Every finding on record at Heritage Hall Front Royal

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide all required documentation to the receiving facility upon a hospital transfer for one of 20 residents in the survey sample; Resident #11. The findings include: A review of the clinical record revealed a nurse's note dated 3/1/24 documented, Resident voiced increased fatigue, started SQ (subcutaneous) normal saline 0.9% fluids 1000ml (1000 milliliters) bag at 80ml/hr (80 milliliters per hour) in RUQ (right upper quadrant) without difficulties Called NP (nurse practitioner) N/O (new order) Send to ED (emergency department) for further evaluation d/t (due to) hyperkalemia. Voicemail left for emergency contact. No return call at this time. Reported called to (hospital physician). 9-1-1 telephoned EMS (emergency medical services) arrived x2 EMTs (emergency medical technicians) resident transported to (hospital) in stable condition. A physician's progress note dated 3/6/24 documented, Resident seen today for hospital follow up. Resident sent to ED (emergency department) 3/1/24 for Hyperkalemia and acute CKD (chronic kidney disease). Kayexalate (1) given. Resident then transferred to (hospital) ICU (intensive care unit) due to resident becoming lethargic, dizziness and chills Resident stabilized and returned to facility in stable condition Further review of the progress notes failed to reveal any evidence that the comprehensive care plan goals were sent to the hospital with this hospital transfer. A review of the hospital transfer form failed to reveal any evidence that the comprehensive care plan goals were sent. A review of the discharge summary failed to reveal any evidence that the comprehensive care plan goals were sent. A review of the hospital transfer checklist failed to reveal any evidence that the comprehensive care plan goals were sent. On 5/15/24 at 8:39 AM, an interview was conducted with LPN #1 (Licensed Practical Nurse), who completed the hospital transfer documents. She stated that she did not send the care plan goals. She stated that she does not know if she is supposed to. On 5/15/24 at 8:46 AM, LPN #1 followed up and stated I did not send it and I was supposed to. It will be added to the checklist. The facility policy Transfer or Discharge, Facility-Initiated documented, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy Information Conveyed to Receiving Provider: 1. Should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: .f. Comprehensive care plan goals On 5/15/24 at 1:05 PM, ASM #1 (Administrative Staff Member) the Administrator and ASM #4 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey. References: (1) Kayexalate is used to treat hyperkalemia (elevated levels of potassium in the body). Information obtained from https://medlineplus.gov/druginfo/meds/a682108.html

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to develop and/or follow the comprehensive care plan for three of 20 residents in the survey sample, Residents #42 (R42), R14 and R7. The findings include: 1. For R42 the facility staff failed to develop the comprehensive care plan for the use of bed rails. R42 was admitted to the facility with diagnosis that included but was not limited to muscle weakness. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/10/2024, the resident scored two out of 15 on the BIMS (brief interview for mental status), indicating R42 was severely impaired of cognition for making daily decisions. On 05/13/2024 at approximately 7:00 p.m., an observation revealed R42 lying in bed with right and left upper bed rail raised. On 05/14/2024 at approximately 10:14 a.m., an observation revealed R42 lying in bed with right and left upper bed rail raised. The physician's order for R42 dated 07/12/2023 documented in part, May use 1/2 (half) Siderail x 2 (times two) at HOB (head of bed) with bed controls on rails for positioning and support and to promote independence and to assist with defining parameter of the bed for safety awareness. The facility's bed rail assessment for R42 dated 05/07/2024 documented in part, 3. Side rail placement recommendations: b. Left. C. Right. 3a. Side rail placement: a. Side Rail/Assist Bar are indicated and serve as an enabler to promote independence. B. The resident has expressed a desire to have Side Rail/Assist Bar. The facility's Baseline Care Plan for R42 dated 05/26/2023 documented in part, 1/4 (quarter) SIDE RAILS: Yes, 1/2 SR (side rails) x2. Review of the facility's comprehensive care plan for R42 dated 11/11/2023 failed to evidence the use of side rails. On 05/15/2024 at approximately 11:12 a.m., an interview was conducted with LPN (licensed practical nurse) #3, MDS coordinator. After reviewing the comprehensive care plan for R42 dated 11/11/2023 LPN #3 stated that the use of R42's bed rails were not documented on the comprehensive care plan. When asked to describe the process for developing the comprehensive care plan LPN #3 stated that she transfers the information from the baseline care plan to the comprehensive care plan. She further stated that the bed rails were overlooked. The facility's policy Care Plans, Comprehensive Person-Centered documented in part, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation. 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. On 05/15/2024 at approximately 1:00 p.m., ASM (administrative staff member) # 1, administrator, ASM #2, administrator-in-training, ASM # 3, regional nurse consultant and ASM #4, director of nursing, were made aware of the above findings. No further information was provided prior to exit. 27660 2. a. For Resident #14, the facility staff failed to implement the comprehensive care plan for monitoring for side effects for the use of Coumadin (Warfarin) (1). The comprehensive care plan dated, 2/13/24, documented, At risk for bleeding/bruising d/t (due to) Anticoagulation Therapy r/t (related to) Chronic AFIB (atrial fibrillation). The Interventions documented, Evaluate for blood in stools. Evaluate for bruising. Evaluate for hematuria. Evaluate for signs and symptoms of bleeding. Mediation per MD (medical doctor) order. Monitor laboratory results per MD order. Notify MD prn (as needed). The physician order dated, 3/11/24, documented, Warfarin Sodium Oral Tablet 2.5 mg; Give 2.5 mg (milligrams) by mouth in evening for AFIB. Review of the nurse's notes failed to evidence documentation of monitoring for side effects of the Coumadin. An interview was conducted with LPN (licensed practical nurse) #2, on 5/15/24 at 10:13 a.m. When asked the purpose of the care plan, LPN #2 stated, it gives the staff guidance as to the history of the resident. It gives them a guideline to their orientation, fall history, their preferences, diet. Basically, it's how we take care of them. When asked if a resident is on an anticoagulant, is there anything the nurse should be doing, LPN #2 stated, they have to observe for skin issues related to bleeding, check the MD orders, when laboratory test results come back, notify the doctor. When asked where you evidence the no monitoring of the resident for side effects of the anticoagulant, LPN #2 stated, that she was aware of there isn't a specific area to document it. If there is a bruise, they make a note of it, notify the nurse practitioner, and monitor the area. LPN #2 stated the CNAs (certified nursing assistants) report to us if the resident has any changes in the stool or urine. LPN #2 stated, I guess we need to have one of the orders that should monitor so we can document it. ASM (administrative staff member) #1, the administrator, ASM #2, the administrator in training, ASM #3, the regional nurse consultant, ASM #4, the director of nursing, and LPN #4, the assistant director of nursing, were made aware of the above concern on 5/15/24 at 12:57 p.m. No further information was provided prior to exit. (1) Warfarin is used to prevent blood clots from forming or growing larger in your blood and blood vessels. It is prescribed for people with certain types of irregular heartbeat, people with prosthetic (replacement or mechanical) heart valves, and people who have suffered a heart attack. Warfarin is also used to treat or prevent venous thrombosis (swelling and blood clot in a vein) and pulmonary embolism (a blood clot in the lung). Warfarin is in a class of medications called anticoagulants ('blood thinners'). It works by decreasing the clotting ability of the blood. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682277.html. 2 b. For Resident #14, the facility staff failed to develop a care plan for antibiotic use for an upper respiratory infection (URI). The physician order dated, 5/9/24, documented, Doxycycline Mono 100 mg cap (capsule)(an antibiotic): Give 1 capsule orally two times a day for URI for 10 days. The CXR (chest x-ray) completed 5/7/24 - Impression: Very mild bilateral lower lung airspace disease, possible atelectasis, though concerning for pneumonia in the clinical setting of infection. The comprehensive care plan, last updated 4/26/24, was reviewed. There was no documentation related to the respiratory illness and the use of an antibiotic. An interview was conducted with LPN #3 on 5/15/24 at 11:07 a.m. When asked who updates the care plans, LPN #3 stated she was responsible for that. LPN #3 was asked if a resident was on an antibiotic for an upper respiratory infection, should there be a care plan for that, LPN #3 stated, there should be. She stated she had made herself a note to develop one for Resident #14 but thought she had care planned it but didn't. ASM (administrative staff member) #1, the administrator, ASM #2, the administrator in training, ASM #3, the regional nurse consultant, ASM #4, the director of nursing, and LPN #4, the assistant director of nursing, were made aware of the above concern on 5/15/24 at 12:57 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to evidence the monitoring of side effects for the use of an anticoagulant for two of 20 residents in the survey sample, Residents #7 and #14. The findings include: 1. For Resident #7, the facility staff failed to evidence the monitoring of side effects for the use of Xarelto (Rivaroxaban) (1) On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/29/24, the resident scored a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. In Section N - Medications, the resident was coded as receiving an anticoagulant while a resident at the facility. The physician orders dated, 2/3/24, documented, Xarelto Oral Tablet (Rivaroxaban) 15 mg (milligrams); Give 1 tablet my mouth one time a day for afib (atrial fibrillation). The comprehensive care plan dated, 2/13/24, documented, At risk for bleeding/bruising d/t (due to) Anticoagulation Therapy r/t (related to) Chronic AFIB. The Interventions documented, Evaluate for blood in stools. Evaluate for bruising. Evaluate for hematuria. Evaluate for signs and symptoms of bleeding. Mediation per MD (medical doctor) order. Monitor laboratory results per MD order. Notify MD prn (as needed). An interview was conducted with LPN (licensed practical nurse) #2, on 5/15/24 at 10:13 a.m. When asked if a resident is on an anticoagulant, is there anything the nurse should be doing, LPN #2 stated, they must observe for skin issues related to bleeding, check the MD orders, when laboratory test results come back, notify the doctor. When asked where you evidence the no monitoring of the resident for side effects of the anticoagulant, LPN #2 stated, that she was aware of there isn't a specific area to document it. If there is a bruise, they make a note of it, notify the nurse practitioner, and monitor the area. LPN #2 stated the CNAs (certified nursing assistants) report to us if the resident has any changes in the stool or urine. LPN #2 stated, I guess we need to have one of the orders that should monitor so we can document it. The facility policy, Medication Therapy documented in part, 3. All medication orders will be supported by appropriate care processes and practices. ASM (administrative staff member) #1, the administrator, ASM #2, the administrator in training, ASM #3, the regional nurse consultant, ASM #4, the director of nursing, and LPN #4, the assistant director of nursing, were made aware of the above concern on 5/15/24 at 12:57 p.m. No further information was provided prior to exit. (1) Rivaroxaban is used to treat deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in adults. Rivaroxaban is also used to prevent DVT and PE from happening again after initial treatment is completed in adults. It is also used to help prevent strokes or serious blood clots in adults who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body, and possibly causing strokes) that is not caused by heart valve disease. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a611049.html. 2. For Resident #14, the facility staff failed to evidence the monitoring of side effects for the use of Coumadin (Warfarin) (2). On the most recent MDS assessment, a end of therapy assessment, with an assessment reference date of 4/25/24, the resident scored a 15 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. In Section N - Medications, the resident was coded as receiving an anticoagulant while a resident at the facility. The physician order dated, 3/11/24, documented, Warfarin Sodium Oral Tablet 2.5 mg; Give 2.5 mg by mouth in evening for AFIB. Review of the nurse's notes failed to evidence documentation of monitoring for side effects of the Coumadin. The comprehensive care plan dated, 2/13/24, documented, At risk for bleeding/bruising d/t (due to) Anticoagulation Therapy r/t (related to) Chronic AFIB. The Interventions documented, Evaluate for blood in stools. Evaluate for bruising. Evaluate for hematuria. Evaluate for signs and symptoms of bleeding. Mediation per MD (medical doctor) order. Monitor laboratory results per MD order. Notify MD prn (as needed). An interview was conducted with LPN (licensed practical nurse) #2, on 5/15/24 at 10:13 a.m. When asked if a resident is on an anticoagulant, is there anything the nurse should be doing, LPN #2 stated, they have to observe for skin issues related to bleeding, check the MD orders, when laboratory test results come back, notify the doctor. When asked where you evidence the no monitoring of the resident for side effects of the anticoagulant, LPN #2 stated, that she was aware of there isn't a specific area to document it. If there is a bruise, they make a note of it, notify the nurse practitioner, and monitor the area. LPN #2 stated the CNAs (certified nursing assistants) report to us if the resident has any changes in the stool or urine. LPN #2 stated, I guess we need to have one of the orders that should monitor so we can document it. ASM (administrative staff member) #1, the administrator, ASM #2, the administrator in training, ASM #3, the regional nurse consultant, ASM #4, the director of nursing, and LPN #4, the assistant director of nursing, were made aware of the above concern on 5/15/24 at 12:57 p.m. No further information was provided prior to exit. (2) Warfarin is used to prevent blood clots from forming or growing larger in your blood and blood vessels. It is prescribed for people with certain types of irregular heartbeat, people with prosthetic (replacement or mechanical) heart valves, and people who have suffered a heart attack. Warfarin is also used to treat or prevent venous thrombosis (swelling and blood clot in a vein) and pulmonary embolism (a blood clot in the lung). Warfarin is in a class of medications called anticoagulants ('blood thinners'). It works by decreasing the clotting ability of the blood. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682277.html.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 26 residents in the survey sample, Resident # 31. The findings include: The facility staff inaccurately coded two MDS assessments that Resident #31 was receiving insulin when in fact the resident was not receiving insulin. On the most recent MDS assessment, an annual assessment, with an ARD (assessment reference date) of 7/6/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status), indicting the resident was not cognitively impaired for making daily decisions. In Section N - Medications, Resident #31 was coded as receiving one injection during the last seven days of the look back period. In Section N035- Insulin, the resident was coded as receiving one insulin injection in the past seven days of the look back period. Review of the physician orders dated, 7/23/2021, documented the resident was receiving Trulicity 0.75 mg (milligram) injected once a week on Tuesdays. (Trulicity is used with a diet and exercise program to control blood sugar levels in adults with type 2 diabetes [condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood]. Trulicity is also used to reduce the risk of a heart attack, stroke, or death in adults with type 2 diabetes mellitus who also have heart disease or who are at risk of developing heart disease) (1). The previous MDS assessment, a quarterly assessment, with an ARD of 4/4/2022, Resident #31 was coded in Section N - Medications as having received receiving one injection during the last seven days of the look back period. In Section N035- Insulin, the resident was coded as receiving one insulin injection in the past seven days of the look back period. An interview was conducted with LPN (licensed practical nurse) #3, the MDS coordinator, on 9/8/2022 at 12:52 p.m. The two MDS assessments above were reviewed with LPN #3. When asked if Trulicity is coded as an insulin, LPN #3 stated it was not insulin. LPN #3 stated it is used to treat diabetes but it is not insulin. LPN #3 wanted to review the MDS assessments and the RAI (resident assessment instrument) manual and get back with the survey team. On 9/8/2022 at 1:12 p.m. LPN #3 returned and stated that Trulicity was not insulin and she could not find it in the RAI manual that you can code it as insulin. When asked which reference she uses to complete the MDS assessments, LPN #3 stated she uses the RAI manual. ASM #1 was made aware of the above concern on 9/8/2022 at 2:41 p.m. On 9/8/2022 at 3:06 p.m. ASM (administrative staff member) #1, the administrator, stated Trulicity is not an insulin and should not have been coded as insulin on the MDS. ASM #1 presented a copy from the RAI manual for coding Section N - Medications, Insulin. Trulicity was not referred to in the RAI manual. No further information was obtained prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a614047.html

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure ongoing communication with the dialysis center for one of 26 residents in the survey sample, Resident #112. The findings include: The facility staff failed to review the dialysis communication book upon return to the facility and failed to ensure the dialysis center documented in the communication book post dialysis for Resident #112. There was no completed MDS (minimum data set) assessment completed for Resident #112 at the time of the survey. The physician orders dated, 9/2/2022, documented in part, Pre dialysis vitals (blood pressure, temperature, pulse and respirations) Q (every) T - Th - Sat (Tuesday, Thursday, Saturday), complete in dialysis book. Post dialysis vitals Q T-Th-Sat, complete in dialysis book. The baseline care plan dated 9/2/2022, documented in part, Special Treatments/Procedures: Dialysis Tues (Tuesday) Thurs (Thursday) Sat (Saturday) at 6am (6:00 a.m.) and husband to transport. On 9/7/2022, a Wednesday, at 3:42 p.m. a request for Resident #112's dialysis communication book was made to LPN (licensed practical nurse) #4. LPN #4 and ASM (administrative staff member) #2, the director of nursing, began looking for the book throughout the nurse's station. LPN #4 asked LPN #5 to call the resident's husband since he transports her to dialysis. LPN #5 found the book in Resident #112's room, in the back of the wheelchair. The dialysis communication book contained two pieces of paper. One was dated 9/3/2022 and the other dated 9/6/2022. The only documentation on the forms were vital signs taken prior to the resident leaving the facility for dialysis. There was no documentation from the dialysis center. An interview was conducted with LPN #5 on 9/7/2022 at 3:47 p.m. When asked the process for the nurse when a resident returns from dialysis, LPN #5 stated we check the resident's vital signs, alertness, orientation and see if they have any nausea. LPN #4, who was sitting at the nurse's station, stated When the resident returns from dialysis we have to see if there are any notes from the dialysis center. An interview was conducted with LPN #1 on 9/8/2022 at 1:21 p.m. When asked the nurse's responsibilities when a resident returns from dialysis, LPN #1 stated the nurse should get a set of vital signs, check the folder for notes, make sure the resident is stable. When asked if they don't see the communication book, LPN #1 stated they should call the dialysis center. An interview was conducted with LPN #2, the assistant director of nursing, on 9/8/2022 at 1:29 p.m. When asked the purpose of the communication book, LPN #2 stated it's to communicate with the dialysis regarding the resident's condition. The facility policy, Dialysis Protocol documented in part, Communication between the dialysis center and nursing staff at (Name of corporation) will be maintained by phone calls and in written form to ensure the most accurate information exchange possible each time a resident goes for treatment. A progress not will be sent with the resident to the dialysis center. The nurse/doctor at the dialysis center will write a progress notes to include the resident's eight pre and post, any blood transfusions, medications given, and any other information that would be necessary for the nursing staff at (name of corporation) to provide safe, quality care of the resident. ASM #1, the administrator, was made aware of the above concern on 9/8/2022 at 2:41 p.m. No further information was obtained prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to preserve resident dignity for two of 24 residents in the survey sample, Residents #11 and #13. For Resident #11, the facility failed to preserve her dignity by posting multiple signs regarding the resident's feeding needs in plain sight in her room. For Resident #13, the facility failed to preserve her dignity by posting multiple signs regarding the resident's feeding needs in plain sight in her room. The findings include: 1. Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/16/21, she was coded as being severely cognitively impaired for making daily decisions. She was coded as being on a mechanically altered diet. Resident #11 was coded as requiring the assistance of one staff member for eating. She was coded as receiving speech therapy services. Resident #11 was observed in her room on 5/25/21 at 1:17 p.m. and 3:53 p.m.; 5/26/21 at 7:47 a.m. and 10:43 a.m. During each observation on both walls adjacent to Resident #11's head of bed, four signs were clearly visible. The signs read as follows: (1) UPRIGHT at 90 degrees for meals. Supervision for meals. (2) Go SLOW - Give time for multiple swallows between bites. SMALL BITES and SIPS. One at a time. Stay upright for 45 minutes after meals. (3) EFFORTFUL SWALLOW. Swallow as hard as you can. 30 reps (repetitions) a day. (4) One sip at a time. Go slow. Small. Sit up. Brush Teeth 3 times a day. Resident #11 was not able to participate in an interview. A review of Resident #11's Speech Therapy Discharge Summary dated 4/8/21 revealed, in part: Discharge Recommendations and Strategies: To facilitate safety and efficiency, it is recommended the patient use the following strategies during oral intake: alternation of liquid/solids, bolus size modifications, rate modification and general swallow techniques/precautions, along with the following maneuvers: upright posture during meals and upright posture for >30 minutes after meals. A review of Resident #11's comprehensive care plan dated 3/16/21 revealed no information regarding the resident's dignity. The speech therapist was not available for interview during the survey. On 5/26/21 at 2:09 p.m., OSM (other staff member) #3, the social worker, was interviewed. When asked how the placement of signs on Resident #11's walls related to the resident's dignity, OSM #3 stated she thought those kinds of signs (instructions) should be posted out of plain sight, perhaps on the resident's closet door. She stated the signs do not promote a resident's dignity at all. OSM #3 stated she understands why the signs are posted, but the signs are for the staff's benefit, not the resident's. On 5/26/21 at 2:13 p.m., ASM (administrative staff member) #2, the regional director of clinical services, was interviewed. When asked how the placement of signs on Resident #11's walls related to the resident's dignity, ASM #2 stated the signs were not something she would recommend to have posted in plain sight. She stated those are instructions for the benefit of staff members who are serving/supervising/assisting residents with meals. She stated the signs do not provide dignity for the resident. A review of the facility document, Resident Rights, revealed, in part: .Each patient admitted to such Facility .is treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs. On 5/26/21 at 4:52 p.m., ASM #1, the administrator, and ASM #2 were informed of these concerns. No further information was provided prior to exit. REFERENCES (1) [CONDITION(S)] (PD) is a type of movement disorder. It happens when nerve cells in the brain don't produce enough of a brain chemical called [MEDICATION(S)]. Sometimes it is genetic, but most cases do not seem to run in families. This information is taken from the website https://medlineplus.gov/parkinsonsdisease.html. 2. Resident #13 was admitted to the facility 3/15/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/22/21, she was coded as being moderately cognitively impaired for making daily decisions, having scored nine out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the extensive assistance of staff members for eating. Resident #13 was coded as being on a mechanically altered diet. She was coded as receiving speech therapy services. Resident #13 was observed in her room on 5/25/21 at 1:32 p.m. and 4:01 p.m.; 5/26/21 at 2:33 p.m. During each observation on both walls adjacent to Resident #1's head of bed, two signs were clearly visible. The signs read as follows: (1) AS UPRIGHT AS POSSIBLE FOR MEALS! Small bites and sips. One at a time. (2) PULL MEAL TRAY, IF NOT ALERT (sic). Check mouth after meals. A review of Resident #13's Speech Therapy Discharge Summary dated 4/19/21 revealed, in part: Dining/Swallowing Program: Patient currently swallows with difficulty, and tier is progressive .encourage participation. A review of Resident #13's comprehensive care plan dated 3/26/21 revealed no information regarding the resident's dignity. The speech therapist was not available for interview during the survey. On 5/26/21 at 2:09 p.m., OSM (other staff member) #3, the social worker, was interviewed. When asked how the placement of signs on Resident #11's walls related to the resident's dignity, OSM #3 stated she thought those kinds of signs (instructions) should be posted out of plain sight, perhaps on the resident's closet door. She stated the signs do not promote a resident's dignity at all. OSM #3 stated she understands why the signs are posted, but the signs are for the staff's benefit, not the resident's. On 5/26/21 at 2:13 p.m., ASM (administrative staff member) #2, the regional director of clinical services, was interviewed. When asked how the placement of signs on Resident #11's walls related to the resident's dignity, ASM #2 stated the signs were not something she would recommend to have posted in plain sight. She stated those are instructions for the benefit of staff members who are serving/supervising/assisting residents with meals. She stated the signs do not provide dignity for the resident. On 5/26/21 at 4:52 p.m., ASM #1, the administrator, and ASM #2 were informed of these concerns. No further information was provided prior to exit. REFERENCES (1) [CONDITION(S)] (PD) is a type of movement disorder. It happens when nerve cells in the brain don't produce enough of a brain chemical called [MEDICATION(S)]. Sometimes it is genetic, but most cases do not seem to run in families. This information is taken from the website https://medlineplus.gov/parkinsonsdisease.html.

Based on observation, staff interview, and facility documentation review, it was determined the facility staff failed to prepare and serve food in accordance with professional standards for food service safety. The facility staff failed to prepare and serve meals in a sanitary manner during an observation of the lunch, meal tray line in the kitchen. OSM (other staff member #6) was observed wearing the same gloves throughout the meal tray line touching hotdog and hamburger buns placed on meal plates for residents after touching the pushcart, microwave and other items. The findings include: On 8/13/19 between 11:50 AM and 12:18 PM, an observation of the lunch, meal tray-line in the kitchen was conducted. OSM (Other Staff Member) #6, the AM Cook, was observed preparing and serving meals during the lunch, meal tray- line. OSM #6 was observed as she prepared each plate for the dining room and trays of residents eating in their rooms. OSM #6 was observed wearing the same gloves for preparing the plates and bowls. OSM #6 was observed to handling serving spoon handles, tongs, pushing a cart, touching the microwave, and other items potentially contaminating her gloves before handling the plates and bowls for residents' meals. OSM #6 was observed lifting each plate and bowl with her gloved hand observed touching other items, with her thumb on the food contact surface. OSM #6 was also observed to touching hotdog buns and hamburger buns when placing them onto the residents' meal plates with the same-gloved hands throughout the lunch, meal tray- line service. OSM #6 was observed picking up a hotdog bun that contained a mechanical soft hotdog meat from one plate to another plate with the same-gloved hands. On 8/13/19 at 12:19 PM, an interview with OSM #6 was conducted. When asked the concern of wearing the same gloves throughout the meal tray line and touching hotdog and hamburger buns with the gloved hands after touching the pushcart and microwave, OSM #6 stated, Contamination. On 8.13.19 at 12:21 PM, an interview with OSM #5 was conducted. When asked about that above identified concern of wearing the same gloves throughout the meal tray line touching hotdog and hamburger buns placed on meal plates for residents after touching the push cart, microwave and other items. OSM#5 stated, Those are things that she should have changed her gloves and washed her hands. Then put on a new pair of gloves. She should have not touched the microwave and the cart handles and then touched food without changing her gloves and washing her hands. It is an infection control and serving food in a sanitary manner. A review of the facility policy, Safety and Sanitation - Section [NAME] documented in part the following; Policy: Gloves will be worn to maintain safe and sanitary food preparation and service. Procedure: 3. Proper use of gloves; a. Wash hands thoroughly before and after wearing or changing gloves. Bacteria will build up under gloves and should be washed away after wearing gloves. c. Change gloves periodically to minimize the buildup of perspiration and bacteria. d. Change gloves whenever you change an activity, the type of food being worked with, or whenever you leave the work station. Further review of the facility policies, Preventing Foodborne Illness - Food Handling documented in part the following; Policy Statement: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Policy Interpretation and Implementation: 3. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. According to the FDA (Food and Drug Administration) (YEAR) Food Code: 3-304.15 Gloves, Use Limitation. (A) If used, SINGLE-USE gloves shall be used for only one task such as working with READY-TO-EAT FOOD or with raw animal FOOD, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Except when APPROVAL is obtained from the REGULATORY AUTHORITY as specified in 3-301.11(E), EMPLOYEES are preventing cross-contamination of READY-TO-EAT FOOD with bare hands by properly using suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, . On 8/14/19 at 4:57 PM, ASM (Administrative Staff Member) #1, the Administrator, and ASM #2, the Regional Vice President of Operations, were made aware of the findings. No further information was provided by the end of the survey.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to ensure one of 25 Residents in the survey sample was free from physical and verbal abuse, Resident #28. The facility staff failed to protect Resident #28 from being physically and verbally abused by CAN (certified nursing assistant) #3 On [DATE], when LPN (licensed practical nurse) #3 witnessed CNA, (certified nursing assistant) #3 cursing at the resident and placing his arm around Resident #28's neck in a 'choke hold' restraining the resident while applying the residents gown. The findings include: Resident #28 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set), a quarterly assessment, with an ARD (Assessment reference date) of [DATE], coded the resident as scoring a 3 out of 15 on the BIMS (Brief Interview for Mental Status) score, indicating the Resident had severe cognitive impairment for daily decision making. The resident required extensive assistance for dressing; was frequently incontinent of bladder and occasionally incontinent of bowel. On [DATE] at 10:20 PM, the Virginia Department of Health, Office of Licensure and Certification received a Facility Reported Incident (FRI) of an allegation of abuse/mistreat involving Resident #28 and CNA (Certified Nurse Assistant) #3 on [DATE] at approximately 8:40 PM. Review of the FRI revealed the following documentation: Facility Name: (Name of CNA#3) Report Date: [DATE] Incident Date: [DATE]. Resident Involved Name of Resident #28. Injuries: a box with an X for No. The box for Allegation of abuse/mistreatment contained an X. Describe incident location, and action taken: At approximately 8:40 pm on [DATE] nurse (Name of LPN (licensed practical nurse) #3) was alerted to a residents room and witnessed CNA (Name of CNA#3) placing the resident (Resident #28) in a choke hold and swearing at the resident. Charge nurse (name of LPN #3) LPN. Immediately removed CNA #3 (last name of CNA #3) from room and off unit. Name of (Resident #28) was assessed and found to have no marks or bruising. C.N.[NAME] (name of CNA #3) was then escorted from the building. The MD (medical doctor), RP (responsible party) and local law enforcement were notified, and investigation is underway. C.N.[NAME] (last name of CNA #3) has been suspended during investigation and investigation is underway. Final investigation outcome to follow. If applicable, date notification provided to Responsible party [DATE] Physician [DATE] APS (adult protective services [DATE] Law enforcement [DATE] Facility internal investigation: Initiated [DATE] Completed (the box for) No contained an X . Will be conducted/Report forwarded to VDH (Virginia Department of Health)/OLC (Office of Licensure and Certification) [DATE] The fax date and time stamp documented: (MONTH) 15, 2019 10:21PM. Final: During the investigation, local police obtained a statement from Charge nurse (Name of LPN #3), LPN who witnessed the event and removed C.N.[NAME] from area. The police also called C/N.[NAME] (name of CAN #3) and obtained a statement from him. The administrator also interviewed and obtained a written statement from Charge Nurse (Name of LPN #3) and obtained a verbal statement from (Name of CNA #3) as well regarding the incident. (Name of Resident #28)'s physician ordered an ultrasound of the neck area to rule out any soft tissue damage and the ultrasound results were negative for any injury. She had light bruising noted the day after the incident in two areas of the neck that has since resolved. Based on statements from staff who witnessed the event, and the bruising noted to the residents neck, the allegation of physical abuse is substantiated and C.N.[NAME] (Name of CNA #3) has been terminated from employment at name of facility and has been reported to the Department of Health Professionals (DHP) for physical abuse towards resident (Name of Resident #28). The follow up report documented the final report was provided to the RP, Physician, APS, DHP, Ombudsman on [DATE] and Law Enforcement [DATE]. Resident #28, a previous resident at the facility and expired on [DATE]. Therefore, unable to interview resident. A review of the facility's Incident Witness Statement written by LPN (Licensed Practical Nurse) #3, dated [DATE], documented in part the following: at approx. (sic) 8:40 PM resident was yelling help stop and could be heard at nursing stations. This nurse went to room to check on resident and observed the following: Resident was in her w/c (wheelchair) very upset waiving her arms around as CNA #3 (last name) was attempting to put a gown on. As resident continued to wave her arms, CNA #3 (last name) took his right arm and put around resident's neck in a choke hold (Sic.) and stated, 'Sit still you (EXPLETIVE) (EXPLETIVE) I'm tired of your (EXPLETIVE).' This nurse immediately went over to CNA #3 and pulled him off resident. At this point resident was crying and stated, 'He does this to me all the time.' CNA #3 was escorted out of the room. Resident was assessed and no injury at initial incident. ADON (Assistant Director of Nursing) was called and informed of incident and instructed nurse to have CNA #3 clock out and leave facility until further noticed. As CNA #3 (last name) was escorted out he stated, 'I'm sorry I got mad. I guess I should just quit.' A review of the clinical record revealed a nurse's note by LPN #3 dated [DATE] at 6:00 AM, documented in part the following; Since incident from [DATE] at 2040 (8:40 PM) resident has been frequently assessed throughout ,[DATE] shift. Vital signs were obtained q (every) 30 mins (minutes) .VS (vital signs) were WNL (within normal limits) for resident .Resident has been resting in bed w/out (without) complaint. During hygiene care, at approx 0200 (2:00 AM), scattered bruising was observed to left side of resident's neck above her shoulder. Resident stated her neck was sore but didn't hurt bad enough for pain meds (medications) . Further review of the clinical record revealed a nurse's note by ASM (Administrative Staff Member) #3, the ADON (assistant director of nursing), dated [DATE] at 8:00 AM, documented in part the following; This nurse assessed this resident neck area and noted 3 pea size areas to L (left) side of neck red in color, no [MEDICAL CONDITION] noted. Denied pain or discomfort. No S/S (signs or symptoms) difficulty in swallowing. Resident took sip of H2O (water) with no difficulty in swallowing. No cough or congestion noted. Resident alert/confused per her norm (normal). No increase anxiety or agitation noted. No crying or tearfulness noted. NP (Nurse Practitioner) in this am. Ordered ultrasound (US) of neck f/u (follow up) injury. US to be arranged. No S/S distress/discomfort noted. Resting quietly in bed with resp (respiration) even/nonlabored. Call bell within reach. The facility's FRI documentation revealed a note dated [DATE], that documented in part the following During a phone conversation [DATE] between (Name of ASM #1, the Administrator), (name of ASM #3,the assistant director of nursing) and (name of CNA #3), (name of CNA #3) gave a verbal statement that he had not placed the resident in a choke hold, but was just restraining her arms to he (sic) side to get her dressed. A review of the clinical record revealed the resident was seen prior to this incident by psychological services. A psychological services progress note dated [DATE], documented in part the following Does the patient have the capacity to participate in and benefit from treatment? Yes Under the section Mental Status Examination documented the following; Judgment: Mod. (moderate) Imp. (Improvement) Affect: Lethargic. Insight: Impaired Orientation: Person, Place Mood: Flat Under the section Long Term Therapy Goals documented the following; Stabilization/Reduction of affective and/or cognitive symptoms. Increase compliance with treatment plan .Reduction of behavioral problems. Under the section Short Term Therapy Goals documented the following; Goal: Reduce heightened sensitivity to bodily distress and reports of physical symptoms due to masked depression or anxiety. Progress made: Moderate. Goal: Adapt to new living patterns while showing acceptance of the loss. Progress made: Moderate A review of the clinical record revealed a physician's orders [REDACTED]. Change ropinirole (3) to 0.25 mg tablet by mouth daily PRN (as needed) pain/RLS (restless leg syndrome) and 1 mg tablet by mouth every hour of sleep PRN pain/RLS. Do not give PRN doses < 8 hours apart. A review of the clinical record revealed a physician's note dated [DATE], documented in part the following; Psychiatric: Affect: appropriate Appearance: appropriate, anxious - varies Mood: appropriate .Thought process: confused Judgement: poor Skin: warm Color: WNL/Pale Assessment and Plan: Plan: 3. Finally seems well controlled with [MEDICATION NAME] (6) .[MEDICATION NAME] .[MEDICATION NAME] ( ) A review of the clinical record revealed a Medication Administration Record [REDACTED]. Pain medications ([MEDICATION NAME] (6), [MEDICATION NAME] (4) none on the date of the incident or after the incident on [DATE]), antianxiety medication ([MEDICATION NAME] (7) on [DATE] none on the day of or after the incident). A review of the clinical record revealed an ultrasound report dated, [DATE], documented in part the following; Findings: No ultrasound abnormality in patient's are of concern. A CT (computed tomography scan) with IV (intravenous) contrast could further evaluate if clinical concern persists for neck pathology. A review of the clinical record revealed nurse's notes that revealed the resident exhibited the behaviors of crying prior to the incident on multiple dates almost daily unrelated to the [DATE] incident. A review of the clinical record revealed a comprehensive care plan which documented in part the following; (Resident #28's name) . At risk for anxiety/depression .observe for change in mental status, dated [DATE]; Potential for side effects related to use of antidepressant and antianxiety medications .monitor resident's mental status functioning on ongoing basis, dated [DATE] . A review of CNA #3's personnel file revealed a Corrective Action Form dated [DATE]. Under the section, Level of Corrective Action documented in part the following: Step 1-Initial Counseling. Under the section, Nature of Infraction documented in part the following: Failure to follow proper nursing (CNA) protocols with resident and not using good customer service. Under the section Corrective Action Taken documented in part the following: Educated, on policy and procedures on customer service and following proper nursing (CNA) protocols. Under the section, If action is repeated or improvements is not shown documented in part the following: (MONTH) lead up to further corrective actions which may lead to termination/suspension. Under the section, Employee Comments documented in part the following: I actively demonstrated to her how to use the call bell so I'm unsure how she could fail to have it. At the bottom, CNA #3, ASM #3, and ASM #1, signed and dated the document on [DATE]. On [DATE] at 1:03 p.m., an interview with LPN #3 was conducted via phone. LPN #3 confirmed his statement above and confirmed Resident #28 was interviewed and her statement. LPN #3 stated regarding the resident's behavior and bruising after the incident, I don't recall finding any - (Resident #28) behavior changes She (Resident #28) had bruising on her neck. It wasn't - I honestly can't remember if the bruising was related to the incident or from before the incident and not related. On [DATE] at approximately 3:30 PM and 3:45 PM, facility staff members LPN #1, OSM (Other Staff Member) #2, OSM #1, LPN #2, CNA #1, CNA #2, and OSM #3 were interviewed regarding suspected resident abuse and each responded by stating to immediately report the incident to the administrative staff immediately. On [DATE] at 4:15 PM, an interview with ASM #3 was conducted. When asked about the events that took place on [DATE], ASM #3 stated, I got a phone call from LPN #3, telling me that he walked in a resident's room and a CNA, CNA #3 looked like to him, had her (Resident #28) in a choke hold. I told him (LPN #3) to immediately escort him (CNA #3) from the building and I would call ASM #1. I called ASM #1 and he came to the building. ASM #1 got here approximately 10 minutes later. I asked if I needed to come in and was told no since ASM #1 was here. When asked about the events that took place the next day, [DATE], ASM #1 stated, The next day I came to work at 8:00 AM and assessed Resident #28. She denied pain to me. Resident #28 sipped water without difficulty. I noticed she had three little red pea sized spots on the left side of her neck. They were non-tender to touch and no facial grimaces. No complaints of pain. Our Nurse practitioner came in and was informed of the incident, and she ordered an ultrasound of the neck. The results were no abnormalities. When asked if the ultrasound conducted in-house, ASM #3 stated, In-house. We have a company who does ultrasounds and x-rays here. When asked about the follow up investigation by the facility, ASM #3 stated, I know we in-serviced the staff on abuse, the proper protocol. We have the Facility Reported Incident mapping at the nurse's station and in my office. The CNA's have the types of abuse written under their nametags. CNA #3 was terminated. ASM #3 stated, One resident loved him and asked for him. But we don't have any documentation of speaking with the residents. No other complaints from speaking with residents during that time period. A group interview was conducted on [DATE] at approximately 09:56 AM with Five cognitively intact residents, (Resident #41, GR Residents #15, #21, #24 and #23. All residents were coded with a BIMS (breif interview for mental status) score of 15 out of ,[DATE] on the MDS assessments, 15 meaning cognitively intact). None of the residents voiced any concerns regarding staff treatment of [REDACTED]. Review of the facility's grievance logs dated (MONTH) (YEAR) through (MONTH) 2019 failed to evidence any concerns regarding resident abuse from facility staff. Review of the facility's Resident Council Meeting Minutes dated (MONTH) (YEAR) through (MONTH) 2019 failed to evidence any concerns regarding resident abuse from facility staff. Review of the FRIs (facility reported incidents) dated (MONTH) (YEAR) through (MONTH) 2019 failed to evidence any concerns regarding resident abuse from facility staff. A review of the facility's policy Abuse, Neglect and Exploitation Prevention and Reporting documented in part the following; Policy: Each resident has the right to be free from abuse .This includes but is not limited to freedom from corporal punishment .any physical .restraint not required to treat the resident's medical symptoms. Resident must not be subject to abuse by anyone, including, but not limited to; facility staff .7. Investigation of Alleged Abuse, Neglect and Exploitation: When suspicion of abuse .or reports of abuse .occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: a. Interview the involved resident .b. If there is no discernible response from the resident, or if the resident's response in incongruent with that of a reasonable person, interview the resident's family, responsible parties .c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements .d. Document the entire investigation chronologically . On [DATE] at 4:57 PM, ASM #1 and ASM #2, the Regional Vice President of Operations, were made aware of the findings. ASM #1 was requested to provide any additional psychiatric documentation and any detailed notes for skin assessments. On [DATE] at 5:30 PM, ASM #1 stated, There are no other psychiatric notes. On [DATE] at 5:35 PM, ASM #3 stated, The Skin Inspection Report documents options for the nurse to choose skin is intact or not intact. The skin not intact - existing is documenting the wound from a recent surgical incision of her right leg. No further information was provided by the end of the survey. References: (1) Cipro: Used to treat bacterial infections in many different parts of the body. This information was obtained from the following website: https://www.mayoclinic.org/drugs-supplements/[MEDICATION NAME]-oral-route/description/drg- 288 (2) Bactrim DS: [MEDICATION NAME] and [MEDICATION NAME] combination: Used to treat infections such as urinary tract infections. This information was obtained from the following website: https://www.mayoclinic.org/drugs-supplements/[MEDICATION NAME]-[MEDICATION NAME]-oral-route/description/drg- 899 (3) Ropinirole: Used alone or with other medications to treat the symptoms of [MEDICAL CONDITION] (PD; a disorder of the nervous system that causes difficulties with movement, muscle control, and balance), including shaking of parts of the body, stiffness, slowed movements, and problems with balance. Ropinirole is also used to treat [DIAGNOSES REDACTED] (RLS or Ekbom syndrome; a condition that causes discomfort in the legs and a strong urge to move the legs, especially at night and when sitting or lying down). Ropinirole is in a class of medications called [MEDICATION NAME] agonists. It works by acting in place of [MEDICATION NAME], a natural substance in the brain that is needed to control movement. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 3.html (4) [MEDICATION NAME]: [MEDICATION NAME] and [MEDICATION NAME] combination is used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated. This information was obtained from the following website: https://www.mayoclinic.org/drugs-supplements/[MEDICATION NAME]-and-[MEDICATION NAME]-oral-route/description/drg- 089 (5) Eliquis: Used to treat deep vein thrombus ([MEDICAL CONDITION]) (blood clot) or [MEDICAL CONDITION] embolism (PE), and to lower your risk of having a repeat [MEDICAL CONDITION] or PE. This information was obtained from the following website: https://www.rxlist.com/eliquis-drug/patient-images-side-effects.htm (6) [MEDICATION NAME] HCL: Used to treat moderate to severe pain when around-the-clock pain relief is needed for a long period of time. This information was obtained from the following website: https://www.mayoclinic.org/drugs-supplements/[MEDICATION NAME]-oral-route/description/drg- 806 (7) [MEDICATION NAME]: Used to treat anxiety disorders. It is also used for short-term relief of the symptoms of anxiety or anxiety caused by depression. This information was obtained from the following website: https://www.mayoclinic.org/drugs-supplements/[MEDICATION NAME]-oral-route/description/drg- 296

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to follow infection control practices for three of seven residents in the medication administration observation, Resident #34, 198 and #21; and for one of 31 residents in the survey sample, Resident #96. 1. The facility staff failed to ensure the medication cup for Resident #34 was free from contamination during medication pass. 2. The facility staff failed to ensure the medication cups for Resident #198 and #21, were free from contamination during medication pass. 3. The facility staff failed to implement physician ordered contact precautions while in Resident #96's room. The findings include: 1. Resident #34 was admitted to the facility 8/18/06 with [DIAGNOSES REDACTED]. Resident #34's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 7/10/18. Resident #34 was coded as being cognitively intact in the ability to make daily decisions scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #34 was coded as requiring limited assistance from one staff member with bed mobility and transfers; extensive assistance from one staff member with dressing, and personal hygiene; total dependence on staff with toileting and bathing. On 8/22/18 at 5:07 p.m., medication administration was conducted with RN (registered nurse) #2. RN #2 was observed preparing the following medications for Resident #34: (1) [MEDICATION NAME] 100 mg (milligrams) capsule (2) [MEDICATION NAME] 150 mg tablet After these medications were prepared, RN #2 grabbed the rim of the medication cup with her bare fingers and transported the medication to Resident #34's room. RN #2 gave the cup to Resident #34, and he took the medications. Resident #34's lips were touching the rim of the cup, where RN #2's bare fingers had touched. On 8/22/18 at 5:14 p.m., an interview was conducted with RN #2. When asked how nurses should hold the medication cup while preparing and transporting medications, RN #2 demonstrated that her fingers should be around the middle of the cup. When asked if nurses could hold the cup by the rim, RN #2 stated that fingers should not be near the rim or inside of the cup. RN #2 stated that holding the cup by the rim would result in contamination. RN #2 was made aware the above observations. RN #2 stated she did not realize that she had held the medication cup by the rim. RN #2 stated that she should not have done that. On 8/22/18 at 6:22 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. The facility policy titled, Administering Medications, documented in part, the following: Staff shall follow established facility infection control procedures (e.g. handwashing, antispetic technique, gloves, isolation, precautions, etc.) for the administration of medications, as applicable. No further information was presented prior to exit. (1) [MEDICATION NAME] is used for the treatment of [REDACTED]. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 19/?report=details. (2) [MEDICATION NAME] used to treat and relieve heartburn. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 47/. 2. The facility staff failed to ensure the medication cups for Resident #198 and #21, were free from contamination during medication pass. Resident #198 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 198 did not have a completed MDS (minimum data set) assessment and was documented as being alert and oriented x 3 (person, place, time). Resident #21 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #21's most recent MDS (minimum data set) assessment was a five day scheduled assessment with an ARD (assessment reference date) of 8/10/18. Resident #21 was coded as severely cognitively impaired in the ability to make daily decisions scoring 07 out of 15 on the BIMS (Brief Interview for Mental Status) exam. On 8/22/18 at 5:20 p.m., medication administration was conducted with RN (registered nurse) #1. RN #1 was observed preparing the following medications for Resident #198: (1) Aspirin 325 mg (milligrams) - 1 tablet (2) [MEDICATION NAME] 5/325 mg- 1 tablet After these medications were prepared, RN #1 grabbed the rim of the medication cup with her bare fingers and transported the medication to Resident #198s room. RN #1 gave the cup to Resident #198, and he took the medications. Resident #198's lips were touching the rim of the cup, where RN #1's bare fingers had touched. RN #1 then threw away the medication cup and washed her hands. RN #1 then proceeded to prepare Resident #21's medications. On 8/22/18 at 5:30 p.m., RN #1 grabbed an empty medication cup, her bare fingers touching the rim of the cup, and a packet of Pro-Stat (3) protein powder and proceeded to Resident #21's room. RN #1 then placed the medication cup on Resident #21's over bed table and emptied the contents of the Pro-Stat into the cup, mixing it with water. RN #1 then picked up the medication cup by the rim of the cup, with her bare fingers and gave the cup to Resident #21. Resident #21 drank the Pro-Stat liquid. Resident #21's lips touched the rim of the cup, where RN #1's bare fingers had touched. RN #1 then washed her hands. On 8/22/18 at 5:35 p.m., an interview was conducted with RN #1. When asked how nurses should hold the medication cup while preparing and transporting medications, RN #1 stated that the top and the inside of the cup should not be touched to avoid contamination. When asked if she touched the rim of Resident #198's and Resident #21's medication cup with her bare fingers, RN #1 stated that she was not sure. RN #1 was then made aware of the above observations. RN #1 stated that she was not aware that she had done that. RN #1 stated that it was an infection control issue to touch the rim of the medication cup. On 8/22/18 at 6:22 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. No further information was presented prior to exit. (1) Aspirin- Used to decrease mild to moderate pain associated with [MEDICAL CONDITION] disorders. This information was obtained from Davis's Drug Guide, 11th edition, p. 1087. (2) [MEDICATION NAME]- Opioid [MEDICATION NAME] used to treat pain. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 90/?report=details. (3) Pro-Stat- Supplemental protein used for wound healing. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 49/. 3. The facility staff failed to implement physician ordered contact precautions while in Resident #96's room. Resident #96 was admitted to the facility on [DATE]. Resident #96's [DIAGNOSES REDACTED]. Resident #96's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/6/18, coded the resident as being cognitively intact. Review of Resident #96's clinical record revealed a physician's orders [REDACTED]. Resident #96's comprehensive care plan dated 6/11/18 documented, CI (Contact isolation) (2) [MEDICAL CONDITION] (3) and ESBL in urine .Approaches: Contact isolation . Resident #96's CNA (certified nursing assistant) care plan failed to document information regarding contact isolation. On 8/22/18 at 8:28 a.m., CNA #1 was observed in Resident #96's room and assisting the resident with a beverage. CNA #1 was not wearing a gown, mask or gloves. CNA #1 did not wash her hands before leaving the room. On 8/22/18 at 1:38 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 was asked what she should do before entering and when leaving a contact isolation room. LPN #5 stated, I'm going to use my protective gear which should be outside the room; put on whatever is suitable for the isolation. Knock on the door ask to enter the room. Before I leave, once I have done what I need to do, remove my stuff at the door to be able to wash my hands to leave the room. On 8/22/18 at 2:12 p.m., an interview was conducted with CNA #1. CNA #1 was asked what she should do before entering a contact isolation room. CNA #1 stated, Gown up, mask and gloves. CNA #1 was asked what she should do before leaving a contact isolation room. CNA #1 stated, Take it off, put it in the isolation carts in the room When asked if she should wash her hands, CNA #1 stated, Uh huh. On 8/22/18 at 6:15 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the regional nurse consultant) were made aware of the above findings. The facility document titled, Isolation- Categories of Transmission-Based Precautions documented, Contact Precautions; 1. In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .4. Gloves and Handwashing: In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile) when entering the room. While caring for a resident, change gloves after having contact with infective material (for example, fecal material and wound drainage). Remove gloves before leaving the room and perform hand hygiene. After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room. 5. Gown: Wear a disposable gown upon entering the Contact Precautions room or cubicle. After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces . No further information was presented prior to exit. (1) Extended-spectrum ß-lactamase is an enzyme that allows bacteria to become resistant to a wide variety of [MEDICATION NAME] and cephalosporins. Bacteria that contain this enzyme are known as ESBLs or ESBL-producing bacteria. ESBL-producing [MEDICATION NAME] are resistant to strong antibiotics including extended spectrum cephalosporins. This information was obtained from the website: https://www.cdc.gov/drugresistance/biggest_threats.html (2) Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. This information was obtained from the website: https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf (3) [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) causes a range of illnesses, from skin and wound infections to pneumonia and bloodstream infections that can [MEDICAL CONDITION] and death. Staph bacteria, [MEDICAL CONDITION], are one of the most common causes of healthcare-associated infections. This information was obtained from the website: https://www.cdc.gov/drugresistance/biggest_threats.html

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide a dignified dining experience for three of 31 residents in the survey sample, Residents #3, #24 and 335. 1. The facility staff failed to provide dignity for Resident #3 during lunch on 8/21/18. CNA (Certified nursing assistant) #1 stood while feeding the resident a portion of lunch. 2. The facility staff failed to provide dignity for Resident #24 during lunch on 8/21/18. CNA #1 stood while feeding the resident a portion of lunch and food from the resident's lips with a spoon. 3. The facility staff failed to feed Resident #35 immediately after placing a meal tray in front of the resident. On 8/21/18, a CNA placed a meal tray on the table in front of Resident #35 and the resident was not fed for eight minutes. The findings include: 1. The facility staff failed to provide dignity for Resident #3 during lunch on 8/21/18. CNA (Certified nursing assistant) #1 stood while feeding the resident a portion of lunch. Resident #3 was admitted to the facility on [DATE]. Resident #3's [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 8/7/18, coded the resident's cognitive skills for daily decision-making as severely impaired. Section G coded Resident #3 as requiring extensive assistance of one staff with eating. On 8/21/18 at 12:20 p.m., CNA #1 was observed feeding Resident #3 and another resident sitting across the table in the restorative dining room. CNA #1 stood while alternating bites of food to each resident until another CNA came in to feed Resident #3. On 8/22/18 at 1:38 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 was asked what should be done to provide a dignified dining experience. LPN #5 stated, We want to make sure we tell them what there is to eat. Give them as many choices as we can. Offer everything. We don't want to do too big of a bite so that creates less of a mess. Conversation. When asked where staff should be positioned in relation to a resident he or she is feeding, LPN #5 stated, Sitting next to them. On 8/22/18 at 2:12 p.m., an interview was conducted with CNA #1. CNA #1 was asked what should be done to provide a dignified dining experience. CNA #1 stated, That's why we have restorative dining; anybody that needs to be helped they come over and help us. When asked where she should be positioned when feeding a resident, CNA #1 stated, If somebody is right there, I sit beside them. Resident #3's comprehensive care plan dated 8/6/18 failed to document information regarding the above concern. On 8/22/18 at 6:15 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the regional nurse consultant) were made aware of the above findings. The facility policy titled, Assistance with Meals documented, 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity for example: a. Not standing over residents while assisting them with meals . No further information was presented prior to exit. 2. The facility staff failed to provide dignity for Resident #24 during lunch on 8/21/18. CNA #1 stood while feeding the resident a portion of lunch and food from the resident's lips with a spoon. Resident #24 was admitted to the facility on [DATE]. Resident #24's [DIAGNOSES REDACTED]. Resident #24's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/29/18, coded the resident's cognitive skills for daily decision-making as severely impaired. Section G coded Resident #24 as requiring extensive assistance of one staff with eating. On 8/21/18 at 12:20 p.m., CNA #1 was observed feeding Resident #24 and another resident sitting across the table in the restorative dining room. CNA #1 stood while alternating bites of food to each resident until another CNA came in to feed the other resident. On multiple occasions, CNA #1 was observed scraping excess food from Resident #24's lips with the spoon. On 8/22/18 at 1:38 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 was asked what should be done to provide a dignified dining experience. LPN #5 stated, We want to make sure we tell them what there is to eat. Give them as many choices as we can. Offer everything. We don't want to do too big of a bite so that creates less of a mess. Conversation. When asked where staff should be positioned in relation to a resident he or she is feeding, LPN #5 stated, Sitting next to them. LPN #5 was asked how food should be removed from a resident's face. LPN #5 stated, Use a napkin. If they needed help I would do it. LPN #5 was asked how she would feel if food was removed from her face with a spoon. LPN #5 stated, I guess like an infant. On 8/22/18 at 2:12 p.m., an interview was conducted with CNA #1. CNA #1 was asked what should be done to provide a dignified dining experience. CNA #1 stated, That's why we have restorative dining; anybody that needs to be helped they come over and help us. When asked where she should be positioned when feeding a resident, CNA #1 stated, If somebody is right there, I sit beside them and wipe their mouth when stuff is all over it. When asked how she wipes the resident's mouth, CNA #1 stated, I use their protective cover (a clothes cover). When asked if she could use a napkin, CNA #1 stated, We can use napkins. When made aware of this surveyor's observation, CNA #1 stated, I was wiping her face. Resident #24's comprehensive care plan dated 6/28/18 failed to document information regarding the above concern. On 8/22/18 at 6:15 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the regional nurse consultant) were made aware of the above findings. No further information was presented prior to exit. 3. The facility staff failed to feed Resident #35 immediately after placing a meal tray in front of the resident. On 8/21/18, a CNA placed a meal tray on the table in front of Resident #35 and the resident was not fed for eight minutes. Resident #35 was admitted to the facility on [DATE]. Resident #35's [DIAGNOSES REDACTED]. Resident #35's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/13/18, coded the resident's cognition as severely impaired. Section G coded Resident #35 as requiring extensive assistance of one staff with eating. On 8/21/18 at 12:18 p.m., a CNA placed a covered meal tray in front of Resident #35. The resident was not offered assistance with the meal for eight minutes. On 8/22/18 at 1:38 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 was asked how long it should take to offer assistance to a resident after a meal tray has been placed in front of him or her. LPN #5 stated, If there is food sitting in front of them they shouldn't be waiting too long. When asked to describe too long, LPN #5 stated, I would say they shouldn't be waiting more than five minutes. There may be a case where you put the tray down and someone needs a straw so you get that then return; other than that you should be feeding them. When asked how she would feel if she required assistance with eating and a meal was placed in front of her for eight minutes before receiving assistance, LPN #5 stated, Hungry. On 8/22/18 at 2:12 p.m., an interview was conducted with CNA #1. CNA #1 was asked how long it should take to offer assistance to a resident after a meal tray has been placed in front of him or her. CNA #1 stated, When we place it there. Resident #35's comprehensive care plan dated 7/12/18 failed to document information regarding the above concern. On 8/22/18 at 6:15 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the regional nurse consultant) were made aware of the above findings. No further information was presented prior to exit.

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide a homelike dining experience for three of 31 residents in the survey sample, Residents #3, #24, #35. The facility staff failed to provide a homelike dining experience for Residents #3, #24 and #35 during lunch on 8/21/18. The residents were served meal plates on serving trays. The findings include: Resident #3 was admitted to the facility on [DATE]. Resident #3's [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 8/7/18, coded the resident's cognitive skills for daily decision-making as severely impaired. Section G coded Resident #3 as requiring extensive assistance of one staff with eating. Resident #24 was admitted to the facility on [DATE]. Resident #24's [DIAGNOSES REDACTED]. Resident #24's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/29/18, coded the resident's cognitive skills for daily decision-making as severely impaired. Section G coded Resident #24 as requiring extensive assistance of one staff with eating. Resident #35 was admitted to the facility on [DATE]. Resident #35's [DIAGNOSES REDACTED]. Resident #35's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/13/18, coded the resident's cognition as severely impaired. Section G coded Resident #35 as requiring extensive assistance of one staff with eating. On 8/21/18 at 12:13 p.m., a dining observation was conducted in the restorative dining room. The staff served Residents #3, #24 and #35 their meal plates on serving trays and did not remove the trays while assisting the residents with their meals. Some other residents' meal plates were observed removed from the serving trays. On 8/22/18 at 2:12 p.m., an interview was conducted with CNA (certified nursing assistant) #1 (a CNA who served lunch in the restorative dining room on 8/21/18). CNA #1 was asked why some residents were served meals on trays and others were not. CNA #1 stated, They were supposed to come off the trays. We might have been a little nervous because you guys are here .The ones we feed, they don't touch their food. When asked if there was any reason Residents #3, #24 and #35's meals were left on trays, CNA #1 stated, No. We took them off didn't we? When asked why staff is supposed to remove meals from serving trays, CNA #1 stated, It's nice dining; more like being at home. On 8/22/18 at 6:15 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the regional nurse consultant) were made aware of the above findings. The facility document titled, Quality of Life- Homelike Environment documented, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for two of 31 residents in the survey sample, Residents #6, and #96. 1. The facility staff failed to implement the comprehensive care plan for the administration of oxygen for Resident #6. 2. The facility staff failed to implement Resident #96's comprehensive care plan for contact precautions. The findings include: 1. The facility staff failed to implement the comprehensive care plan for the administration of oxygen for Resident #6. Resident #6 was admitted to the facility 4/20/16 with diagnoses, which included but were not limited to: anxiety disorder, arthritis, depression, diabetes, high blood pressure, and dementia. The most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 5/28/18, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. In Section O - Special Treatments, Procedures, and Programs, the resident was coded as having used oxygen within the last 14 days of the look back period. The comprehensive care plan dated, 5/30/18, documented in part, Problem/Need: At risk for SOB (shortness of breath) due to DX (diagnosis) of [MEDICAL CONDITION] ([MEDICAL CONDITION] - general term for chronic, nonreversible lung disease that is usually a combination of [MEDICAL CONDITION] and chronic [MEDICAL CONDITION]) (1). The Approaches documented in part, O2 (oxygen) as ordered. Observation was made of Resident #6 on 8/22/18 at 8:06 a.m. The resident was in bed with her oxygen on via the nasal cannula (plastic tube with two prongs that insert into the nose) connected to an oxygen concentrator. The oxygen concentrator was set at 4L/min (liters/minute). A second observation was made of Resident #6 on 8/22/18 at 9:48 a.m. The resident was still in the bed with her oxygen on via the nasal cannula connected to an oxygen concentrator. The oxygen concentrator was set at 4L/min. On 8/22/18 at 9:50 a.m., the oxygen concentrator was observed with LPN (licensed practical nurse) #3. LPN #3 verified that the oxygen flow meter was set at 4L/min. LPN #3 stated he did not have any residents prescribed for 4 liters. He stated she probably is supposed to be on 2 liters. LPN #3 went to the clinical record and verified the resident was to be on 2L/min per the physician order. The physician order [REDACTED].@ (at) 2L/m (liters per minute) via nasal cannula at HS (hours of sleep - bedtime) per resident request. Remove O2 at 2L/min NC (nasal cannula) QAM (every morning). The (MONTH) (YEAR) Treatment Administration Record (TAR) documented the above physician order. The TAR documented the administration of the oxygen every evening for each evening in August. There was no documented nurse's notes for 8/22/18. An interview was conducted with LPN #5 on 8/22/18 at 1:53 p.m. When asked the purpose of the care plan, LPN #5 stated, It's to provide a plan of care to make sure all of their needs are met. When asked if it should be followed, LPN #5 stated, Yes, it should be. An interview was conducted with ASM (administrative staff member ) #2, the director of nursing, and LPN #1, the assistant director of nursing, on 8/22/18 at 2:44 p.m. When asked the purpose of the care plan, ASM #2 stated, It's to establish the goals of the resident and so that all the staff will be able to provide the care to reach their (the resident's) goals. When asked if the care plan should be followed, ASM #2 stated, Yes, unless it is no longer appropriate. Then it should be updated. The facility policy, Care Plans, Comprehensive Person-Centered documented in part, A comprehensive, person - centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. According to Fundamentals of Nursing Lippincott Williams and Wilkins 2007 pages 65-77 documented, A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care .expect to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders . Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, LPN (licensed practical nurse) #1, the assistant director of nursing, and ASM #5, the administrator in training, were made aware of the above concern on 8/22/18 at 6:00 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. 2. The facility staff failed to implement Resident #96's comprehensive care plan for contact precautions. Resident #96 was admitted to the facility on [DATE]. Resident #96's [DIAGNOSES REDACTED]. Resident #96's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/6/18, coded the resident as being cognitively intact. Review of Resident #96's clinical record revealed a physician's orders [REDACTED]. Resident #96's comprehensive care plan dated 6/11/18 documented, CI (Contact isolation) (2) [MEDICAL CONDITION] (3) and ESBL in urine .Approaches: Contact isolation . Resident #96's CNA (certified nursing assistant) care plan failed to document information regarding contact isolation. On 8/22/18 at 8:28 a.m., CNA #1 was observed in Resident #96's room, assisting the resident with a beverage. CNA #1 was not wearing a gown, mask or gloves. CNA #1 did not wash her hands before leaving the room. On 8/22/18 at 1:38 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 was asked the purpose of a care plan. LPN #5 stated, To provide a plan of care to make sure we hit all areas of care for that patient to make sure their needs are being met. When asked how CNAs and nurses ensure they follow care plans, LPN #5 stated, We have a mini care plan for the CNAs that's on the inside of the closet door. Each person has one that the CNA can follow and report (verbal shift to shift report). LPN #5 was asked what she should do before entering and when leaving a contact isolation room. LPN #5 stated, I'm going to use my protective gear which should be outside the room; put on whatever is suitable for the isolation. Knock on the door ask to enter the room. Before I leave, once I have done what I need to do, remove my stuff at the door to be able to wash my hands to leave the room. On 8/22/18 at 2:12 p.m., an interview was conducted with CNA #1. CNA #1 was asked what she should do before entering a contact isolation room. CNA #1 stated, Gown up, mask and gloves. CNA #1 was asked what she should do before leaving a contact isolation room. CNA #1 stated, Take it off, put it in the isolation carts in the room When asked if she should wash her hands, CNA #1 stated, Uh huh. On 8/22/18 at 6:15 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the regional nurse consultant) were made aware of the above findings. No further information was presented prior to exit. (1) Extended-spectrum ß-lactamase is an enzyme that allows bacteria to become resistant to a wide variety of [MEDICATION NAME]'s and cephalosporins. Bacteria that contain this enzyme are known as ESBLs or ESBL-producing bacteria. ESBL-producing [MEDICATION NAME] are resistant to strong antibiotics including extended spectrum cephalosporins. This information was obtained from the website: https://www.cdc.gov/drugresistance/biggest_threats.html (2) Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. This information was obtained from the website: https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf (3) [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) causes a range of illnesses, from skin and wound infections to pneumonia and bloodstream infections that can [MEDICAL CONDITION] and death. Staph bacteria, [MEDICAL CONDITION], are one of the most common causes of healthcare-associated infections. This information was obtained from the website: https://www.cdc.gov/drugresistance/biggest_threats.html

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for one of 31 residents in the survey sample, Resident #11. A. The facility staff failed to follow professional standards of practice for documenting notification of the physician for an elevated blood sugar for Resident #11. B. The facility staff failed follow professional standards of practice for the documenting the actual blood sugar readings for Resident #11. The findings include: A. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/20/18, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating she was moderately impaired to make cognitive daily decisions. The resident was coded as requiring no assistance to limited assistance for her activities of daily living. The physician order [REDACTED]. Below 130 = O (units) 131 - 180 = 4 u (units) 181 - 240 = 8 u 241 - 300 = 1- u 301 - 350 = 12 u 351 - 400 = 16 u > (greater than) 400 = 20 u & (and) call MD (medical doctor). The (MONTH) (YEAR) Medication Administration Record [REDACTED]. RN (registered nurse) #2 documented this. Review of the MAR indicated [REDACTED]. The comprehensive care plan dated, 5/30/18, documented in part, Problem/Need: Diabetes Mellitus risk for high and lows of BS. Resident predicts her needs and intake based on how she thinks she is feeing vs (versus) actual number of glucose readings. The Approaches documented in part, Give medications per orders. BS per order. Notify MD of changes in BS or s/s (signs and symptoms) of hypo/[MEDICAL CONDITION] (too low or too high blood sugars). An interview was conducted with RN #2 on 8/22/18 at 6:46 p.m. RN #2 was asked to review the above order for sliding scale insulin. She was asked to review the MAR for 6/26/18. When asked if she notified the doctor of the blood sugar, RN #2 stated, I know I did it. I wrote it in her (the doctor's) communication book. RN #2 further stated, I've been doing this for a long time. If it's not documented, I may have hit cancel or enter and it disappeared but I know I did it. RN #2 was asked to provide evidence that she documented the notification in the doctor's communication book. An interview was conducted with administrative staff member (ASM) #2, the director of nursing on 8/23/18 at 8:10 a.m. The blood sugar and nurse's notes were reviewed with ASM #2. When asked if they had found documentation of the notification in the doctor's communication book, ASM #2 stated they had not found it. ASM #2 further stated, If it's not documented it's not done. An interview was conducted with LPN (licensed practical nurse) #3 on 8/23/18 at 8:20 a.m. When asked if the sliding scale should be followed as written, LPN #3 stated, Absolutely. When asked where physician notification documented if the blood sugar is greater than 400 and the doctor was notified as ordered, LPN #3 stated, In the nurse's notes. On 8/23/18 at 8:56 a.m., LPN #1 presented a document of blood sugars for Resident #11, which was printed on 6/27/18 at 6:32 a.m. The attending physician signed the paper. LPN #1 stated, We print these out on the 11-7 (11:00 p.m. to 7:00 a.m.) shift for the doctors and nurse practitioners for the days they are coming to the facility. When asked if this document is part of the clinical record, LPN #1 stated, No, Ma'am. The facility policy, Charting and Documentation documented in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .2. The following information is to be documented in the resident medical record: a. Objective observations. b. Medications administered. c. Treatments or services performed. d. Changes in the resident's condition. e. Events, incidents or accidents involving the resident. f. Progress toward or changes in the care plan goals and objectives. The following quotation is found in Lippincott's Fundamentals of Nursing 5th edition (2007, page 237): The client record serves as a legal document of the client's health status and care received .Because nurses and other healthcare team members cannot remember specific assessments or interventions involving a client years after the fact, accurate and complete documentation at the time of care is essential. The care may have been excellent, but the documentation must prove it. Administrative staff member (ASM) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 8/23/18 at 9:50 a.m. When asked the standard of practice the facility uses, ASM #2 stated, Lippincott. No further information was provided prior to exit. (1) This information was obtained from the following website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cd88e313-6193-4413-beff-7d 0060d B. The facility staff failed follow professional standards of practice for the documenting the actual blood sugar readings for Resident #11. The (MONTH) (YEAR) MAR indicated [REDACTED]. On 7/7/18, 7/8/18 and 7/22/18 at 4:30 p.m. there was no documented blood sugar reading. RN # 1 completed all three dates. The (MONTH) (YEAR) MAR indicated [REDACTED]< (less than) 130. Review of the Vital Signs section of the electronic record failed to evidence documentation of the blood sugar readings on the above dates and times. Review of the nurse's notes for the above dates failed to evidence documentation of the blood sugar readings. An interview was conducted with RN #1 on 8/22/18 at 6:25 p.m. The above MAR indicated [REDACTED]. When asked if the actual number for the blood sugar reading should be included in the MAR, RN #1 stated, I don't know why it isn't there. An interview was conducted with LPN #3 on 8/23/18 at 8:20 a.m. When asked where the blood sugar readings are documented, LPN #3 stated, A box comes up and you put it there. It then populates to the blood sugar section in the vital signs. When asked if a nurse should document the blood sugar as less than 130, LPN #3 stated, It's probably not in the best interest to do that. The facility policy, Obtaining a Finger stick Glucose Level documented in part, Documentation .The person performing this procedure should record the following information in the resident's medical record: 6. The blood sugar results. The following quotation is found in Lippincott's Fundamentals of Nursing 5th edition (2007, page 980) Procedure: Measuring Blood Glucose by Skin Puncture .15. Share test results with client and record obtained values in the client chart. Administrative staff member (ASM) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 8/23/18 at 9:50 a.m. When asked the standard of practice the facility uses, ASM #2 stated, Lippincott. No further information was provided prior to exit.

Based on observations, resident interview, staff interview, family interview, facility document review, and clinical record review it was determined the facility staff failed to administer Oxygen per the physicians order for one of 31 residents in the survey sample, Residents #196. The facility staff failed to ensure a trained staff member administered oxygen to resident #196 The findings include: Resident #196 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. (1) There was no minimum data set (MDS) assessment completed at the time of the survey. The Nursing Admission assessment dated [DATE] documented that the resident was alert and oriented. The physician order [REDACTED]. On 08/21/18 at 03:45 p.m., Resident #196 was observed lying in bed wearing a NC connected to an oxygen concentrator with the oxygen flow rate set to 2.5L/min. At this time, an interview with Resident #196 was conducted. Resident #196 stated they normally use 2.5 (liters of oxygen). On 08/22/18 at 08:04 a.m. a second observation was made; again the resident was lying in bed with oxygen set to 2.5L/min. The resident was asked if she adjusted her own oxygen, the resident denied doing this. On 08/22/18 2:16 p.m., a third observation was made. The resident was lying in bed with her daughter present at bedside without a NC being worn. The oxygen flow meter on the oxygen concentrator was turned on at a rate of 2-2.5L/min but was not being worn by the resident. At that time, the daughter who was with the resident was interviewed. Resident #196's daughter stated staff had took off the oxygen to transfer her (Resident #196) back to bed thirty minutes prior but didn't put the oxygen back on. Review of the care plan dated 8/13/2018, failed to evidence documentation of the use of oxygen for Resident #196. An interview was conducted with Licensed Practical Nurse (LPN) #3 on 8/22/18 at 2:20 p.m. When asked what oxygen had been ordered for Resident #196, LPN #3 responded 2L/min. LPN #3 was then informed of the above observations of the resident receiving oxygen at 2.5 L/min. and informed Resident #196's NC was not being worn as ordered by the physician. LPN #3 was then asked to measure the resident's oxygen level using pulse oximetry. The result of this measurement was observed to be 80% (normal >90%). LPN #3 then placed O2 via NC on Resident #196 and the resident's oxygen level was then noted to be 93% via pulse oximetry. LPN #3 was then asked to read Resident #196's oxygen flow meter. LPN #3 read the flow meter and stated 2L. When asked how an oxygen flow meter was supposed to be read, LPN#3 responded, The bottom of the ball is supposed to be at the top of the line. LPN 3# was then asked which staff had worked with Resident #196 earlier. LPN #3 replied certified nursing assistant (CNA) #1. When asked if CNA's can remove or adjust oxygen LPN#3 stated, No. During an interview on 08/22/18 2:40 p.m. with CNA (Restorative Aid) #1, when asked if CNA's are allowed to administer oxygen, adjust oxygen or put and take oxygen on or off a resident, CNA#1 answered yes. When CNA#1 was asked if she remove or adjust the oxygen for Resident # 196, CNA #1 answered yes. On 8/22/18 at 2:44 p.m., an interview was conducted with administrative staff member (ASM) #2, the director of nursing (DON), and LPN # 1, the assistant director of nursing. Both were asked if the restorative aid was a CNA to which they both stated yes. When asked if a CNA can remove oxygen, turn it on or off, or adjust it in any way, ASM#2 answered, That's the nurse's responsibility that would be a No. Review of the job description for a CNA did not evidence any documentation regarding the administration of oxygen. The Medication Administration Record [REDACTED]. According to the facilities oxygen administration policy prior to oxygen administration both the physicians order and care plan should be reviewed. According to Fundamental of Nursing, Perry and Potter, 6th edition, page 1122, Oxygen should be treated as a drug. It has dangerous side effects, such as atelectasis or oxygen toxicity. As with any drug, the dosage or concentration of oxygen should be continuously monitored. The nurse should routinely check the physician's orders [REDACTED]. The six rights of medication administration also pertain to oxygen administration. The administrator ASM #1 and ASM# 2 were made aware of the above concern 8/22/18 at 6:00 p. No further information was provided prior to exit. 1. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure treatment was provided in accordance with professional standards of practice, and the comprehensive care plan for one of 31 residents in the survey sample, Resident #11. The facility staff failed to follow the physician orders [REDACTED].#11. On 8/4/18 at 11:30 a.m., LPN (licensed practical nurse) #6 administered 16 units of [MEDICATION NAME](a short acting insulin (1)) to Resident #11, instead of the physician prescribed 12 units of [MEDICATION NAME]for a blood sugar reading of 348. The findings include: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/20/18, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating she was moderately impaired to make cognitive daily decisions. The resident was coded as requiring no assistance to limited assistance for her activities of daily living. The comprehensive care plan dated, 5/30/18, documented in part, Problem/Need: Diabetes Mellitus risk for high and lows of BS. Resident predicts her needs and intake based on how she thinks she is feeing vs (versus) actual number of glucose readings. The Approaches documented in part, Give medications per orders. BS per order. Notify MD of changes in BS or s/s (signs and symptoms) of hypo/[MEDICAL CONDITION] (too low or too high blood sugars). The physician order [REDACTED]. Below 130 = O (units) 131 - 180 = 4 u (units) 181 - 240 = 8 u 241 - 300 = 1- u 301 - 350 = 12 u 351 - 400 = 16 u > (greater than) 400 = 20 u & (and) call MD (medical doctor). The (MONTH) (YEAR) MAR (medication administration record) documented the above order. On 8/4/18 at 11:30 a.m., the nurse documented the blood sugar as 348. The documented amount of insulin administered was 16. The next recorded blood sugar on 8/4/18 at 4:30 p.m. documented the blood sugar as 74. An interview was conducted with LPN (licensed practical nurse) #3, on 8/23/18 at 8:22 a.m. When asked if physician orders [REDACTED].#3 stated, Absolutely. An interview was conducted with LPN #6, the nurse that gave the insulin on 8/4/18 at 1:30 a.m., on 8/23/18 at 10:02 a.m. The above order for insulin was read to LPN #6. When asked what amount of insulin per the order, should the resident have received, for the blood sugar reading of 348, LPN #6 stated, 12 units. The MAR for (MONTH) of (YEAR) was reviewed with LPN #6 and her documentation of administering 16 units. LPN #6 stated, That was an error. When asked if that was following the physician's orders [REDACTED]. The blood sugar on 8/4/18 at 4:30 p.m. was shared with LPN #6. LPN #6 stated, I didn't realize I did that. That's a mistake and I am responsible. The facility policy, Administering Mediations, documented in part, Medications shall be administered in a safe and timely manner, and as prescribed .7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication .20. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered. b. The dosage. c. The route of administration. d. The injection site (if applicable) .g The signature and title of the person administering the drug. In Fundamentals of Nursing 6th edition, 2005; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc.; Page 419. The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]. Administrative staff member (ASM) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 8/23/18 at 9:50 a.m. (1) This information was obtained from the following website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cd88e313-6193-4413-beff-7d 0060d

Based on observations, resident interview, staff interview, family interview, facility document review, and clinical record review it was determined the facility staff failed to administer oxygen per the physicians order for two of 31 residents in the survey sample, Residents #196 and Resident #6. 1. The facility staff failed to administer oxygen, per the physician order, for Resident #196. 2. The facility staff failed to administer oxygen per the physician order, for Resident #6. The findings include: 1. Resident #196 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. (1) There was no minimum data set (MDS) assessment completed by the time of the survey. The Nursing Admission assessment dated [DATE], documented the resident was alert and oriented. The physician order [REDACTED]. On 08/21/18 at 03:45 p.m., Resident #196 was observed lying in bed wearing a NC connected to an oxygen concentrator with the oxygen flow rate set to 2.5L/min. At this time, an interview with Resident #196 was conducted. Resident #196 stated they normally use 2.5 (liters of oxygen). On 08/22/18 at 08:04 a.m. a second observation was made; again the resident was lying in bed with oxygen set to 2.5L/min. The resident was asked if she adjusted her own oxygen, the resident denied doing this. On 08/22/18 2:16 p.m., a third observation was made. The resident was lying in bed with her daughter present at bedside without a NC being worn. The oxygen flow meter on the oxygen concentrator was turned on at a rate of 2-2.5L/min but was not being worn by the resident. At that time, the daughter who was with the resident was interviewed. Resident #196's daughter stated staff had took off the oxygen to transfer her (Resident #196) back to bed thirty minutes prior but didn't put the oxygen back on. Review of the care plan dated 8/13/2018, failed to evidence documentation of the use of oxygen for Resident #196. An interview was conducted with Licensed Practical Nurse (LPN) #3 on 8/22/18 at 2:20 p.m. When asked what oxygen had been ordered for Resident #196, LPN #3 responded 2L/min. LPN #3 was then asked to read Resident #196's oxygen flow meter (Resident #196 was not observed wearing the nasal cannula at this time, but the oxygen concentrator was running). LPN #3 read the flow meter and stated 2L. When asked how an oxygen flow meter was supposed to be read, LPN #3 responded, The bottom of the ball is supposed to be at the top of the line. LPN #3 then placed O2 via NC on Resident #196. Observation of Resident #196 oxygen flow meter revealed the flow rate was set at 2.5 L/min. and not 2 L/mi. as ordered. An interview was conducted with LPN #4 on 8/22/18 at 3:30 p.m. when asked how an oxygen flow meter is read LPN #4 responded, The ball has to be mid-level to the line. Interview on 8/22/18 at 2:44 p.m. with administrative staff member (ASM) #2, the director of nursing (DON), and LPN # 1, the assistant director of nursing. When asked how the oxygen flow meter should be read, LPN# 1 stated, The line should be through the center of the ball. According to the Resperonics EverFlo user manual page 6 for the oxygen concentrator that was at Resident #196's bedside, Adjust the flow . until the ball is centered on the line marking the specific flow rate. The Medication Administration Record [REDACTED]. According to the facilities oxygen administration policy 8. Place appropriate oxygen device on the resident .10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. According to Fundamental of Nursing, Perry and Potter, 6th edition, page 1122, Oxygen should be treated as a drug. It has dangerous side effects, such as atelectasis or oxygen toxicity. As with any drug, the dosage or concentration of oxygen should be continuously monitored. The nurse should routinely check the physician's orders [REDACTED]. The six rights of medication administration also pertain to oxygen administration. The administrator ASM #1 and ASM# 2, the director of nursing were made aware of the above concern 8/22/18 at 05:10 p.m. No further information was provided prior to exit. 1. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. 2. The facility staff failed to administer oxygen per the physician order [REDACTED].>Resident #6 was admitted to the facility 4/20/16 with diagnoses, which included but were not limited to: anxiety disorder, arthritis, depression, diabetes, high blood pressure, and dementia. The most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 5/28/18, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. The resident was coded as requiring extensive assistance of one or more staff members for most of her activities of daily living except eating in which she was independent after set up assistance was provided. In Section O - Special Treatments, Procedures, and Programs, the resident was coded as having used oxygen within the last 14 days of the look back period. Observation was made of Resident #6 on 8/22/18 at 8:06 a.m. The resident was in bed with her oxygen on via the nasal cannula (plastic tube with two prongs that insert into the nose), connected to an oxygen concentrator. The oxygen concentrator was set at 4L/min (liters/minute). A second observation was made of Resident #6 on 8/22/18 at 9:48 a.m. The resident was still in the bed with her oxygen on via the nasal cannula connected to an oxygen concentrator. The oxygen concentrator was set at 4L/min. On 8/22/18 at 9:50 a.m., the oxygen concentrator was observed with LPN (licensed practical nurse) #3. LPN #3 verified that the oxygen flow meter was set at 4L/min. LPN #3 stated he did not have any residents prescribed for 4 liters. He stated she probably is supposed to be on 2 liters. LPN #3 went to the clinical record and verified the resident was to be on 2L/min per the physician order. The physician order [REDACTED].@ (at) 2L/m (liters per minute) via nasal cannula at HS (hours of sleep - bedtime) per resident request. Remove O2 at 2L/min NC (nasal cannula) QAM (every morning). The (MONTH) (YEAR) Treatment Administration Record (TAR) documented the above physician order. The TAR documented the administration of the oxygen every evening for each evening in August. There was no documented nurse's notes for 8/22/18. The comprehensive care plan dated, 5/30/18, documented in part, Problem/Need: At risk for SOB (shortness of breath) due to DX (diagnosis) of [MEDICAL CONDITION] ([MEDICAL CONDITION] - general term for chronic, nonreversible lung disease that is usually a combination of [MEDICAL CONDITION] and chronic [MEDICAL CONDITION]) (1). The Approaches documented in part, O2 as ordered. The facility policy, Oxygen Administration documented in part, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration .Steps in Procedure: 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, LPN (licensed practical nurse) #1, the assistant director of nursing, and ASM #5, the administrator in training, were made aware of the above concern on 8/22/18 at 6:00 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a resident was free of unnecessary medications for one of 31 residents in the survey sample, Resident #11. Resident #11 received a higher dose of [MEDICATION NAME](a short acting insulin (1)) then what was prescribed by the physician for a blood sugar reading of 348 on 8/4/18 at 11:30 a.m. The findings include: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/20/18, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating she was moderately impaired to make cognitive daily decisions. The resident was coded as requiring no assistance to limited assistance for her activities of daily living. The physician order [REDACTED]. Below 130 = O (units) 131 - 180 = 4 u (units) 181 - 240 = 8 u 241 - 300 = 1- u 301 - 350 = 12 u 351 - 400 = 16 u > (greater than) 400 = 20 u & (and) call MD (medical doctor). The (MONTH) (YEAR) MAR (medication administration record) documented the above order. On 8/4/18 at 11:30 a.m., the nurse documented the blood sugar as 348. The documented amount of insulin administered was 16. The next recorded blood sugar on 8/4/18 at 4:30 p.m. documented the blood sugar as 74. The comprehensive care plan dated, 5/30/18, documented in part, Problem/Need: Diabetes Mellitus risk for high and lows of BS. Resident predicts her needs and intake based on how she thinks she is feeing vs (versus) actual number of glucose readings. The Approaches documented in part, Give medications per orders. BS per order. Notify MD of changes in BS or s/s (signs and symptoms) of hypo/[MEDICAL CONDITION] (too low or too high blood sugars). An interview was conducted with LPN (licensed practical nurse) #3, on 8/23/18 at 8:22 a.m. When asked if physician orders [REDACTED].#3 stated, Absolutely. An interview was conducted with LPN #6, the nurse that gave the insulin on 8/4/18 at 1:30 a.m., on 8/23/18 at 10:02 a.m. The above order for insulin was read to LPN #6. When asked what amount of insulin per the order, should the resident have received, for the blood sugar reading of 348, LPN #6 stated, 12 units. The MAR for (MONTH) of (YEAR) was reviewed with LPN #6 and her documentation of administering 16 units. LPN #6 stated, That was an error. When asked if that was following the physician's orders [REDACTED]. The blood sugar on 8/4/18 at 4:30 p.m. was shared with LPN #6. LPN #6 stated, I didn't realize I did that. That's a mistake and I am responsible. The facility policy, Administering Mediations, documented in part, Medications shall be administered in a safe and timely manner, and as prescribed .7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication .20. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered. b. The dosage. c. The route of administration. d. The injection site (if applicable) .g The signature and title of the person administering the drug. According to Fundamentals of Nursing, Seventh Edition, 2009: by Perry and Potter Chapter 35 Medication Administration Chapter 35, pg 707 reads: Professional standards, such as the American Nurses Association's Nursing: Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication, 2. The right dose, 3. The right client, 4. The right route, 5. The right time, and 6. The right documentation. Administrative staff member (ASM) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 8/23/18 at 9:50 a.m. (1) This information was obtained from the following website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cd88e313-6193-4413-beff-7d 0060d

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a resident was free of a significant medication error for one of 31 residents in the survey sample, Resident #11. The facility staff administered four more units of [MEDICATION NAME](a short acting insulin (1)) to Resident #11, than what the physician's orders [REDACTED]. The findings include: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/20/18, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating she was moderately impaired to make cognitive daily decisions. The resident was coded as requiring no assistance to limited assistance for her activities of daily living. The physician order [REDACTED]. Below 130 = O (units) 131 - 180 = 4 u (units) 181 - 240 = 8 u 241 - 300 = 1- u 301 - 350 = 12 u 351 - 400 = 16 u > (greater than) 400 = 20 u & (and) call MD (medical doctor). The (MONTH) (YEAR) MAR (medication administration record) documented the above order. On 8/4/18 at 11:30 a.m., the nurse documented the blood sugar as 348. The documented amount of insulin administered was 16. The next recorded blood sugar on 8/4/18 at 4:30 p.m. documented the blood sugar as 74. The comprehensive care plan dated, 5/30/18, documented in part, Problem/Need: Diabetes Mellitus risk for high and lows of BS. Resident predicts her needs and intake based on how she thinks she is feeing vs (versus) actual number of glucose readings. The Approaches documented in part, Give medications per orders. BS per order. Notify MD of changes in BS or s/s (signs and symptoms) of hypo/[MEDICAL CONDITION] (too low or too high blood sugars). An interview was conducted with LPN (licensed practical nurse) #3, on 8/23/18 at 8:22 a.m. When asked if physician orders [REDACTED].#3 stated, Absolutely. An interview was conducted with LPN #6, the nurse that gave the insulin on 8/4/18 at 1:30 a.m., on 8/23/18 at 10:02 a.m. The above order for insulin was read to LPN #6. When asked what amount of insulin per the order, should the resident have received, for the blood sugar reading of 348, LPN #6 stated, 12 units. The MAR for (MONTH) of (YEAR) was reviewed with LPN #6 and her documentation of administering 16 units. LPN #6 stated, That was an error. When asked if that was following the physician's orders [REDACTED]. The blood sugar on 8/4/18 at 4:30 p.m. was shared with LPN #6. LPN #6 stated, I didn't realize I did that. That's a mistake and I am responsible. The facility policy, Administering Mediations, documented in part, Medications shall be administered in a safe and timely manner, and as prescribed .7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication .20. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered. b. The dosage. c. The route of administration. d. The injection site (if applicable) .g The signature and title of the person administering the drug. According to Fundamentals of Nursing, Seventh Edition, 2009: by Perry and Potter Chapter 35 Medication Administration Chapter 35, pg 707 reads: Professional standards, such as the American Nurses Association's Nursing: Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication, 2. The right dose, 3. The right client, 4. The right route, 5. The right time, and 6. The right documentation. [MEDICATION NAME] . is a rapid-acting human insulin analog used to lower blood glucose.5.3 [DIAGNOSES REDACTED] is the most common adverse effect of all insulin therapies, including [MEDICATION NAME]. Severe [DIAGNOSES REDACTED] can cause [MEDICAL CONDITION], may lead to unconsciousness may be life threatening or cause death. 10 OVERDOSAGE: Excess insulin administration may cause [DIAGNOSES REDACTED] and [DIAGNOSES REDACTED]. Mild episodes of [DIAGNOSES REDACTED] usually can be treated with oral glucose. Adjustments in drug dosage, meal patterns, or exercise may be needed. More severe episodes with coma, [MEDICAL CONDITION], or neurologic impairment may be treated with intramuscular/subcutaneous [MEDICATION NAME] or concentrated intravenous glucose. Sustained carbohydrate intake and observation may be necessary because [DIAGNOSES REDACTED] may recur after apparent clinical recovery. [DIAGNOSES REDACTED] must be corrected appropriately. (2) Administrative staff member (ASM) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 8/23/18 at 9:50 a.m. (1) This information was obtained from the following website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cd88e313-6193-4413-beff-7d 0060d (2) This information was obtained from the webiste:https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3a1e73a2-3009-40d0-876c-b4cb2be56fc5

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of 31 residents in the survey sample, Resident #11. A. The facility staff failed to document the notification of the physician for an elevated blood sugar for Resident #11. B. The facility staff failed to document the actual blood sugar readings for Resident #11. The findings include: A. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/20/18, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating she was moderately impaired to make cognitive daily decisions. The resident was coded as requiring no assistance to limited assistance for her activities of daily living. The physician order [REDACTED]. Below 130 = O (units) 131 - 180 = 4 u (units) 181 - 240 = 8 u 241 - 300 = 1- u 301 - 350 = 12 u 351 - 400 = 16 u > (greater than) 400 = 20 u & (and) call MD (medical doctor). The (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. RN (registered nurse) #2 documented this. The comprehensive care plan dated, 5/30/18, documented in part, Problem/Need: Diabetes Mellitus risk for high and lows of BS. Resident predicts her needs and intake based on how she thinks she is feeing vs (versus) actual number of glucose readings. The Approaches documented in part, Give medications per orders. BS per order. Notify MD of changes in BS or s/s (signs and symptoms) of hypo/[MEDICAL CONDITION] (too low or too high blood sugars). An interview was conducted with RN #2 on 8/22/18 at 6:46 p.m. RN #2 was asked to review the above order for sliding scale insulin. She was asked to review the MAR for 6/26/18. When asked if she notified the doctor of the blood sugar, RN #2 stated, I know I did it. I wrote it in her (the doctor's) communication book. RN #2 further stated, I've been doing this for a long time. If it's not documented, I may have hit cancel or enter and it disappeared but I know I did it. RN #2 was asked to provide evidence that she documented the notification in the doctor's communication book. An interview was conducted with administrative staff member (ASM) #2, the director of nursing on 8/23/18 at 8:10 a.m. The blood sugar and nurse's notes were reviewed with ASM #2. When asked if they had found documentation of the notification in the doctor's communication book, ASM #2 stated they had not found it. ASM #2 further stated, If it's not documented it's not done. An interview was conducted with LPN (licensed practical nurse) #3 on 8/23/18 at 8:20 a.m. When asked if the physician ordered sliding scale should be followed as written, LPN #3 stated, Absolutely. when asked if the blood sugar is greater than 400 and you notify the doctor, where is the notification documented, LPN #3 stated, In the nurse's notes. On 8/23/18 at 8:56 a.m. presented a document of blood sugars for Resident #11 that was printed on 6/27/18 at 6:32 a.m. The attending physician signed the paper. LPN #1 stated, We print these out on the 11-7 (11:00 p.m. to 7:00 a.m.) shift for the doctors and nurse practitioners for the days they are coming to the facility. When asked if this document is part of the clinical record, LPN #1 stated, No, Ma'am. The facility policy, Charting and Documentation documented in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .2. The following information is to be documented in the resident medical record: a. Objective observations. b. Medications administered. c. Treatments or services performed. d. Changes in the resident's condition. e. Events, incidents or accidents involving the resident. f. Progress toward or changes in the care plan goals and objectives. The following quotation is found in Lippincott's Fundamentals of Nursing 5th edition (2007, page 237): The client record serves as a legal document of the client's health status and care received .Because nurses and other healthcare team members cannot remember specific assessments or interventions involving a client years after the fact, accurate and complete documentation at the time of care is essential. The care may have been excellent, but the documentation must prove it. Administrative staff member (ASM) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 8/23/18 at 9:50 a.m. (1) This information was obtained from the following website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cd88e313-6193-4413-beff-7d 0060d B. The facility staff failed to document the actual blood sugar readings for Resident #11. The (MONTH) (YEAR) MAR indicated [REDACTED]. On 7/7/18, 7/8/18 and 7/22/18 at 4:30 p.m. there was no documented blood sugar reading. RN # 1 completed all three dates. The (MONTH) (YEAR) MAR indicated [REDACTED]< (less than) 130. Review of the Vital Signs section of the electronic record failed to evidence documentation of the blood sugar readings on the above dates and times. Review of the nurse's notes for the above dates failed to evidence documentation of the blood sugar readings. An interview was conducted with RN #1 on 8/22/18 at 6:25 p.m. The above MAR indicated [REDACTED]. When asked if the actual number for the blood sugar reading should be included in the MAR, RN #1 stated, I don't know why it isn't there. An interview was conducted with administrative staff member (ASM) #2, the director of nursing on 8/23/18 at 8:10 a.m. The blood sugar and nurse's notes were reviewed with ASM #2. When asked if they had found documentation of the physician notification in the doctor's communication book, ASM #2 stated they had not found it. ASM #2 further stated, If it's not documented it's not done. An interview was conducted with LPN #3 on 8/23/18 at 8:20 a.m. When asked where the blood sugar readings are documented, LPN #3 stated, A box comes up and you put it there. It then populates to the blood sugar section in the vital signs. When asked if a nurse should document the blood sugar as less than 130, LPN #3 stated, It's probably not in the best interest to do that. The facility policy, Obtaining a Finger stick Glucose Level documented in part, Documentation .The person performing this procedure should record the following information in the resident's medical record: 6. The blood sugar results. Administrative staff member (ASM) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 8/23/18 at 9:50 a.m.

Based on staff interview and clinical record review, it was determined that the facility staff failed to provide written notification to the RR (resident representative) for a facility-initiated transfer for one of 31 residents in the survey sample, Resident #96. Resident #96 transferred to the hospital on [DATE]. The facility staff failed to provide written notification of the facility-initiated transfer to the resident's representative. The findings include: Resident #96 was admitted to the facility on [DATE]. Resident #96's [DIAGNOSES REDACTED]. Resident #96's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/6/18, coded the resident as being cognitively intact. Review of Resident #96's clinical record revealed the resident was transferred to the hospital on [DATE] due to a fever and abnormal vital signs. Further review of Resident #96's clinical record failed to reveal written notification of the transfer was provided to the resident's representative. On 8/22/18 at 1:38 p.m., an interview was conducted with LPN (licensed practical nurse) #5 (one of the nurses who assisted with Resident #96's hospital transfer). LPN #5 stated she calls a resident's representative when a resident is transferred to the hospital. When asked if she provides written notice to the representative, LPN #5 stated, Typically they don't come in to us; they go to the hospital. If they come in to get their belongings. When again asked if she provides written notice, LPN #5 stated, I don't do that. On 8/22/18 at 2:29 p.m., LPN #5 presented other requested documentation regarding Resident #96's hospital transfer and a blank consent for inter-facility or intra-facility transfer form. The consent for inter-facility or intra-facility transfer form documented, Resident: _______. Date: _______. Time: ______. I have been fully informed of my rights regarding transfers. I understand that I am being transferred from (name of facility) to (blank space to be filled out). I understand the reason for transfer to be (blank space to be filled out) . The form designated a signature line for the resident and/or RR. On 8/22/18 at 4:56 p.m., another interview was conducted with LPN #5. LPN #5 stated she called but could not reach Resident #96's representative when the resident was transferred to the hospital on [DATE]. LPN #5 stated that later that day, the representative came to the facility to see the resident so she informed the representative that Resident #96 had been transferred to the hospital. LPN #5 stated Resident #96's representative went to the hospital to see the resident and then came back to the facility and gave staff an update on the resident's condition. When asked if she ever attempted to give Resident #96's representative the consent for the inter-facility or intra-facility form, LPN #5 stated she did not. When asked if she filled out the form and sent the form with Resident #96 to the hospital, LPN #5 stated she did not. On 8/22/18 at 6:15 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 (the regional nurse consultant) were made aware of the above findings. The facility document titled, Discharging the Resident failed to document information regarding the above concern. No further information was presented prior to exit.