returned to her treatment cart to obtain supplies. The Wound Care Nurse obtained assistance from Certified Nursing Assistant (CNA) EE who was wearing gloves and no gown. CNA EE proceeded to remove and change R22's soiled brief. CNA EE then washed her hands, changed gloves, and continued to assist the Wound Care Nurse with no gown on.Interview with CNA EE on 2/11/2026 at 11:05 AM confirmed that she was not wearing a gown and that R22 was under enhanced barrier precautions. She acknowledged that she should have worn a gown. Interview with the Director of Nursing (DON) on 2/12/2026 at 12:36 PM revealed, that nurses and CNA's were to check the sign on the door and that staff should read what the sign says before entering. The DON further revealed that staff were to wear gowns and gloves for residents under enhanced barrier precautions.

Based on record review, staff interviews, and review of the facility policy titled Comprehensive Care Plan the facility failed to ensure the care plan was followed for two person assistance toileting for one Resident ((R) R1) of three residents which resulted in R1 having a fall. On 4/12/2025, actual harm was identified when Certified Nursing Assistant (CNA) BB was providing care alone resulting in R1 falling out of bed and sustaining a left femoral neck fracture and left frontal scalp hematoma. Findings include Review of the Comprehensive Care Plans dated 3/1/2022, revealed Policy: 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 admission Record revealed resident was admitted to the facility on [DATE] with the following diagnoses that include but are not limited to hemiplegia and hemiparesis following cerebral infarction, atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, restless legs syndrome, hypertension, adult failure to thrive, and neuralgia and neuritis. Review of the medical record revealed R1 admitted to the facility with the facility with the diagnoses that included but are not limited to hemiplegia and hemiparesis following cerebral infarction, atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, restless legs syndrome, hypertension, adult failure to thrive, and neuralgia and neuritis. Review of the Minimum Data Set (MDS) admission dated 1/15/2025 revealed R1 was dependent for eating, shower, bathing, roll left or right, personal hygiene, upper and lower body dressing, self-care and toilet hygiene. Review of the care plan dated 1/22/2025 revealed resident needs assistance with grooming, bathing and personal hygiene related to inability to care for themselves, mobility impairment, range of motion limitations, self-care impairment, contracture left hand, hemiplegia and hemiparesis affecting the left nondominant side, muscle weakness. He has an assist rail to left side of bed. Interventions included toileting assist of two; transfers assist of two people; bathing assist of two; bed mobility assistance of two; and dressing assistance of two. An interview with Registered Nurse (RN) MDS Coordinator on 4/22/2025 at 2:56 pm revealed the [NAME] should be pulled from the electronic health record (EHR). It was reported that R1 was very contracted and could not give help with his care. RN MDS Coordinator reported that CNA BB should have had another CNA to assist her. It was further reported that CNA BB could have gotten another CNA from another hall or the nurse to assist her with caring for R1. It was reported that the care plan should have been followed for the safety of the resident. RN MDS Coordinator confirmed again that two people were needed, one for each side of the bed, when caring for R1. Cross reference F689

Based on medical record review, staff interviews and review of the facility policy Accidents and supervision, the facility failed to ensure that one resident (R1) of three residents was provided with enough staff to complete perineal care of residents while in bed. On 4/12/2025, actual harm was identified when Certified Nursing Assistant (CNA) BB was providing care alone resulting in R1 falling out of bed and sustaining a left femoral neck fracture and left frontal scalp hematoma. Findings include: Review of the facility policy, Accidents and Supervision dated 3/1/2022, revealed Policy: the resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazards (s) and risk (s). 2. Evaluating and analyzing hazard (s) and risk (s). 3. Implementing interventions to reduce hazard(s) and risk (s). 4. Monitoring for effectiveness and modifying interventions when necessary. 5. Supervision - Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency. b. Based on the individual resident's assessed needs and identified hazards in the resident environment. Review of the closed medical record revealed R1was admitted to the facility with the following diagnoses that include but are not limited to hemiplegia and hemiparesis following cerebral infarction, atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, restless legs syndrome, hypertension, adult failure to thrive, and neuralgia and neuritis. Review of NSG: Fall Risk Evaluation dated 4/12/2025 revealed a score of five indicating low risk. Review of Progress Notes dated 4/12/2025 revealed resident had a five-centimeter (5 cm) laceration to the top of the scalp and was sent to the ER (emergency room) for evaluation. Review of the facility 5-day follow-up dated 4/12/2025 revealed an interview that resident was turned to the right side to clean his bottom and then positioned on his backside where he was in the middle of the bed. CNA proceeded to the other side of the bed to clean that side of his bottom. The resident then shifted leg to the right side causing his bottom half to roll off the bed. Review of the hospital emergency room medical records dated 4/12/2025 revealed multiple computed tomography (CT) scans of cervical spine revealed no fracture or subluxation for R1. No paravertebral soft tissue swelling; CT Brain revealed left frontal scalp hematoma. There are no mass effects for midline shift; CT Chest revealed the patient has scoliosis as well as kyphosis. No sternal fracture or rib fracture is relatively identified. CT Abdomen and Pelvis revealed left femoral neck fracture, no evidence of acute injury within the chest, abdomen and pelvis. It was also noted that R1 had a Do Not Resuscitate (DNR) status with comfort care. A telephone interview on 4/22/2025 at 11:53 am with Certified Nursing Assistant (CNA) BB revealed she was doing her last round on 4/12/2025 and went to change R1. She stated that she rolled the resident to the right side and then adjusted the bed so she could roll him. She reported that she had her supplies, and she then walked to the other side of the bed. While walking to the other side of the bed, she reported that R1 started trying to put his feet off the bed. The bed did not have regular side rails. R1 is reported as getting one foot out of the bed and then rolled off the bed. CNA BB reported that she tried to catch him, but the bedside table was on the side she was walking to which slowed her from getting to R1 before he fell. After he fell, she noticed that his head was bleeding and she left the room to get the nurse. It is reported that LPN CC assessed R1 and he was then taken to the local hospital via Emergency Medical Services (EMS). CNA BB further stated she was trained that R1 was a one person assist for care. Lastly, CNA BB reported that there was only one CNA per hall so R1 was a one person assist because of that. An interview with CNA EE on 4/22/2025 at 1:40 pm revealed she worked with R1 in the past and had the assistance of CNA AA because it was easier to provide care with two people. R1 was reported as being very contracted. CNA EE stated that she was not comfortable changing R1 by herself. An interview with CNA FF on 4/22/2025 at 2:15 pm revealed R1 required two people to assist because he was very contracted, and it was hard to roll him. CNA FF reported that two people were also needed to help maintain his posture. CNA FF further reported that she trained CNA BB that R1as a two-person assist. It was also reported that R1 required two-person assistance and normally a CNA from another hall would have to help with assisting R1. An interview with LPN GG on 4/22/2025 at 2:22 pm revealed R1was total care and had severe contractions resulting in his legs being stiff, but he could kick his legs off the bed resulting in his feet dangling off the bed. LPN GG further explained that R1 required two people for his ADLs and the 2nd person was needed to maintain posture, the resident could not help with any aspect of his care. An interview with the Director of Nursing (DON) on 4/22/2025 at 3:17 pm revealed she does not know why CNA BB did not have a second person assisting with R1. DON further reported that the nurse could have assisted the CNA with bed mobility and toileting for R1. The DON reported that CNA BB should have waited for someone to assist her with caring for R1. An interview with the Administrator on 4/22/2025 at 3:23 pm revealed that she is unsure why CNA BB did not have a second person assisting her with R1. The Administrator reported that the CNA had not started the process for perineal care and R1 had a side of his body that he favored. The Administrator further reported that R1 had a tendency to throw his legs and his weight would follow his legs and R1 could not stop himself from falling. LPN CC was unavailable for an interview. Cross reference F656

Based on observations, staff interviews, record reviews, and review of the facility's policy titled, Medication Administration, Facility B failed to ensure over-the-counter medication were not stored at the bedside for one of 55 residents (R) (R151). This deficient practice had the potential to allow unauthorized access of unsecured medications to residents and visitors. Findings include: A review of Facility B's policy titled, Medication Administration, revised date 4/2022, revealed, Policy: Self-Administration of medication: Residents can self-administer medication if they can do so safely and are authorized to do so by their attending physician and interdisciplinary team. The medications will be kept in a lock safe box in the resident's room. The resident will open and self-administer his/her medications. The nurse will record the resident's self-administration of the medication on the medication record. Any self-administration error that occurs must be reported to the interdisciplinary team and the resident will be re-evaluated for continued self-administration. Resident Self -Administration of Medication dated 4/1/2024 documented it is the policy of this facility to support each residents right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Review of electronic medical records (EMR) revealed R151 was admitted with diagnoses of but not limited to shortness of breath, respiratory failure, heart failure, type 2 diabetes mellitus with diabetic neuropathy, atrial fibrillation, cerebral infarction, pneumonia and obstructive sleep apnea. Review of R151 EMR revealed there was no physician order for cough drops. Review of R151 EMR revealed there was no care plan for self-administration of medication. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed a Basic Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment. Review of nurses' notes dated 1/7/2025 documented R151 had [name brand] cough drops on his over the bed table. He stated that his wife brought them. When asked if other candy works just as good for throat irritation, he stated no. Explained that these could not be kept in the room but would speak with his wife and see if could find alternative or if needed get an order for these. He stated understanding. Spoke with his daughter, I could not reach wife. She stated he has always used these even at home and explained they could not be kept in room related to be considered a medication. She stated understanding. An Observation on 1/7/2025 at 11:02 am revealed a plastic zip closure storage bag of cough drops on R151 bedside table. An interview on 1/7/2025 at 2:11 pm with Licensed Practical Nurse (LPN) CC confirmed that R151 could not have cough drops at his bedside without a physician's order. LPN CC revealed a family member must have brought the cough drop into the facility. LPN CC stated she spoke with R151 and advised him that he could not have cough drops at his bedside. An interview on 1/9/2025 at 1:45pm with the Director of Nursing (DON) revealed R151's family member bought the over-the-counter medication into the facility, and it was discussed upon admission that no medication could be brought into the facility. DON expects staff to monitor for medication brought in from outside the facility, in the resident's room when rounding. Staff will be reeducated about self-administration of medication. An interview on 1/9/2025 at 1:55 pm with Administrator revealed her expectations was for staff to follow policies and procedure. Staff will be reeducated as she was made aware of cough drops being found at the resident's bedside.

Based on record reviews, interviews, and review of the facility's policy titled, Bed Hold Prior to Transfer, Facility A failed to provide a notice of bed hold for one of four residents (R) (R2) reviewed for hospitalization . Findings included: Review of facility A's policy titled, Bed Hold Prior to Transfer, revised on 3/1/2023, revealed Policy: It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital or the resident goes on therapeutic leave. Policy Explanation and Compliance Guidelines: Notice before Transfer. 2. The facility will have policies that address holding the resident's bed during periods of absence, such as during hospitalization or therapeutic leave. 3. The facility will provide written information about these policies to residents and/or resident representatives prior to and upon transfer for such absences. Record review revealed R2 was admitted to the facility with diagnoses of but not limited to sepsis, dementia severe with psychotic disturbance, and epilepsy. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R2's Brief Interview for Mental Status (BIMS) score was unable to be determined. Review of medical records revealed R2 was transferred to the hospital from the facility, on 10/22/2024 and readmitted to the facility on [DATE]. R2 was transferred to the hospital from the facility on 1/4/2025 and readmitted to the facility the same day. Further review revealed no evidence of the provision of a notice of bed hold provided to R2's representative on either date. During a telephone interview on 1/9/2025 at 9:17 am with R2's representative, who was from the Office of the State Guardian revealed she did not receive a notice of bed hold in writing from the facility when R2 went to the hospital on 10/22/2024 or on 1/4/2025. The representative revealed the facility failed to notify her that R2 went to the hospital on 1/4/2025 and was only made aware of the hospital stay when she visited the resident at the facility on 1/8/2025. Interview on 1/9/2025 at 8:39 am with Licensed Practical Nurse (LPN) AA revealed when a resident is transferred to the hospital staff complete documentation in the electronic health record, notifies the family/representative, and calls the hospital to give a report such as the medications the resident is taking and vitals. She confirmed that nothing is given in writing to the family/representative or resident regarding the bed hold policy. Interview on 1/9/2025 at 8:47 am with LPN BB revealed that when a resident is transferred to a hospital, the facility notifies the resident's representative or family via telephone. She confirmed nothing is given in writing to the resident or the representative regarding the bed hold policy. Interview on 1/9/2025 at 8:55 am with the Business Office Manager (BOM) revealed that due to the resident's poor cognition, he was not given anything in writing regarding a bed hold. The BOM revealed the resident's representative was notified via telephone about the bed hold policy on 10/22/2024 and 1/5/2025 and to him, that was adequate notification. He confirmed that there was nothing given in writing to the resident's representative regarding the bed hold policy on 10/22/2024 and 1/4/2025. On 1/9/2025 at approximately 11:45 am, the Administrator from the sister facility (facility B) who was present to assist facility A's Administrator with the survey, revealed he found bed hold agreements; however, they were not completed. They had the residents name and responsible party listed but it was missing the responsible party's signature, address, and phone number. Later, an interview with facility A Administrator at 1:00 pm revealed that the forms were completed via telephone and nothing in writing was sent to the representative/guardian.

Based on interviews, record review, and review of the facility's policy titled, Transfer and Discharge, Facility A failed to provide notice of transfer/discharge to residents or their representatives for one of four sampled residents (R) (R2) reviewed for hospitalization . Findings included: Review of Facility A's policy titled, Transfer and Discharge revised on 7/1/2024, revealed 12. Emergency Transfers/Discharges-initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified) G. Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated. R2 was admitted to the facility with diagnoses of but not limited to sepsis, dementia severe with psychotic disturbance, and epilepsy. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R2's Brief Interview for Mental Status (BIMS) score was unable to be determined. Review of medical records revealed R2 was transferred to the hospital from the facility on 10/22/2024 and readmitted to the facility on [DATE]. R2 was also transferred to the hospital from the facility on 1/4/2025 and readmitted to the facility the same day. Further review revealed no evidence of the provision of transfer/discharge notice was provided to R2's representative. During a telephone interview on 1/9/2025 at 9:17 am with the resident's representative, who was from the Office of the State Guardian, revealed she did not receive a notice of transfer/discharge in writing from the facility when the resident went to the hospital on 10/22/2024 or on 1/4/2025. The representative stated the facility failed to notify her that R2 was sent to the hospital on 1/4/2025 and was only made aware of the hospital stay when she visited the resident at the facility on 1/8/2025. Interview on 1/9/2025 at 8:39 am with Licensed Practical Nurse (LPN) AA revealed when a resident is transferred to the hospital staff complete a transfer document in the electronic health record, notifies the family/representative via telephone, and calls the hospital to give a report such as the medications the resident is taking and vitals. She confirmed that nothing is given in writing to the family/representative or resident regarding reason for transfer/discharge. Interview on 1/9/2025 at 8:47 am with LPN BB revealed that when a resident is transferred out of the facility to the hospital, the facility notifies the resident's representative or family via telephone. She revealed staff complete a transfer form in [named electronic system] and that the facility calls the hospital to give a report. LPN BB revealed the resident's code status, and a list of medications are sent with emergency services. She confirmed nothing is given in writing to the resident or the representative regarding reason for transfer/discharge. Interview on 1/9/2025 at 8:55 am with the Business Office Manager (BOM) revealed that due to R2's poor cognition, he was not given anything in writing regarding a reason for transfer/ discharge on 10/22/2024 or on 1/4/2025. The BOM revealed that R2's representative was notified via telephone the resident was being transferred to the hospital on 10/22/2024 and 1/5/2025 and to him, that was adequate notification. He confirmed that there was nothing given in writing to the resident's representative regarding the reason for transfer/discharge on 10/22/2024 or 1/4/2025. Interview on 1/9/2025 at 1:00 pm with the Administrator revealed that R2's representative was called on 10/22/2024 and 1/4/2025 but nothing in writing regarding a notice or reason for transfer/discharge was given to the representative/guardian.

Based on observations, staff interviews, record review, and review of the facility's policies titled, Comprehensive Care Plan and Nail Care Policy, Facility A failed to implement the care plan for two of 55 residents (R) (R22 and R12). Specifically, the facility failed to provide a scoop mattress for resident (R22) and failed to provide proper nail care for (R12). The sample size was 55. Findings include: Review of the facility A's policy titled, Comprehensive Care Plan, revised 1/1/2023, revealed that it is the policy of this facility to develop and implement a comprehensive person-centered plan of each resident, consistent with rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. 1. Review of the electronic medical record (EMR) revealed R22 was admitted to the facility with pertinent diagnoses including but was not limited to depression and anxiety. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not assessed due to short-term and long-term memory issues. Review of the care plan for R22, dated 11/27/2024, revealed a risk for falls. Goals included but not limited to not having any fall related injuries by next review. Interventions included but not limited to using scoop mattress. Observation on 1/9/2024 at 2:42 pm of R22 revealed that her bed had a standard facility mattress, and she was lying at a 30-degree angle elevation. An interview on 1/09/2024 at 2:55 pm with Licensed Practical Nurse (LPN) AA confirmed that R22 was not on a scoop mattress as care planned. An interview on 1/9/2024 at 3:10 pm with the Director of Nursing (DON) confirmed that R22 was not on a scoop mattress as care planned. She revealed that care plans should be implemented as written. Observation and interview on 1/9/2025 at 3:10 pm with the Administrator, accompanied by the DON to R22's bedside, confirmed there was not a scoop mattress in use. 36377 2. Record review of the medical record revealed R12 had diagnoses of but not limited to dementia, gastro esophageal reflux disease, and left-hand contracture. Review of R12's Quarterly MDS assessment dated revealed R12 was assessed a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment; MDS also revealed R12 required total assistance with all Activities of Daily Living (ADL). Review of the ADL care plan for R12, created 11/10/2021 and last revised 5/15/2023, documented R12 needs assist with grooming, bathing, and personal hygiene r/t (related to) mobility impairment and self-care impairment. Interventions included nail care as needed. During an observation on 1/7/2025 at 10:01 am to 12:46 pm of R12, his left hand and fingers were curled into a fist causing the long discolored yellowish fingernails to become embedded into lower palm of the hand. Also, an odor was coming from R121's hand. Interview on 1/7/2025 at 12:46 pm with family member of R12, Family Member A revealed concerns with R12 having long nails that needed trimming and a foul odor in the palm of the left hand. She further stated her opinion that the odor was a result from staff not washingR12's left palm. Interview on 1/7/20255 at 1:08 pm with the DON and Administrator, the DON confirmed an odor coming from R12's left hand and her staff failed to trim the R12's fingernails. Interview on 1/9/2025 at 3:36 pm with the MDS Coordinator revealed that in her professional opinion, the intervention nail care as needed included trimming the fingernails and cleaning underneath the nails. She revealed her expectation was that the care plan is followed.

Based on observations, record reviews, staff interview, and review of the facility's policy titled, Nail Care, Facility A failed to perform nail care for one totally dependent resident (R) (R12), who had a left-hand contracture. The sample size was 55 residents. Findings include: Review of facility A's undated policy titled, Nail Care, documented, 1. Assessments of resident nails will be conducted on admissions and readmission to determine the resident nail condition, needs and preferences for nail care, if possible. a. Report unusual or abnormal conditions, needs, and preferences for nail care, if possible. a. Report unusual or abnormal conditions of the nails to the physician and the responsible party (e.g. (example given), curling, color changes, separations from the nailbed, redness, bleeding, pain, odor, infection, etc.) 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Principles of nail care. a. Nails should be kept smooth to avoid skin injury. Record review of the medical record revealed R12 had diagnoses of but not limited to left hand contracture and dementia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of three which indicates severe cognitive impairment. Section GG assessed resident as totally dependent for all Activities of Daily Living (ADLs) skills. Review of R12's Physician Order Form (POF) dated January 2025 listed an order dated 1/9/2024 for nail care weekly every Tuesday. During an observation on 1/7/2025 at 10:01 am to 12:46 pm, R12 was observed lying in bed with a left-hand contracture. Continued observation revealed R12's left hand was curled into a fist and a foul odor was noted. R12's fingernails (on the left hand) were long and had a thick yellowish discoloration. The long fingernails were observed to be embedded into the lower palm of R12's hand resulting in one of the fingernails pinching the palm. There was no breakage in skin but had the potential to result in a skin tear or cause discomfort. During an interview on 1/7/2025 at 12:46 pm with Family Member A of R12. Family Member A reported that staff were not trimming the resident fingernails. The family member also complained of R12's hand having a sour odor from not being washed. During an interview on 1/7/2025 at 1:08 pm with the Director of Nursing (DON) and Administrator, the DON confirmed R12's fingernails were long and embedded into R12's palm. The DON also confirmed that R12's left hand had a mild odor. During a later interview on 1/9/2025 at 1:25 pm with the DON, she revealed her expectation that all staff, including her certified nursing assistants and licensed nursing staff, monitor all residents for nail care. DON revealed that nail care included trimming and cleaning underneath the nails. DON further revealed that long nails have the potential to put the resident at risk of injury.

Based on observations, staff interviews, record reviews, and review of the facility's policy titled, Oxygen Administration, Facility B failed to ensure oxygen administered by nasal cannula was set at the prescribed rate for one of 42 residents (R) (R30) receiving oxygen therapy. The deficient practice has the potential to cause adverse consequences for the R30. Findings included: Review of facility B's policy titled, Oxygen Administration, revised 3/1/2023, revealed under, Policy Explanation and Compliance Guidelines, Oxygen is administered under orders of a physician, except in the case of an emergency. Review of the medical record for R30 revealed pertinent diagnoses included but not limited to dementia, chronic obstructive pulmonary disease (COPD), anxiety disorder, and allergic rhinitis. Review of the Quarterly Minimum Data Set assessment dated [DATE] Section C - Cognitive Patterns assessed a Brief Interview for Mental Status (BIMS) score of 8. This score suggests moderate cognitive impairment. Section J - Health Conditions, indicates R30 has shortness of breath or trouble breathing with exertion and when lying flat. Review of the care plan for R30, updated on 11/19/2024, documented at risk for alteration in respiratory status related to COPD and allergic rhinitis. She has a history of smoking cigarettes, has order for oxygen via nasal cannula; administer oxygen as ordered per physician's order. Review of physician's orders included, may apply oxygen at 2 liters per minute via nasal cannula for complaints of shortness of breath and discomfort, and monitor oxygen saturation every shift. Observation on 1/7/2025 at 11:30 am R30 was lying in the bed, with no respiratory distress noted. She had oxygen on at 4 liters by nasal cannula. Observation on 1/8/2025 at 9:00 am R30 was sleeping in bed, no distress noted. Oxygen on at 4 liters nasal cannula. Interview and observation on 1/8/2025 at 10:52 am with LPN FF revealed the nurses are responsible for checking the oxygen rate every shift. The nurse states she checks the oxygen every time she goes in the room. R30 is sleeping with oxygen on at 4 liters nasal cannula. LPN FF revealed R30 uses the oxygen constantly. LPN FF verified the oxygen was set at 4 liters nasal cannula. LPN FF confirmed the order was for 2 liters nasal cannula. Interview on 1/8/2025 at 10:55 am with LPN GG, confirmed the oxygen order was for 2 liters by nasal cannula. Interview on 1/9/2025 at 3:30 pm with the DON revealed the facility does not have a respiratory department, the nurses are responsible for making sure the oxygen is on the correct liters. Interview on 1/9/2025 at 3:50 pm with LPN GG, revealed the residents nurse for that shift is responsible for making sure the oxygen rates are correct. The Certified Medical Assistants (CMA) can look at the oxygen and let the nurse know if it is incorrect, and the oxygen rate is listed on the Medication Administration Record.

Based on record review and staff interview, and review of the facility's policy titled, Use of Psychotropic Medication, Facility B failed to indicate the need to extend orders for as needed (PRN) antianxiety medication for one of four residents (R) (R18) beyond 14 days and failed to document the reason for the extension to be in effect. Findings include: Review of facility B's policy titled, Use of Psychotropic Medication, with a revised date of 5/1/2024 revealed under 9. PRN (as needed) orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. (that is) 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. Record review revealed R18 admitted to the facility with diagnosis of Alzheimer's/ Dementia including patterns of psychosis and hallucinations or delusions, and physical and verbal behaviors. Review of physician orders included but not limited to Alprazolam 0.5 mg (milligram) PRN every 12 hours as needed for anxiety related to diagnosis of generalized anxiety disorder. The start date was 11/4/2024 and the duration/end date was 11/4/2025. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed R18 with a BIMS score of 2 indicated severe cognitive impairment, mood symptoms included anxiety, depression, and pain, and received antipsychotic and antidepressant medications. Review of the care plan for R18 included anxiety. Interventions included anti-anxiety medications, provide medications as ordered by physician and evaluate for effectiveness. Anti-anxiety medications. Monitor for side effects and report to physician. Review of the clinical record for R18 did not document the rationale for its continued use Alprazolam 0.5 mg PRN past 14 days. Interview on 1/9/2025 at 9:45 am with DON (Director of Nursing) regarding how often Hospice provider comes into the building. DON confirmed that an antipsychotic medication required a 14-day limit unless a rationale is provided in the medical record. R18 receives Alprazolam Oral Tablet 0.5 mg (milligram) every 12 hours PRN (as needed). The prescription was written for 11/4/2024 to 11/4/2025. Interview on 1/9/2025 at 10:11 am with primary physician regarding the rational for writing the prescription for Alprazolam 0.5 mg involved convenience. Physician was aware of 14-day limit for anti-anxiety/psychotropic medication.

Based on observations, staff interviews, and review of the facility policy titled, Date marking for food safety, facility A failed to discard food in the walk-in cooler by the use by date and failed to label and date opened food items in the walk-in refrigerator and dry storage area, this deficient practice had the potential to effect 86 of the 89 residents receiving an oral diet. Findings include: Review of facility A's policy titled Date marking for food safety, revised on [DATE], revealed under Policy: The facility adheres to date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Under, Policy Explanation and Compliance Guidelines for Staffing: 2. The food shall be clearly marked to indicate the date or by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening and the day/date the item must be consumed or discarded. 6. The head cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Manager, or designee shall spot check refrigerators weekly for compliance and document accordingly. Corrective action shall be taken as needed. The tour of the kitchen on [DATE] started at 8:45 am with the Dietary Manager (DM). The following concerns were identified during the tour: Walk in cooler- 4 large containers of peeled garlic with an expiration date of [DATE]. A large box of sweet potatoes that appeared rotten with mold, a white fuzzy substance, with an in date of [DATE] and no expiration/out date. A large box of carrots that appeared to be old, rotten, and wilted with an in date of [DATE] and no expiration/out date. 2 large boxes of tomatoes that were soft (overripen) and discolored with what appeared to be mold, a black and white substance with an in date of [DATE] and no expiration/out date. A large box of bananas that were overripen, black in color. No in/out date. Dry pantry- bag of pasta that was opened with no use by date. Interview on [DATE] at 9:30 am with the Dietary Manager revealed that she and her staff are responsible for labeling food items with an open and use by date. She stated that all food should be discarded by the item's use by date and expiration date. She confirmed that all items identified during initial walk through were either expired or not labeled correctly. She revealed that she assigned the task to one of her dietary aid's but that they overlooked the items the surveyor discovered. Interview on [DATE] at 2:30 pm with Administrator revealed that her expectations were that dietary staff abide by policy by labeling and dating all food items. She revealed dietary staff should be looking for, and discard, expired food items daily. She stated if these things were not completed it could potentially affect all residents receiving an oral diet.

Based on observations, staff interview and record review, it was determined that the facility failed to develop a comprehensive plan of care to address the potential risk for skin tears and brusing and actual skin tears and bruising for one resident (#54) on Unit I in a total sample of 31 residents. Findings include: Unit I Resident #54 had [DIAGNOSES REDACTED]. It was observed on 4/09/12 at 12:14 p.m. that resident #54 had bruising on his/her arms, hands and fingers. There was an "MD communication" fax form dated 2/11/12 that licensed nursing staff had sent to the physician about the resident having had a skin tear, treatment was started and geri-gloves had been applied to prevent any more skin tears. There was a 2/12/12 physician's orders [REDACTED]. Licensed nursing staff documented in the nursing notes that the resident had sustained seven skin tears on his/her upper extremities between 1/22/12 and 3/26/12. However, the facility did not develop a care plan and describe the care and services that were to be provided to prevent skin tears and to promote healing of his/her actual skin tears. See F323 for additional information regarding resident #54.

Based on observations, staff interview and record review, it was determined that the facility failed to ensure that nursing staff consistently provided care to prevent or to reduce the potential for acquiring new skin tears by one resident (#54) on Unit I in a total sample of 31 residents. Findings include: Unit I Resident #54 had [DIAGNOSES REDACTED]. B12 deficiency, [DIAGNOSES REDACTED], and gastro-esophageal reflux disease. The resident was observed on 4/09/12 at 10:35 a.m. and 12:14 p.m. to have skin discolorations and bruises on both of his/her arms, hands and fingers. Nursing staff had not put any type of protective clothing or devices on the resident's arms or hands to protect them from getting new skin tears. According to the nursing notes, the resident had sustained the following skin tears: his/her left outer forearm on 1/22/12; on his/her left upper hand on 1/24/12; to his/her left wrist on 1/27/12 and; on his/her left lower arm on 2/11/12. Licensed nursing staff had faxed a "MD communication" form dated 2/11/12 to the resident's physician regarding the resident's skin tear which was being treated and the initial application of geri-gloves to prevent any more skin tears. There was a 2/12/12 physician's orders [REDACTED]. Licensed nursing staff documented in the nursing notes that the resident had sustained additional skin tears on his/her right anticubital space on 2/28/12, his/her left lower arm on 3/10/12 and his/her right wrist on 3/26/12. Nursing staff had not applied geri-gloves to the resident's arms as ordered during the following observations: on 4/9/12 at 10:35 a.m., 2:28 p.m., and 4:38 p.m.; on 4/10/12 at 7:30 a.m., 9 a.m., 10:30 a.m., and 3:35 p.m.; on 4/11/12 at 7:48 a.m., 10:10 a.m., 12:30 a.m., 3:10 p.m. and 4 p.m. and; on 4/12/12 at 8:10 a.m. During an interview on 4/12/12 at 9:15 a.m., registered nurse "CC" confirmed that nursing staff should have applied geri-gloves on the resident but they had not. After surveyor inquiry, "CC" said that she would apply geri-gloves on the resident and develop a care plan to address his/her skin tears with interventions such as the use of the geri-gloves. Although the resident sustained [REDACTED]. Although the resident had a physician's orders [REDACTED]. In addition, the resident sustained [REDACTED].

Based on observations, staff interviews, record review, review of the facility's policies and procedures, and review of documentation about the facility's surface disinfectant, it was determined that the facility failed to maintain an Infection Control Program that ensured proper infection control and provision of aseptic technique to prevent cross contamination and prevent indirect contact transmission of a blood borne infection or a microscopic pathogen by failing to ensure ten (10) nurses cleaned and/or disinfected glucometers between use on residents and to monitor implementation of their infection control policy and procedures. These practices effected twenty six (26) insulin dependent, sampled residents but had the potential to effect all 46 of the residents whose blood sugar levels required monitoring. Therefore, it was determined that an immediate jeopardy existed for 46 residents who had diabetes and required fingerstick blood glucose monitoring from July 27, 2010 through July 28, 2010 when a plan of correction was implemented by the facility to remove the jeopardy. Therefore, it was determined that the immediate jeopardy was removed on July 29, 2010 and the scope and severity was lowered to an "E" level. However, the facility remains out of compliance in order to ensure that licensed nursing staff continues to implement the correct procedures to clean and disinfect blood glucose testing machines; that supervisory nursing staff continues to monitor to ensure that blood glucose testing machines are clean and disinfected according to the manufacturer's directions; and that the Performance Improvement Committee monitors the facility's interventions to ensure that the infection control policies and procedures are implemented as planned. The Center for Disease Control's (CDC) section "Diabetes Care Procedures and Techniques" of the "Recommended Infection-Control and Safe Injection Practices to Prevent Patient-To-Patient Transmission of Bloodborne Pathogens", recommended that if a glucometer used for one patient must be re-used for another patient, then the device must be cleaned and disinfected. Hand hygiene was to be performed immediately after the removal of (contaminated) gloves and before touching other medical supplies intended for use on other residents. In the Centers for Medicare and Medicaid Services (CMS) October, 2009 "Infection Prevention and Control Training" it was documented that, when cleaning a glucose meter, or any other object potentially contaminated with blood, either a EPA approved germicidal disinfectant which was labeled effective against [DIAGNOSES REDACTED] (TB) or hepatitis B virus (HBV), or a 1:10 bleach to water (minimal) concentration must be used. Alcohol was not included as an EPA approved germicidal disinfectant. The facility was using the EPA approved germicidal disinfectant CaviWipes which was labeled to be used to clean and disinfect hard non-porous surfaces of non-critical patient care equipment and environmental surfaces. The label noted that non-critical equipment did not come in contact with non-intact skin or mucous membranes. The directions for use on the CaviWipes container documented that CaviWipes would clean and disinfect, when used as directed. The cleaning instructions were for staff to use one CaviWipes towelette to pre-clean surfaces to remove gross debris. For use as a virucide, including HIV-1, HBV and HCV applications, staff was supposed to use a second CaviWipe towelette to thoroughly wet the surface and ensure the surface remained visibly wet for two minutes at room temperature (69 degrees F.). For tuberculocidal disinfection, staff were to allow the surface to remain visibly wet for three minutes at room temperature. The facility's Policy and Procedure for cleaning and disinfecting the glucometer, Blood Glucose Monitoring Technique, included a procedure that the meter was to be cleaned between each resident using an antimicrobial wipe. The Policy and Procedure did not include instructions to clean and disinfect between resident use. Unit I 1. On 7/28/10 at 11:12 a.m., licensed nursing staff "BB" used one CaviWipe to clean the glucometer before obtaining a finger stick blood sugar level for resident #108. Nurse "BB" then used one CaviWipe to clean the glucometer after obtaining the finger stick blood sugar level for the resident. Although licensed nursing staff " BB " had used one CaviWipe to clean the glucometer before and after obtaining the finger stick blood sugar level for resident #108 as the manufacturer's directions documented, " BB " had failed to thoroughly disinfect the glucometer before and after its use by wiping the glucometer with a second CaviWipe. There was not any visible blood contamination on the glucometer at those times. 2. On 7/28/10 at 3:35 p.m., licensed nurse "AA" failed to clean and disinfect the glucometer after obtaining a finger stick blood sugar level for resident #112. On 7/28/10 from 3:36 p.m. to 3:56 p.m., licensed nurse "AA" failed to clean and disinfect the same glucometer before obtaining the blood sugar levels between residents #112, "A", "B", "C", "D" "E" and "F". After obtaining the finger stick blood sugar level for resident "B", licensed nurse "AA" stated that she/her cleaned the glucometer between each resident and then wiped the surface of the glucometer with an alcohol prep pad. Nurse "AA" wiped the glucometer with only an alcohol prep pad between residents and before giving it to another nurse to use. However, alcohol is not an EPA approved germicidal disinfectant. There was not any visible blood contamination on the glucometer at those times. 3. During an observation of blood sugar levels being obtained on 7/28/10 from 4:07 p.m. to 4:29 p.m., licensed nurse "CC" cleaned the glucometer between residents #102, #115, #114, and "H" with only an alcohol prep pad. However, alcohol is not an EPA approved germicidal disinfectant. 4. During an observation on 7/28/10 from 4:05 p.m. to 4:30 p.m., licensed nurse "BB" failed to clean and disinfect the glucometer prior to obtaining the blood sugar level for resident #113. After obtaining the blood sugar level for resident #113, licensed nurse "BB" wiped the glucometer using only an alcohol prep pad prior to obtaining the blood sugar level of resident "G". Nurse "BB" failed to clean and disinfect the glucometer between obtaining the blood sugar levels for residents #113 and "G". Unit II 1. During an observation on 7/28/10 at 11:30 a.m., licensed nurse "VV" took the Accuchecks Inform glucometer out of its plastic storage box and obtained resident #212's blood sugar level. Afterwards, he/she wiped the front and back of the glucometer with one CaviWipe and let it dry for approximately five minutes but, did not use a second wipe to disinfect it before obtaining resident #217's blood sugar level. After "VV" obtained resident ' #217's blood sugar level, he/she wiped the front and back of the glucometer with one CaviWipe then waited approximately five minutes for it to dry before placing it in its plastic storage box. 2. During an observation on 7/28/10 at 4:20 p.m. licensed nurse "XX" cleaned the front and back of the glucometer with one CaviWipe and let it dry for three minutes before obtaining resident #212's blood sugar level. However, he/she failed to use a second CaviWipe to disinfect the glucometer. After obtaining resident #212's blood sugar level, nurse "XX" then cleaned the front and back of the glucometer with one CaviWipe and let it dry for three minutes. However, he/she did not use a second CaviWipe to disinfect the glucometer before obtaining resident #217's blood sugar level. Nurse"XX" then wiped the front and back of the glucometer with one CaviWipe and let it dry for three minutes. However, he/she did not disinfect the glucometer before placing it back into its plastic storage box. 3. During an observation on 7/28/10 at 4:20 p.m., licensed nurse "ZZ" cleaned the front and back of the glucometer with one CaviWipe and let it dry for two minutes before obtaining resident #221's blood sugar level. However, he/she failed to use a second CaviWipe to disinfect the glucometer. After obtaining resident #221's blood sugar level, nurse "ZZ" cleaned the front and back of the glucometer with one CaviWipe and let it dry for two minutes before obtaining resident #214's blood sugar level. However, he/she did not use a second CaviWipe to disinfect the glucometer. After obtaining resident #214's blood sugar level, nurse "ZZ" wiped the front and back of the glucometer with one CaviWipe and let it dry for two minutes. However, he/she did not disinfect the glucometer before placing it back into its plastic storage box. 4. During an observation on 7/28/10 at 11:40 a.m., licensed nurse "YY" cleaned the front and back of the glucometer with one CaviWipe and let it dry for three minutes before obtaining resident #208's blood sugar level. However, he/she failed to use a second CaviWipe to disinfect the glucometer. After obtaining resident #208's blood sugar level, nurse "YY" then cleaned the front and back of the glucometer with one CaviWipe and let it dry for three minutes before obtaining resident #218's blood sugar level. He/She did not use a second CaviWipe to disinfect the glucometer. After obtaining resident #218's blood sugar level, nurse "YY" wiped the front and back of the glucometer with one CaviWipe and let it dry for three minutes. Nurse "YY" then obtained resident #216's blood sugar level without using a second CaviWipe to disinfect the glucometer. After obtaining resident #218's blood sugar level, nurse "YY" wiped the front and back of the glucometer with one CaviWipe and let it dry for three minutes. However, he/she did not disinfect the glucometer before placing it back into the storage box. 5. During an observation on 7/28/10 at 4:20 p.m., licensed nurse "UU" cleaned the front and back of the glucometer with one CaviWipe and let it dry for two minutes before obtaining resident #219's blood sugar level. However, he/she failed to use a second CaviWipe to disinfect the glucometer. After obtaining resident #219's blood sugar level, nurse "UU" then cleaned the front and back of the glucometer with one CaviWipe and let it dry for two minutes before obtaining resident #220's blood sugar level. However, he/she did not use a second CaviWipe to disinfect the glucometer. After obtaining resident #220's blood sugar level, nurse "UU" wiped the front and back of the glucometer with one CaviWipe and let it dry for three minutes. However, he/she did not disinfect the glucometer before placing it back into its plastic storage box. 6. During an observation on 7/27/10 at 4:15 p.m., licensed nurse "WW" obtained resident #208's blood sugar level without cleaning and disinfecting the glucometer. After obtaining resident #208's blood sugar level, nurse "WW" then cleaned the front and back of the glucometer with one CaviWipe and let it dry for three minutes. However, he/she did not use a second wipe to disinfect the glucometer before placing it in the storage box. Nurse "WW" stated at that time that he/she used one CaviWipe to clean the glucometer after each use and waited three minutes. The facility provided an acceptable Credible Allegation of Compliance on 7/29/10 which included the following: The Medical Director was consulted and the facility's policy and procedure for Blood Glucose Monitoring Technique was revised on 7/28/10 and titled Blood Glucose Monitoring and Cleaning Technique. The revised policy and procedure was provided to the facility and licensed nursing staff. Completed 7/28/10. All licensed nursing staff on Unit I and Unit II were educated by the respective Directors of Nursing (DON), Assistant DON, Infection Control Nurses and Education Coordinators on appropriate cleaning and disinfecting of the glucometer machines with the CaviWipes product. Completed 7/28/10. After reviewing the policy and receiving education, the licensed nursing staff performed a return demonstration. Successful completion of the training was documented on a skills checklist. Completed 7/28/10. No licensed nursing staff would be allowed to perform glucometer testing without successfully completing the additional education and returning the skills demonstration. Implemented 7/28/10. Licensed nurses, who were not on duty or were on leave during the survey, were to be educated with a return skills demonstration by 8/5/10. A plan was implemented for the Quality Assurance nurse, Shift Supervisor, Infection Control Nurse, Education Coordinator, DON or ADON to randomly observe at least 5 glucometer tests per week and report the results to the Quality Assurance Committee. Implemented 7/28/10. Therefore, it was determined that the immediate jeopardy was removed on 7/28/10 and the scope and severity was lowered to an "E" level. However, the facility remains out of compliance in order to ensure that licensed nursing staff continues to implement the correct procedures to clean and disinfect blood glucose testing machines; that supervisory nursing staff continues to monitor to ensure that blood glucose testing machines are clean and disinfected according to the manufacturer's directions; and that the Performance Improvement Committee monitors the facility's interventions to ensure that the infection control policies and procedures are implemented as planned.

Based on observation, staff interview, and review of the facility's infection control policies and procedures, it was determined that the facility failed to be administered in a manner that ensured that 11 licensed nurses were trained and implemented effective procedures to clean and disinfect glucometers between use for 26 of the 46 residents whose blood glucose level were monitored by fingersticks. An immediate jeopardy was identified on July 27, 2010 after observations of blood glucose testing revealed that the licensed nursing staff had failed to clean and disinfect glucometers between use by four nurses for 17 residents (#102, #104, #108, #112, #113, #114, #115, #116, "A" ,"B", "C", "D", "E", "F", "G", "H", "I" ) on Unit I, and by six nurses between nine residents (#208, #212, #214, #216, #217, #218, #219,#220, #221) on Unit II through July 28, 2010. The facility implemented a plan of correction on July 28, 2010 to remove the jeopardy. It was determined by interviews with licensed nurses and the Director of Nurses, and observations of glucose monitoring with the glucometer for four nurses on Unit I and three nurses on Unit II on July 29, 2010 that the immediate jeopardy had been removed. However, the facility remained out of compliance at a lower scope and severity of 'E', a pattern of deficiency with the potential for more than minimal harm, for all residents who received blood glucose monitoring in order to complete training of all licensed nursing staff; to ensure that the facility's system of monitoring glucometer testing was maintained; and to ensure that the findings of the observations were reported to the Administrator and the Performance Improvement committee as planned. Findings include: 1. The facility failed to maintain an Infection Control program that ensured proper infection control and the provision of aseptic technique to prevent cross contamination and indirect contact transmission of a bloodborne infection or a microscopic pathogen by failing to ensure that 10 nurses effectively cleaned and disinfected glucometers between use for 26 of 46 diabetic residents who required fingersticks for blood glucose level monitoring. See F441 for additional information. 2. The June, 2010 facility's protocol, "Blood Glucose Monitoring Technique" did not conform to the CDC guidelines to prevent cross-contamination of blood borne pathogens. Although the protocol included cleaning the glucometer between residents, it did not include cleaning and disinfecting it. The protocol was to clean the meter with an antimicrobial wipe instead of an EPA approved germicidal disinfectant which was labeled as effective against [MEDICAL CONDITIONS], B,[MEDICAL CONDITION] a 1:10 bleach to water (minimal) concentration as recommended by CDC.

Based on observation, staff interview and record review, it was determined that the facility failed to provide interventions to address pain management during range of of motion exercises for one resident (#110), failed to clarify the need for a laboratory test for one resident (#101), and failed to follow physician's orders [REDACTED].#212, #215 and #217), from a total sample of 40 residents. Findings include: Unit I 1. Resident #110's [DIAGNOSES REDACTED]. On the 5/16/10 annual Minimum Data Set (MDS) assessment, licensed nursing staff coded the resident as having had a partial loss of voluntary movement of both arms and hands, and full loss of voluntary movement of both legs and feet. Licensed staff also coded the resident as totally dependent on staff for bed mobility and transfers. During the Initial Tour of the Facility on 7/27/10 at 11:30 a.m., licensed nurse "FF" stated that the resident had contractures of both lower extremities. At that time, the resident was observed to have voluntary movement with tremors of his/her right arm. Observation on 7/28/10 at 11:40 a.m. revealed the resident holding his/her left hand in a fisted position. The resident's left knee was held in a flexed position, with the hip flexed and externally rotated. On 7/28/10 at 11:40 a.m., the Restorative Certified Nursing Assistant (RCNA) assisted the resident with active-assisted range of motion exercises of his/her right arm and shoulder. However, as the RCNA provided passive range of motion on the resident's left hand and left leg, he/she began exhibiting increased tremors of his/her left arm and facial grimacing. At that time, the RCNA told the resident, "I know it hurts". The RCNA then stated that the resident always had a little pain while receiving passive range of motion exercises on his/her left hand and leg. However, when the RCNA provided passive range of motion exercises on the resident's right lower extremity, the resident exhibited no indication of pain or discomfort (i.e., tremors or facial grimacing). Following completion of splint application on the resident's right knee, the RCNA stated that she had previously reported the resident's pain during range of motion exercises to the charge nurse. On 7/28/10 at 12 p.m., licensed nurse "AA" stated that the RCNA had reported that the resident experienced pain with range of motion in the past. Although the resident had physician's orders [REDACTED]. 2. Resident #101 was receiving [MEDICATION NAME] (a medication) prior to being hospitalized from [DATE] through 5/10/10. The medication was not reordered by the physician when the resident returned from the hospital. However, a review of the clinical record revealed the resident continued to have a physician's orders [REDACTED]. Nursing staff obtained that laboratory test ([MEDICATION NAME] level) on 7/13/10. Charge nurse "FF" stated on 7/28/10 at 3:15 p.m. that nursing staff failed to clarify the need for continuing to obtain a [MEDICATION NAME] level until after surveyor inquiry on 7/28/10 at which time the physician discontinued the laboratory order. 3. Resident #102 had a physician's orders [REDACTED]. For blood sugar levels greater than 400, licensed nursing staff were supposed to administer 12 units of [MEDICATION NAME] R insulin and call the physician. A nurse's note documented on 5/11/10 that around 8:10 p.m., the resident's blood sugar level was checked three times and readings of 456, 420, and 557 were obtained. However, the physician was not notified at that time. The resident's blood sugar level was checked again around 8:35 p.m. and was 435. At that time, the physician was called and ordered nursing staff to administer 12 units of [MEDICATION NAME] R. Charge nurse "FF" stated on 7/28/10 at 10:50 a.m., after reviewing the 5/11/10 nurse's note, that the nursing staff had not followed the correct procedure when the resident's blood sugar levels were greater than 400. Unit II 1. Resident #212 had a 5/19/09 physician's orders [REDACTED]. However, review of the May and June 2010 Medication Administration Records (MARs) revealed that the licensed nurses had incorrectly held the resident's insulin twice in May 2010 and four times in June 2010 due to blood sugar level results having been between 78 and 98. There was not a physician's orders [REDACTED]. 2. Resident #217 had a 12/9/09 physician's orders [REDACTED]. However, review of the May, June and July 2010 MARs revealed that the licensed nurses had incorrectly held the resident's insulin four times in May 2010, three times in June 2010 and once in July 2010 when the resident's blood sugar levels were between 100 and 3. Review of resident #215's closed record revealed a 4/20/10 physician's orders [REDACTED]. However, review of May 2010 MAR indicated [REDACTED]. In addition, the resident had a 4/20/10 physician's orders [REDACTED]. However, review of the May 2010 MAR indicated [REDACTED]. There was no evidence that nursing staff had notified the physician about those blood sugar levels and about not administering the insulin as ordered on those days.