Every finding on record at Highland Care Center

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food items in the refrigerator and freezer were undated and opened to air. Findings included:On 7/22/26 at 10:31 AM, a follow-up tour of the kitchen was conducted. The following was observed:a. The walk-in refrigerator had two packages of strawberries that were opened and undated. b. The walk-in refrigerator had an opened plastic package of shredded cheese that was opened and undated.c. The walk-in refrigerator had an opened plastic package of hotdogs that was undated.d. The dessert freezer had a package of donut holes that was opened and undated.e. The dessert freezer had a package of cinnamon rolls that was opened and undated.f. The reach-in freezer had an opened box with an opened plastic sack of broccoli that was open to air and undated.g. The reach-in freezer had an opened box of dinner rolls that was open and undated.On 7/22/26 at 10:53 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that all items in the refrigerators and freezers should be dated with the date they were placed in the refrigerator or freezer and then again when they were opened. The DM stated that he had some kitchen staff that would forget to date items once they were opened.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 out of 41 sampled residents, a resident with an indwelling Foley catheter did not have Enhanced Barrier Precautions (EBP) in place and staff did not wear personal protective equipment (PPE) during high contact activities. Resident identifier: 2.Findings included:Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acquired absence of right leg below knee.On 7/20/26 at 3:17 PM, an observation was conducted of resident 2. Resident 2 was observed with a Foley catheter and there was no EBP signage posted outside of resident 2's door. There was no PPE observed to be available for use.On 7/7/26, an active physician's order documented Urinary Catheter: 16 F [French] 30cc [cubic centimeters].On 7/22/26 at 7:46 AM, an observation was conducted of Registered Nurse (RN) 2 assisting resident 2 with a transfer from his bed to wheelchair. Prior to assisting resident 2 with the transfer RN 2 was observed to assist resident 2 with putting on his shorts. RN 2 did not don PPE prior to assisting resident 2. On 7/22/26 at 12:03 PM, an interview was conducted with RN 2. RN 2 stated that resident 2 was on EBP for the urinary catheter. RN 2 stated that EBP was used for any type of indwelling device like a supra pubic catheter, intravenous line (IV), and a Jackson Pratt (JP) drain. RN 2 stated that EBP would be for any wound that needed to be covered. RN 2 stated that other precautions would go into effect if the resident had something other than a multidrug-resistant organism (MDRO). RN 2 stated the Minimum Data Set nurse or the Admissions nurse would put EBP into effect for the residents. RN 2 stated PPE would be used for anything that would require contact to the area and she would wear a gown and gloves. RN 2 stated that EBP would be an extra barrier for contact. On 7/22/26 at 12:17 PM, resident 2 was observed to not have EBP signage outside his door or PPE available for use. On 7/22/26 at 1:30 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she also worked as the Infection Preventionist. The ADON stated staff would implement EBP when a resident had a peripherally inserted central catheter (PICC) or a new wound. The ADON stated the resident would have a physician's order for EBP, the EBP would be care planned, the proper signage would be placed on the resident's door, and PPE would be placed on the resident's door. The ADON stated she would audit the residents on EBP to ensure the EBP needed to continue. The ADON stated that EBP would be implemented for residents with a Foley catheter, picc line, wounds, JP drains, or anything like a port or any device that was exiting or entering the body. The ADON stated that resident 2's wound had dehisced and he was on EBP but the wound had resolved. The ADON stated that she was not aware that resident 2 had a Foley catheter. The ADON stated that EBP was for high contact activities or whenever staff were touching the resident.The facility policy Enhanced Barrier Precautions was reviewed. Policy:It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Policy Explanation and Compliance Guidelines:1. Prompt recognition of need: .c. The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities.2. Initiation of Enhanced Barrier Precautions: .b. An order for enhanced barrier precautions will be obtained for residents with any of the following:i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgicalwounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., centrallines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters,PICC lines, midline catheters) even if the resident is not known to be infected or colonizedwith a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomieswithout an associated indwelling medical device are not an indication for EBP.) .3. Implementation of Enhanced Barrier Precautions:a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., woundirrigation, tracheostomy care).b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room.e. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education.4. High-contact resident care activities include:a. Dressingb. Bathingc. Transferringd. Providing hygienee. Changing linensf. Changing briefs or assisting with toiletingG. Deice care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline cathetersh. Wound care: any skin opening requiring a dressing .

Based on interview and record review, the facility failed to ensure that laboratory reports were accurately maintained and readily available within the medical record. Specifically, for 2 out of 41 sampled residents, residents did not have their laboratory results located in their medical record. Resident identifiers: 9 and 11.Findings included:1. Resident 9 was admitted to the facility on [DATE] with diagnoses which included other specified disorders of brain and white matter disease.On 6/2/26 at 11:42 AM, an Event Initial Note revealed . new medication Macrobid 100mg [milligrams] po [by mouth] bid [twice a day] x [for] 7 days for UTI [urinary tract infection] while waiting for urine culture results. therapy reported to this nurse that resident 'seemed off' This nurse reported to House MD [Medical Doctor] and straight cathed for sample. Urine was brown, consistency of sludge, dip tested positive for leukocytes and protien [sic]On 6/5/26 at 10:11 AM, a Nurses Note revealed MD reviewed culture UA [urinalysis] result.On 6/5/26 at 10:13 AM, an Event Initial Note revealed .Pt c/o [complaint of] dysuria, urgency, frequency. UA collected & inhouse dipped for (+) [positive] UTI. MD ordered Macrobid pending UA culture. Culture received w/ [with] (+) UA result, MD reviewed. Order to DC [discontinue] Macrobid, start Augmentin.The laboratory test dated 6/2/26, for the UA with culture and sensitivity were not located in resident 9's medical record.2. Resident 11 was admitted to the facility on [DATE] with diagnoses which included other intervertebral disc degeneration, lumbar region with mention of lumbar back pain or lower extremity pain.A physician's order dated 5/20/26, revealed CMP [Comprehensive Metabolic Panel],CBC [Complete Blood Count] lipid panel A1c [Glycated Hemoglobin] every 6 months r/t [related to] medications two times a day every 6 month(s) starting on the 20th for 1 day(s) NOC [night] shift ensure order is in [name redacted] PORTALThe laboratory tests dated 5/20/26, were not present in resident 11's medical record.A physician's order dated 7/10/26, revealed CBC, CMP, TSH [Thyroid Stimulating Hormone], Free T4 [thyroxine], A1c, Lipid panel, Mag [magnesium],Prealbumin one time only for 1 Day.The laboratory tests dated 7/10/26, were not located in resident 11's medical record.On 7/22/26 at 12:58 PM, an interview was conducted with the Assistant Director of Nursing (ADON).The ADON stated that the facility's new system automatically uploaded lab results directly to a resident's electronic medical record, a task that was previously handled by the medical records department. The ADON stated that she was unsure why the results for resident 9 and resident 11 were not in their medical record. The ADON stated that she located the lab results from the external lab company and they were not readily available in resident 9 and resident 11's medical record.

Based on record review and interview, the facility failed to ensure a physician's order was obtained prior to executing a diagnostic test for laboratory services. Specifically, 1 out of 41 residents sampled it was found that a Urinalysis (UA) with Culture and Sensitivity (C&S) was conducted without an active physician's order. Resident Identifier: 9.Findings included:Resident 9 was admitted to the facility on [DATE] with diagnoses which included other specified disorders of brain and white matter disease.A review of Resident 3's medical record was conducted on 7/20/26 through 7/22/26.On 6/2/26 at 11:42 AM, an Event Initial Note revealed . new medication Macrobid 100mg [milligrams] po [by mouth] bid [twice a day] x [for] 7 days for UTI [urinary tract infection] while waiting for urine culture results. therapy reported to this nurse that resident seemed off This nurse reported to House MD [Medical Doctor] and straight cathed for sample. Urine was brown, consistency of sludge, dip tested positive for leukocytes and protien [sic]On 6/5/26 at 10:11 AM, a Nurses Note revealed MD reviewed culture UA [urinalysis] result.On 6/5/26 at 10:13 AM, an Event Initial Note revealed .Pt c/o [complaint of] dysuria, urgency, frequency. UA collected & inhouse dipped for (+) [positive] UTI. MD ordered Macrobid pending UA culture. Culture received w/ [with] (+) UA result, MD reviewed. Order to DC [discontinue] Macrobid, start Augmentin.A physician's order for the UA with C&S was unable to be located in resident 9's medical record.On 7/22/26 at 12:50 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the physician would write down an order and hand it to the nurse. RN 1 stated it is the nurse's responsibility to enter the order into the resident's medical record and enter a progress note. RN 1 stated an active order was required to execute any order. On 7/22/26 at 12:58 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that floor nurses were responsible for entering written physician orders into the system. The ADON stated that the night-shift nurse then verified that these orders were correctly processed and ready for the following day's lab draws. The ADON stated that to ensure compliance, she followed up to confirm that the labs were completed and that the corresponding orders were in place. The ADON stated that an active order was strictly required before staff could obtain any UA with a C&S sample.

Based on interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 of 41 sampled residents, the facility failed to provide consecutive scheduled doses of a resident's phosphate binder. Resident identifier: 10.Findings included: Resident 10 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, hyperkalemia, and anemia.A physician's order for Dialysis scheduled for [facility name redacted] on T [Tuesday], TH [Thursday], ST [Saturday] . was started on 6/25/26.A physician's order for Sevelamer Carbonate Oral Packet 0.8 GM [grams] (Sevelamer Carbonate) Give 2 packet by mouth three times a day for Gut health Administer with meals. was started on 6/25/26. The July 2026 Medication Administration Record (MAR) was reviewed. Code 19, which indicated See Progress Note, was documented for seven consecutive scheduled Sevelamer Carbonate administrations between 7/18/26 and 7/20/26.Progress Notes documented that Sevelamer Carbonate Oral Packet 0.8 GM was on order on the follow dates and times: a. 7/18/26 at 4:20 PMb. 7/19/26 at 7:38 AMc. 7/19/26 at 11:08 AMd. 7/19/26 at 4:26 PMe. 7/20/26 at 8:12 AMf. 7/20/26 at 11:46 AMg. 7/20/26 at 5:10 PMOn 7/21/26 at 2:54 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2, who stated that the pharmacy delivered three times a day. LPN 2 stated that if a medication was ordered in the morning it would typically be delivered that day. LPN 2 stated that medications could be reordered through the facility's electronic medical record system, fax, or phone call. LPN 2 stated that medications should be reordered seven days in advance if insurance would allow. LPN 2 stated that the reorder date was documented on the medications blister pack and the electronic medical record system. It should be noted that resident 10's Sevelamer Carbonate was documented as unavailable for three consecutive days. On 7/21/26 at 3:03 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 10's Sevelamer Carbonate was out of stock. RN 3 stated that he contacted the pharmacy that morning when he realized the Sevelamer Carbonate was unavailable, and expected delivery later that day. RN 3 stated that he was unsure why the Sevelamer Carbonate was out of stock and that it should have been already delivered if it was reordered on 7/18/26. RN 3 stated he was unsure if the provider had been notified that resident 10 had missed the Sevelamer Carbonate administrations. RN 3 stated that resident 10, who was a dialysis resident, could experience an upset stomach as a possible complication of missing consecutive doses of her phosphate binder. RN 3 stated that resident 10 had not complained of an upset stomach. It should be noted that RN 3 stated that Sevelamer Carbonate was unavailable on 7/21/26, but resident 10's MAR documented that the scheduled dose of Sevelamer Carbonate on 7/21/26 at 8:00 AM, was administered. On 7/21/26 at 12:00 PM, the dose was not administered due to code 2, which indicated resident 10 was Out of Facility.On 7/21/26 at 3:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the nurses could reorder medications through the facility's electronic medical record system, fax, or phone call. The DON stated that nurses should reorder medications when there were seven doses remaining. The DON stated that the pharmacy delivered three to four times a day, and that if a medication was reordered on 7/18/26, it should have already been delivered. The DON stated she did not know off the top of her head what potential complications resident 10, who was a dialysis resident, could experience due to missing consecutive doses of her phosphate binder.On 7/21/26 at 4:14 PM, an interview was conducted with the Registered Dietitian (RD). The RD stated that a phosphate binder prevented phosphate in the food eaten by a resident from being absorbed. The RD stated that if a resident receiving dialysis, like resident 10, missed several consecutive doses of a phosphate binder they could experience high phosphate levels, which could lower calcium levels. The RD stated that potential symptoms included muscle cramps, tingling pain, and heart issues. The RD stated that she was unaware of any missed Sevelamer Carbonate administrations for resident 10.

Based on observation, interview, and record review, the facility failed to ensure the interdisciplinary team (IDT) determined clinical appropriateness before residents exercised the right to self-administer medications. Specifically, for 1 of 41 sampled residents, the IDT did not evaluate if it was clinically appropriate before a resident stored and self-administered medications in his room. Resident identifier: 69.Findings included:Resident 69 was admitted to the facility on [DATE] with diagnoses which included cellulitis of left lower limb and sepsis.On 7/20/26 at 10:44 AM, an observation was made in resident 69's room of two bottles of Oxymetazoline 0.05% nasal spray. One bottle was observed on resident 69's bedside table and one bottle was observed in his open nightstand drawer. An interview was conducted with resident 69. Resident 69 stated that he was given the medication at the hospital. Resident 69 stated that he administered the medication once in the morning and once in the evening to improve his nasal congestion. It should be noted that no evaluations, progress notes, or physician orders relating to self-administering medications were located in resident 69's medical record. Additionally, it should be noted that no physician orders for Oxymetazoline 0.05% nasal spray were located in resident 69's medical record. On 7/21/26 at 12:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1, who stated that she was not aware that any residents in the facility could store medications at bedside or self-administer medications. LPN 1 stated that she would have to ask what the facility's protocol was for residents to be able to self-administer medications in the facility. LPN 1 stated that she was unaware that resident 69 had Oxymetazoline 0.05% nasal spray in his room. LPN 1 stated that she believed resident 69 was able to safely self-administer the nasal spray, but she would remove the medication from his room until there were physician orders placed for him to self-administer the medication. After reviewing resident 69's medical record, LPN 1 stated that there were no physician orders for Oxymetazoline 0.05%, and that she would contact the physician. On 7/21/26 at 12:54 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that residents did not typically self-administer medications, although there was a process where residents could self-administer medications if it was requested. The DON stated that before a resident could self-administer medications a Self-administration of Medication Evaluation was completed. The DON stated that the Self-administration of Medication Evaluation documented: the residents cognition; if the resident was capable of storing, opening and closing the medications containers; if the resident could accurately tell time and determine when the medication needed to be self-administered; if they were physically capable of self-administering the medication, and if the resident had knowledge of what the medication was used for. The DON stated that if the resident was approved to self-administer the medication it would be careplanned and ordered by the physician. The DON stated that the Oxymetazoline 0.05% nasal spray would be kept in the medication cart until the required evaluation, careplaining, and orders had been completed. The facility provided an undated policy titled Resident Self-Administration of Medication, which stated It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible, and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 41 sampled residents, two residents eloped from the facility that required supervision. Resident identifiers: 55 and 68.Findings included: 1. Resident 55 was admitted to the facility on [DATE] with diagnoses which included, Parkinson's Disease with dyskinesia, unsteadiness on feet, other abnormalities of gait and mobility, cognitive communication deficit, and cognitive communication deficit. The facility reported to the State Survey Agency on 5/7/26 at 5:30 AM, that resident 55 was unable to be located in the facility. Facility staff initiated a search of the facility and a Certified Nursing Assistant (CNA) reported seeing resident 55 running down the north hallway toward the stairwell area. Around 6:10 AM, a CNA coming to work identified resident 55 walking down a high-traffic street and transported resident 55 back to the facility. A wandering assessment completed on 4/16/26, documented that resident 55 scored a 13 which indicated a high risk for wandering. An admission Minimum Data Set assessment dated [DATE], revealed that resident 55 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderate cognitive impairment. Resident 55's progress notes revealed the following: a. On 4/16/26 at 2:18 AM, a 72 hour admission charting note documented, .Has had some episodes of wandering and elopement attempts, has a new wanderguard d/t [due to] this. Resident confused. b. On 4/24/26 at 7:03 PM, a nurses note documented, .resid [resident] noted this afternoon X [times] 1 to get out of the facility and found by therapist walking in the front parking lot-redirected backinto [sic] facility and cont [continue] frequent checks. c. On 4/25/26 at 8:18 PM, a nurses note documented, .resid has been more calm this shift, walking up/down mostly north hall, occas [occasionally] to south, sometimes going to front door, looking out, sitting at north lobby, will occcas stand in the doorways of other resid's room. d. On 5/7/26 at 3:05 PM, an administrator note documented, Spoke with [resident 55] today regarding his elopement incident. [Resident 55] stated that he had been walking around and 'doing circles.' I asked him to demonstrate how he exited the facility. We proceeded down the north hall, where he identified a door near the therapy department that had been left slightly ajar. The Administrator immediately ensured the door was properly closed and securely latched. Resident denied any injuries or concerns at this time. During the conversation, he expressed that he misses his son at home. Following the discussion, the resident continued pacing the facility halls. On 7/22/26 at 11:54 AM, an interview was conducted with the Administrator (Admin). The Admin stated that resident 55 was admitted to the facility with Parkinson's Disease and his cognition fluctuated. The Admin stated that resident 55 was exit-seeking and he would try to get outside. The Admin stated that he tried to educate resident 55 about not going outside. The Admin stated that resident 55 was able to leave the facility through a door that did not latch properly and would not have alarmed with the wander guard. The Admin stated that a CNA found resident 55 outside the facility and brought him back.The Admin stated that after resident 55 eloped, he had maintenance recalibrate the door and fix the latch. On 7/22/26 at 12:16 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 55's behavior was very erratic and his cognition fluctuated. The DON stated that there were days that resident 55 would run down the hallways. The DON stated that resident 55 was a wanderer and an elopement risk. The DON stated that resident 55 would often try and go outside and would walk up and down the facility hallways. The DON stated that resident 55 had a wander guard placed because of his high wandering score. 2. Resident 68 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, dementia, Alzheimer's Disease, and cognitive communication deficit. On 7/20/26 at 1:03 PM, an interview was conducted with resident 68's family member. The family member stated that resident 68 had dementia. The family member stated that resident 68 had a wander guard and the facility had removed the wander guard. The family member stated that while she was sleeping resident 68 had gone upstairs and somehow got out the front door. The family member stated they were unsure how long resident 68 had been outside but resident 68 had walked around the outside of the facility to the bottom door and staff saw resident 68 outside. The family member stated after that incident the staff put the wander guard back on resident 68. A care plan focus initiated on 2/13/26, documented that resident 68 was at risk for wandering and or elopement, may go out with supervisor/family. Wander guard in use. The interventions initiated on 2/13/26, included assisting in reorientation to room, facility, and activity areas with verbal cues. Encourage group activities and attempt to keep occupied. Encourage resident 68 to stay in common areas of the building for observation if needed. When wandering, redirect resident 68 to another activity. An intervention initiated on 5/4/26, included a wander guard monitoring device to notify staff and remind resident 68 not to exit the facility without escort, will assess per facility protocol. On 5/4/26, a physician's order documented Monitor wander guard placement and function. Check skin is free from breakdown r/t [related to] placement. two times a day. On 5/13/26 at 2:22 PM a BIMS Evaluation documented that resident 68 had a BIMS score of 99. A BIMS score of 99 indicated that the resident was unable to complete the interview. On 5/14/26 at 4:52 PM, an Elopement Evaluation documented that resident 68 had a history of elopement while at home. Resident 68 wanders and the wandering behavior was a pattern or goal-directed. Resident 68 had an elopement Score of 5.0. [It should be noted that an elopement risk score of 5 generally indicates that a resident meets the threshold for being at risk for wandering or leaving a facility unsupervised.] On 6/15/26 at 1:23 AM, a Nurses Note documented Resident had an incident last evening 6/14/26 around 7:15pm where wife's brother and some other visitors were seeing [resident 68] and his wife and when they left, [resident 68's] wife [name redacted] found staff and stated that her husband had followed the visitors and that she could not locate him. Staff looked for [resident 68] and he was ultimately located by staff outside the building and brought back inside without incident.[Name redacted] and the nurse on duty called the visitors at 7:23pm and gave education to them, visitors stated that they had not let [resident 68] out but that they had seen him following someone who was delivering food to the building but agreed that next time they visited they would make sure that [resident 68] was safe inside of his room when they left. Administrator [name redacted] of incident at 7:20pm via telephone. The June 2026 Medication Administration Record [MAR] was reviewed. The MAR documented that resident 68 had a wander guard in place and staff were checking placement and function every shift. On 7/22/26 at 12:08 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated if a resident had a wander guard the door would alarm when the resident would get too close and the door would alarm until the resident moved. RN 2 stated that she was not sure it was functioning because she had tested another resident's wander guard that day and the door only alarmed for a minute. RN 2 stated the wander guard alarm system was the same throughout the facility at all of the exit doors. On 7/22/26 at 12:32 PM, an interview was conducted with the Admin. The Admin stated that residents were reviewed on admission for elopement risk. The Admin stated the staff also did a community assessment to ensure the residents were safe to go out in the community. The Admin stated if a resident with a wander guard got close to the door the alarm would alert the staff and the staff would have to enter a code to turn the alarm off. The Admin stated there was a time when resident 68 left the facility with friends and family. The Admin stated it was reported to him that resident 68 had followed family out of the facility and that same family had seen resident 68 and brought him back into the facility. The Admin stated that resident 68 should have had a wander guard on but resident 68 had a wander guard on now. The Admin stated if a door was open the door would alarm but resident 68 would still be able to get out. The Admin stated that resident 68 could also get out if the door did not fully latch. The Admin stated if a door was open or not latched the alarm should still alert staff that someone was outside and the staff would need to enter the code to turn off the alarm. The facility policy Elopements and Wandering Residents was reviewed. Policy: This facility ensured that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents as Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff.

Based on interview and record review, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner, or clinical nurse specialist. Specifically, for 1 out of 58 sampled residents, a resident had a basic metabolic panel (BMP) collected on two occasions without a physician's order. Resident identifier: 12. Findings included: Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affection right dominant side, type 2 diabetes mellitus, dementia, altered mental status, atrial fibrillation, cognitive communication deficit, protein-calorie malnutrition, dysphagia, major depressive disorder, anxiety disorder, and essential hypertension. Resident 12's medical record was reviewed on 6/10/24. A physician's order with a start date of 5/15/24, documented BMP to be drawn three times weekly on Monday Wednesday and Friday, Noc [night] shift to print order and put it in the lab book. one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday]. The physician's order was discontinued on 6/2/24. On 6/3/24, a Lab Results Report documented that a BMP was collected and completed. No documentation could be located or provided to indicate a physician's order was written for the lab collected on 6/3/24. On 6/4/24 at 1:00 AM, an encounter documented by the Medical Director (MD) documented . Chief Complaint / Nature of Presenting Problem: Lab results review Hypernatremia Hypokalemia Hyperchloremia History Of Present Illness: . We will recheck pt [patient] BMP again in 2 days. Follow-up Plan: . We will recheck pt BMP again in 2 days. On 6/4/24 at 5:30 PM, a Nurses Note documented Note Text: New orders to increase tube feed freewater by 20mL/hr [milliliters per hour] to treat hypernatremia, recheck BMP in 3 days on 6/7/24, and to increase AM Lantus dose to 13 units r/t [related to] high blood sugars. Orders placed in PCC [electronic medical record system], copy of order placed in lab book, and amount of water flush changed on feeding machine. On 6/4/24 at 8:15 PM, an Alert Charting Note documented Reason for alert charting : med [medication] changes Interventions: AM Lantus increased to 13U [units]; increase water flush with his enteral feeding to 80ml/hr r/t DX [diagnosis] of hypernatremia; BMP to be drawn in 3 days (6/7/24) . On 6/5/24, a Lab Results Report documented that a BMP was collected and completed. No documentation could be located or provided to indicate a physician's order was written for the lab collected on 6/5/24. A physician's order with a start date of 6/7/24, documented Check BMP on 6/7/24 one time only for 1 Day. A physician's order with a start date of 6/10/24, documented BMP to be drawn weekly on mondays. one time a day every Mon for labs. The physician's order was created on 6/3/24. On 6/10/24 at 3:09 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that when she got a lab order she would put it into the computer, print the face sheet and lab order, and put the face sheet and lab order in the lab book on the date to be drawn. RN 1 stated if the lab was not an urgent lab the lab came every Monday, Wednesday, and Friday. RN 1 stated that urgent labs were drawn in house and the lab would come pick them up. RN 1 stated there was a lab tracking sheet in the front of the lab book and the nurse communication book. RN 1 stated that she would update the resident's family with everything. RN 1 stated that she would inform the resident's family before the lab was drawn, why the lab was being drawn, and the results of the lab. On 6/10/24 at 3:15 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that first thing in the morning should would check the labs. The ADON stated the outside lab company had an on-line service that she was able to review. The ADON stated that when the lab was ordered she would write it down and make sure it got done. The ADON stated if the lab was an ongoing lab she would track the lab. The ADON stated she would pull and print the lab orders for the lab book. The ADON stated she would check the results screen, any unmatched labs were matched to the residents, and she would make sure the MD signed the labs. The ADON stated that urgent labs were draw by the staff and the labs would be sent with the courier. The ADON stated that the courier was usually at the facility within an hour. The ADON stated that results with urgent labs were fairly quickly, same day, and the lab would fax the results to the facility. The ADON stated that sometimes the MD would give verbal orders and those were hard to track.

Based on interview and record review, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions (GDR) unless clinically contraindicated, in an effort to discontinue these drugs. A GDR must be attempted in two separate quarters, with at least one month between attempts, within the first year in which an individual was admitted on a psychotropic medication or after the facility had initiated such medication, and then annually. Specifically, for 1 out of 58 sampled residents, a resident taking an antidepressant medication for insomnia had not received a GDR on that medication since 2022, and the medication was not clinically contraindicated. Resident identifier: 23. Findings included: Resident 23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, cerebral infarction due to embolism, nontraumatic subarachnoid hemorrhage, spastic hemiplegia affecting left nondominant side, pseudobulbar affect, dysphagia, aphasia, major depressive disorder, insomnia, hypotension, and cognitive communication deficit. Resident 23's medical record was reviewed on 6/6/24. On 5/20/22, a physician's order documented traZODone HCl [hydrochloride] Tablet Give 50 mg [milligrams] by mouth at bedtime for insomia [sic]. The physician's order was discontinued on 7/13/22. On 7/14/22, a physician's order documented traZODone HCl Tablet 50 MG Give 1 tablet by mouth at bedtime related to INSOMNIA, UNSPECIFIED. A physician documented clinical contraindication was unable to be located. On 3/28/24, a Nurses Note documented Note Text : IDT [Interdisciplinary Team] psychotropic review. Reviewing abilify, bupropion and trazodone. Tracking in place. Consent in place. Defer to [behavioral health name redacted.] [Note: The progress notes were reviewed from June 2023 to current. This Nurses Note was the only psychotropic review note able to be located.] On 6/11/24 at 10:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the psychotropic meetings were held monthly and a note was made. The DON stated that the Pharmacist consultant attended the psychotropic meetings. The DON stated she would do a piece of the alphabet and new admissions so residents did not get missed. The DON stated she would look at the residents who were in the window for a GDR, look at the alert charting to see if the resident had failed a GDR, and looked at where the residents were at with their medications. The DON stated they had tracking in place for behaviors, we make sure the medications had the right diagnosis, and look at the resident's Preadmission Screening and Resident Review level 2. The DON stated that not having a GDR of the trazodone probably had something to do with resident 23's spouse.

Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 58 sampled residents, a resident's antihypertensive medication was not held when the diastolic blood pressure (DBP) was below the physician's ordered parameters. Resident identifier: 8. Findings included: Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, Parkinson's disease without dyskinesia without mention of fluctuations, major depressive disorder, generalized anxiety disorder, dementia, chronic pain, and essential hypertension. Resident 8's medical record was reviewed on 6/6/24. On 4/28/23, a physician's order documented dilTIAZem HCl [hydrochloride] ER [extended release] Oral Tablet Extended Release 24 Hour (Diltiazem HCl) Give 240 mg [milligrams] by mouth one time a day for Hold for SPB [sic] [systolic blood pressure] < [less than] 120, DBP < 80, or P [pulse] < 60 related to ESSENTIAL (PRIMARY) HYPERTENSION. A review of the May and June 2024 Medication Administration Record documented when the DBP was less than 80 and the diltiazem was administered to resident 8 when it should have been held according to the physician's order. a. On 5/2/24, 162/77 b. On 5/10/24, 151/78 c. On 5/14/24, 130/77 d. On 5/15/24, 135/79 e. On 5/16/24, 134/66 f. On 5/20/24, 128/74 g. On 5/23/24, 134/76 h. On 5/25/24, 131/77 i. On 5/27/24, 153/76 j. On 5/28/24, 160/64 k. On 5/31/24,142/78 l. On 6/1/24, 136/76 m. On 6/3/24, 130/76 n. On 6/4/24, 132/76 o. On 6/5/24, 130/77 p. On 6/6/24, 116/74 On 6/10/24 at 10:50 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 reviewed the diltiazem physician's order and stated that she was unsure how the physician's order was wrote and she would need to get clarification. On 6/10/24 at 12:28 PM, an interview was conducted with RN 2. RN 2 reviewed the diltiazem physician's order and stated that yes if any of the parameters were below what was specified then the medication should be held. RN 2 stated that the floor nurses would input the physician's orders or sometimes the Director of Nursing (DON) or the Assistant Director of Nursing would help. On 6/10/24 at 12:39 PM, an interview was conducted with the DON. The DON reviewed the diltiazem physician's order and stated that yes it should be held when any of those parameters were outside of what the physician had ordered. The DON stated it was usually to hold with the systolic blood pressure was below the physician's ordered parameters. The DON stated that she would check with the doctor. On 6/10/24 at 12:53 PM, a follow up interview was conducted with the DON. The DON stated the doctor had changed the physician's order because resident 8 usually ran in the 70's anyway's. The DON stated that the doctor changed the physician's order to hold if the DBP was below 90.

Based on interview and record review, the facility did not electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) system within 14 days of completing a resident's assessment. Specifically, for 1 out of 58 sampled residents, the facility did not transmit a resident's completed discharge MDS assessment to CMS. Resident identifier: 57. Findings included: Resident 57 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses of polyosteoarthritis, pain in left hip, carpal tunnel syndrome bilateral upper limbs, cerebral infarction due to embolism of left middle cerebral artery, essential hypertension, noninfective gastroenteritis and colitis, major depressive disorder, insomnia, ischemic optic neuropathy right eye, and ischemic optic neuropathy left eye. Resident 57's medical record was reviewed from 6/3/24 through 6/11/24. A discharge MDS assessment was completed on 1/31/24. Question A0140 of the assessment had the response, Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State, The assessment submission information stated, Do not submit to CMS. On 6/5/24 at 2:11 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the discharge MDS assessment for resident 57 had been completed, but it had not been transmitted to CMS because she had marked that the facility did not have Medicare or Medicaid certified beds on question A0410 of the assessment.

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, several surfaces that came into contact with food or food preparation utensils were found to be dirty, staff were observed to not practice hand hygiene, food was exposed to open air, and there were several instances of potential physical food contaminants. Findings included: On 6/5/24, an inspection of the facility kitchen was conducted. On 6/5/24 at 11:26 AM, an observation was made of a metal rack used to store clean meal trays after they were sent through the dishwasher. There was metal plating surrounding the metal rack. The metal plating was noted to be rusty. There was a meal tray touching the rusty surface. There was also a small red bug crawling on the metal rack. On 6/5/24 at 11:29 AM, an observation was made of a vent blowing air from the ceiling. The vent was noted to be covered in a thick layer of dust. On 6/5/24 at 11:34 AM, an observation was made of a metal storage cart used to store clean baking sheets. The racks of the cart were noted to be dirty and covered in food crumbs. The dirty racks were in contact with the baking sheets. On 6/5/24 at 11:52 AM, an observation was made of a container of coffee grounds. The container of coffee grounds did not have a lid on it and was open to the air. The coffee grounds were not actively in use. On 6/5/24 at 12:14 PM, an observation was made of the lunch tray line. Dietary Aide (DA) 1 was observed grabbing their cell phone out of their pocket and looked at the phone screen. DA 1 put the phone back in their pocket. DA 1 then wrote in permanent marker on the saran wrap covering a hotel pan full of chicken noodle soup. DA 1 then opened the walk-in fridge and placed the soup in the fridge. DA 1 then wiped their right arm across their forehead. DA 1 then touched a cup of hot chocolate. DA 1 dumped out the hot chocolate and opened a new packet of hot chocolate powder and poured it into the cup. DA 1 then took a cart full of meal trays from the kitchen to the hallway. DA 1 was not observed to wash their hands during the series of events. On 6/5/24 at 12:17 PM, an observation was made of a stack of clean plates on a drying rack. The plate on top of the stack of dishes was noted to still have food debris on it. On 6/5/24 at 12:18 PM, an observation was made of the ceiling above food preparation areas. The ceiling was noted to have food debris and stains. On 6/5/24 at 1:48 PM, an interview was conducted with the Assistant Dietary Manager (ADM). The ADM stated that there is a cleaning schedule for the kitchen. The ADM stated that the kitchen should be cleaned daily. On 6/6/24 at 3:02 PM, an additional interview was conducted with the ADM. The ADM stated that the kitchen staff were actually responsible for cleaning the vents in the kitchen, not maintenance. The ADM stated that the vents were not on the kitchen cleaning list, but they had been added and that she had stayed late the previous night to clean the vents.

Based on observation and interview it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility did not have detergent for the dish machine, there was cardboard duct taped to the hood vent, refrigerators at the nurses stations were soiled and there were soiled areas in the kitchen. Findings include: 1. On 1/2/24 at 9:49 AM, a dirty meal tray was observed at the bottom of the ice and water cart in the hallway outside room [ROOM NUMBER]. 2. On 1/2/24 at 10:00 AM, an observation was made of the facility dish machine. There were 3 tubes coming from the dish machine. One tube was in a bucket labeled Ultra San, another labeled Rinse Aide and a third labeled Dish Machine Detergent. The Ultra San was a liquid sanitizer. The detergent was observed to be a clear color. The dish machine was observed to have 50 parts per million of chloride bleach. An interview was conducted with Dietary Aide (DA) 1. DA 1 stated the dish machine needed to have a temperature above 140 degrees Fahrenheit. DA 1 stated the dish machine used sanitizer. DA 1 was observed to check the sanitizer solution. The chloride bleach strip turned to a dull purple color which was 50 parts per million. An interview was conducted with the Head Cook (HC). The HC stated the facility had not ran out of sanitizer and detergent. The HC stated the new Dietary Manager (DM) was watching to see how much detergent and sanitizer was used to know when to order. On 1/2/24 at 2:25 PM, an observation was made of the dish machine with the DM. DA 1 and DA 2 were observed to be putting dishes away from the dish machine. The DM was observed to look at the dish machine chemicals. There were 3 tubes from the dish machine into solutions. There was one tube that went to Ultra San, another to the Quarts Sanitizer, and another to a rinse agent. There was a container labeled Dish Machine Detergent that was a clear substance. There was no tube to the dish machine into the detergent. The DM stated the container was water that dripped from the dish machine because the disposal did not work. The DM then stated the the clear liquid was 1 part bleach and 4 parts water because the facility had ran out of dishwashing detergent. The DM stated the facility ran out of dish machine detergent on 1/1/24 and he had mixed the bleach mixture. The DM stated the clear liquid was bleach, water and the remaining about of dish detergent. The DM stated he was instructed to mix the solution by a corporate staff member. The DM stated he was unable to remember who the staff member was. 3. On 1/2/24 at 10:00 AM, an observation was made of the kitchen. The following observations were made: a. The steam table in the dining room was observed to be soiled on the plastic glass. Underneath the shelf above the food basins on the steam table were observed to be soiled. b. In the walk in refrigerator there were 10 chocolate mighty shakes in a container. There were no dates on the mighty shakes or on the container. The label revealed Store Frozen .Used thawed within 14 days. c. The front of oven had a dried liquid substance on the front of it. d. There was food splatter on the ceiling above the trayline in the dining room. 4. On 1/2/24 at 10:30 AM, the resident snack refrigerator at the North hall nurse's station was observed. There was a chocolate frosty in the door with no date and was thawed. There was an orange substance spilled on the shelves. 5. On 1/2/24 at 10:35 AM, the resident snack refrigerator at the South Hall nurse's station was observed. There was a large green substance in the bottom of the refrigerator. There were grocery sacks with no dates or labels. There was a pizza box with no date. There was an espresso cold drink opened and covered with a glove with no date. At 10:38 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated they were not sure who was responsible for cleaning the refrigerators at the nurses station. LPN 1 stated they were not sure how long the refrigerator had been dirty or why the items were not labeled or dated. LPN 1 stated It's kind of gross. On 1/2/24 at 2:14 PM, an interview was conducted with the DM. The DM stated he did not know why there was cardboard duct taped to the hood vent. The DM stated the facility needed the hood vent replaced. The DM stated the fans were really loud. The DM stated he was not aware that there were refrigerators at the nurses station. The DM stated the Administrator talked to him about the dietary staff cleaning the refrigerators and checking their temperatures. On 1/2/24 at 2:15 PM, an interview was conducted with the HC. The HC stated the cardboard was because the vent blew cold air onto the staff members. The HC stated the mighty shakes should have been dated. The HC asked DA 2 when the mighty shakes were pulled from the freezer. The HC stated DA 2 stated to him the mighty shakes were pulled from the freezer on 12/30/23. On 1/2/24 at 2:44 PM, an interview was conducted with the facility Registered Dietitian (RD). The RD stated she was at the facility 1 to 2 times per week and completed a monthly kitchen audit. The RD stated she was newly employed by the facility and was looking at completing some quality improvement. The RD stated she had been walking through the kitchen with the new DM. The RD stated in her first report, there were concerns with the facility dish machine. The RD stated the booster breaker was turning off and staff had to watch the water temperatures for all dish machine cycles. The RD stated there was detergent, rinse aide and sanitizer when she completed her audit. The RD stated the dish machine should have detergent and sanitizer instead of 2 sanitizers. On 1/2/24 at 3:28 PM, an interview was conducted with the Administrator. The Administrator stated the DM had been talking with the company that supplied the chemicals for the dish machine. The Administrator stated he was not aware that the facility did not have dish washing detergent.

Based on observation, interview, and record review, it was determined for 1 of 7 sample residents, that the facility did not ensure a therapeutic diet was offered when there was a nutritional problem and the health care provider ordered a therapeutic diet. Specifically, a resident was not provided a fortified/enhanced diet. Resident identifiers: 4. Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included mycobacterial infections, human immunodeficiency disease (HIV), localized edema, anemia, immune reconstitution syndrome, severe protein calorie malnutrition, hypotension, ascites, splenomegaly and pleural effusion. Resident 4's medical record was reviewed on 1/2/24. On 1/2/24 at 10:15 AM, an observation was made of resident 4 lying in bed with his tube feeding infusing. Resident 4 refused the interview even with translation offered. Resident 4's physician orders revealed a physician's order dated 11/28/23 for a Fortified/enhanced diet, regular texture, with thin consistency. An Admission Nutritional assessment dated [DATE] documented, [Resident 4] needed a fortified/enhanced regular diet. Resident 4's care plan was initiated on 12/5/23 and updated on 12/14/23 revealed, [Resident 4] had potential for or presence of altered nutrition needs. Nutritional risk factor: Need of AN (additional nutritional) support r/t (related to) DX (diagnoses) of HIV. Interventions in place were; Diet per order and observe for signs of malnutrition. The goal developed was, [Resident 4] will receive food of appropriate texture. Will be pleased with meal service and food choices. On 1/2/24 at 10:28 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 4 was able to eat every meal despite having a feeding tube. RN 1 stated the resident just needed assistance sitting up on the edge of his bed. RN 1 stated resident 4 preferred Vietnamese food and RN 1 would occasionally bring it in for resident 4. RN 1 stated resident 4 was very thin and did have extra calories put into his meals. On 1/2/24 at 1:05 PM, an observation was made of a lunch tray taken to resident 4. The tray had a glass of apple juice, mashed potatoes and gravy, two breaded chicken strips with one cut into pieces, and a roll. The meal ticket on the tray for resident 4 documented the meal as regular enhanced. On 1/2/24 at 1:15 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 4 would eat the meals the meals that were brought in to him but he did not eat all the food that was offered. CNA 1 stated resident 4 was on a fortified diet since he was very thin. At 12:35 PM, an interview was conducted with the Head Cook (HC). The HC stated the meal ticket had what type of diet a resident needed. The HC stated the enhanced diet had a hot cereal with milk, butter and brown sugar for breakfast. The HC stated sometimes the soups at lunch and dinner were enhanced. The HC stated there was no item that was enhanced for lunch. On 1/2/24 at 2:55 PM, an interview was conducted with the Registered Dietician (RD). The RD stated with an enhanced diet the residents would receive super cereal for breakfast and whole milk with each meal.

Based on observation and interview it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were observed to enter transmission based precaution (TBP) rooms without the proper personal protective equipment (PPE) in place, staff were observed to enter the facility through a back entrance and walk down a hallway past residents prior to performing the COVID-19 screening process, staff were observed to have placed a spoon on the top of the medicine cart, then used the spoon to obtain applesauce from a communal container of applesauce, mix the applesauce with the medications and then administer the medication mixture to a resident, and the oxygen tubing for a resident was not routinely changed. Resident identifiers: 20, 69 and 228. Findings Include: On 3/15/22 at 9:53 AM, an observation was made of a Physical Therapy Assistant (PTA) entered room [ROOM NUMBER] with only a surgical mask in place. The signage on the door stated a mask, shield, gown, and gloves needed to be worn when entering the room. The PTA stopped at the door, read the signage, then entered the resident room and did not don any additional PPE. An immediate interview was conducted with the PTA, she stated you only need to wear PPE when you have contact with the resident. You do not need to wear it if you did not help the resident in isolation. On 3/15/23 at 9:55 AM, an interview was conducted with LPN 2. LPN 2 stated everyone should wear the PPE when they go into any room that has the sign. New admits are on precautions for 14 days or until there vaccination status was verified. But PPE should be worn if there was a sign on the door regardless. On 3/13/22 at 10:30 AM, a TBP sign was observed on the wall next to room [ROOM NUMBER]'s door. The TBP sign had instructions to check with nursing before entering the room. There was also a small plastic cart with personal protective equipment (PPE) in the hallway next to room [ROOM NUMBER]. On 3/13/22 at 10:43 AM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated the TBP sign and PPE cart near room [ROOM NUMBER] were present because resident 228, who was unvaccinated for COVID-19, was recently admitted and was being isolated in her room for 14 days. On 3/13/22 at 11:24 AM, Maintenance Man (MM) 1 was observed knocking on room [ROOM NUMBER]'s door and telling resident 228 that he needed to change the time on the clock due to Daylight Savings Time. MM 1 was then observed entering the room without donning PPE. On 3/15/22 at 10:35 AM, an interview was conducted with MM 1. The MM 1 stated that the PPE carts outside of residents' rooms are for residents that have infections. The MM 1 further stated that when he sees a PPE cart and a TBP sign near a resident's room that he asks the nurses what PPE he should wear when entering the room. On 3/16/22 at 9:48 AM, an interview was conducted with the facility's ADON/IP. The ADON/IP stated that maintenance workers receive training on TBP and on how to use PPE during their orientation when they first start working and she stated she reminds them daily about residents on TBP. On 03/15/22 at 9:35 AM, an observation was made of Occupational Therapy Assistant (OTA) 1 coming in the back door of the facility and walking through the facility to the front desk to complete the screening process for COVID-19. On 03/15/22 at 01:40 PM, an interview was conducted with the facility receptionist. The receptionist stated that staff come into the building via either the front or back door, and screen in at the reception desk prior to starting work. The receptionist stated visitors must come in through the front door because that is the door that is unlocked. The receptionist stated if they don't have a key card they can't get in the doors in the back. On 03/15/22 at 01:57 PM, an interview was conducted with OTA 1. OTA 1 stated that he came into the building through the back door and went right to the kiosk at the front desk, answered the COVID-19 screening questions, and got cleared to work. OTA 1 stated he believed if staff parked in the back of the building, they could come in the side or back doors. OTA 1 then walked to the door he had entered through earlier and noted there was a stop sign on the door indicating that everyone must enter the building through the front door. OTA 1 then acknowledged that he should have entered the facility through the front door. On 3/15/22 at 8:20 AM, an observation was made of Licensed Practical Nurse (LPN) 3. LPN 3 was observed to have dropped a plastic spoon on top of the medicine cart, then used the spoon to get applesauce from the communal container of applesauce. LPN 3 then used the plastic spoon to mix the medications with the applesauce and administer the medication mixture to resident 69. On 3/16/22 at 12:35 PM, an interview was conducted with the Director of Nursing (DON). The DON stated it was the expectation of the nurses use hand sanitizer and keep the work area clean when passing medications. The top of the cart was not considered always clean. Resident 20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/13/22 at 1:03 PM, a Certified Nursing Assistant (CNA) was observed feeding resident his lunch meal. An oxygen concentrator was observed in the room near resident 20's bed. The oxygen tubing was not labeled and resident 20 could not remember when it was last changed. On 3/16/22 at 1:43 PM an interview was conducted with CNA 1. CNA 1 stated that oxygen tubing was changed monthly on the first Sunday of the month by the CNA Coordinator. On 3/16/22 at 1:45 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she thought oxygen tubing was changed weekly by the CNA Coordinator. On 3/16/22 at 1:48 PM, RN 1 introduced me to the Human Resource Manager and the Discharge Planner. RN 1 stated that they had both been prior CNA Coordinators in the facility. The Human Resource Manager and Discharge Planner stated that when they were CNA Coordinators that they would change oxygen tubing every Friday and label the tubing with the date it was changed. On 3/16/22 at 1:53 PM, an interview was conducted with resident 20. Resident 20 stated he didn't know when his oxygen tubing had last been changed but stated it had been a long time. On 3/16/22 at 2:01 PM, an interview was conducted with the facility's current CNA Coordinator. The CNA Coordinator stated she had just started in her new role as CNA Coordinator on 2/22/22. The CNA Coordinator stated she though that the prior CNA Coordinators changed oxygen tubing every month but stated she did know when resident 20's oxygen tubing was last changed. On 3/16/22 at 2:11 PM, an interview was conducted with the Corporate Resource Nurse (CRN) and the DON. They stated that oxygen tubing was changed weekly. The CRN and DON could not find a facility policy and procedure that included how often oxygen tubing should be changed.

Based on interview and record review it was determined for 3 of 35 sample residents, that the residents were not able to make choices about aspects of their life in the facility, that were significant to the resident. Specifically, residents were not regularly showered three times a week, as was their preference. Resident identifiers: 6, 22, 48. Findings include: 1. Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/14/22, resident 6 was interviewed and stated she was lucky to shower two times a week but only got 1 shower last week. They used to have a shower aide to do the showers now it was just the certified nursing assistants (CNA's). Resident 6 stated she would like to shower 3 times a week and that she has made the staff aware of this. On 3/15/22, resident 6's medical record was reviewed. A form titled Showers located behind the nurses' desk on the pin board revealed that the resident room numbers were separated into two columns. One column labeled Mon, Wed, Fri (Monday, Wednesday, Friday) and the other column labeled Tues, Thurs, Sat (Tuesday, Thursday, Saturday). Resident 6 resided in room [ROOM NUMBER]-B was in the column to shower on Mon, Wed, Fri in the morning. A Care Plan dated 12/6/21 revealed the resident had a potential for self care deficit related to pain, weakness and [CONDITION(S)] with a goal to have all basic self care needs met at all times through the review date. An intervention developed was Teach techniques with adaptive equipment to help make bathing, hygiene and ADL tasks easier. Resident 6's task list was available for the past 90 days. Tasks were completed by the CNA's and revealed the following dates that resident 6 received a shower 3 times a week. a. December 2021, resident 6 received a shower, 3 times a week, for 1 out of 4 weeks in December. b. January 2022, resident 6 received a shower, 3 times a week, for 0 out of 4 weeks in January. c. February 2022, resident 6 received a shower, 3 times a week, for 0 out of 4 weeks in February. d. March 2022, resident 6 received a shower, 3 times a week, for 0 out of the 2 weeks that were evaluated during survey. 2. Resident 22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/13/22 at 2:08 PM, an interview was conducted with resident 22. Resident 22 stated she would like to have more showers. Resident 22 stated she would like a shower every other day but usually only got them twice a week if that often. They are bad at giving us showers. On 3/15/22, resident 22's medical record was reviewed. A Care Plan dated 12/20/19 revealed the resident had a potential for self care deficit related to [CONDITION(S)], weakness and [CONDITION(S)] with a goal to have all basic self care needs met at all times through the review date. An intervention developed was Teach techniques with adaptive equipment to help make bathing, hygiene and ADL tasks easier. A form titled Showers located behind the nurses' desk on the pin board revealed that the resident room numbers were separated into two columns. One column labeled Mon, Wed, Fri (Monday, Wednesday, Friday) and the other column labeled Tues, Thurs, Sat (Tuesday, Thursday, Saturday). Resident 22 resided in room [ROOM NUMBER]-B was in the column to shower on Mon, Wed, Fri in the morning. Resident 22's task list was available for the past 90 days. Tasks were completed by the CNA's and revealed the following dates that resident 22 received a shower 3 times a week. a. December 2021, resident 22 received a shower, 3 times a week, for 1 out of the 4 weeks in December. b. January 2022, resident 22 received a shower, 3 times a week, for 2 out of the 4 weeks in January. c. February 2022, resident 22 received a shower, 3 times a week, for 3 out of the 4 weeks in February. d. March 2022, resident 22 did not receive a shower, 3 times a week, for 0 weeks out of the 2 weeks that were evaluated during survey. 3. Resident 48 was initially admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/13/22 at 1:54 PM, an interview was conducted with resident 48. Resident 48 stated he did not get to bathe when he would like to, which was 3 times a week. He stated he only got to bathe 1 time a week and sometimes none. Resident 48 stated it had been like this for a while because the facility was low on staff. On 3/15/22, resident 48's medical record was reviewed. A Care Plan dated 11/1/21 revealed the resident had a potential for self care deficit related to incontinence, pain weakness and developmental delay with a goal to have all basic self care needs met at all times through the review date. An intervention developed was Teach techniques with adaptive equipment to help make bathing, hygiene and ADL tasks easier. A form titled Showers located behind the nurses' desk on the pin board revealed that the resident room numbers were separated into two columns. One column labeled Mon, Wed, Fri (Monday, Wednesday, Friday) and the other column labeled Tues, Thurs, Sat (Tuesday, Thursday, Saturday). Resident 48 resided in room [ROOM NUMBER]-B was in the column to shower on Mon, Wed, Fri in the morning. Resident 48's task list was available for the past 90 days. Tasks were completed by the CNA's and revealed the following dates that resident 48 received a shower 3 times a week. a. December 2021, resident 22 received a shower, 3 times a week, for 3 out of the 4 weeks of December. b. January 2022, resident 22 received a shower, 3 times a week, for 2 out of the 4 weeks of January. c. February 2022, resident 22 did not receive a shower, 3 times a week, for 0 weeks out of the 4 weeks of February. d. March 2022, resident 22 did not receive a shower, 3 times a week, for 0 weeks out of the 2 weeks that were evaluated during survey. On 3/15/22 at 11:57 AM, an interview was conducted with a Registered Nurse (RN). RN 2 stated there was a shower paper behind the nurses' desk that tells the nurse's and the CNA's when a resident needs to shower according to their room number. On 3/15/22 at 12:00 PM, an interview was conducted with CNA 2. CNA 2 stated the shower book will show when showers were done and any refusals. Showers are now done by the CNA's instead of restorative care. CNA 2 stated we are short staffed, but we try hard to get all our work done. 03/16/22 at 12:06 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the company policy was to ask the residents to shower but we cannot force them. It was expected that the residents get the showers they would like, and they tell us their shower preference when they first come to the facility. The DON stated we will encourage them to shower, offer help if they need it, or provide the shower if they cannot do it by themselves. The DON stated the residents are scheduled for their showers by where their room was located. The nurse was the one who will sign the refusal sheet if a resident does not want to shower. The DON stated that 90 percent of the time we have enough CNAs to get the showers done, but weekend have been hard. Most showers are done during the week.

Based on observation and interview, it was determined that the facility did not store food in accordance with professional standards of food service safety. Specifically, food in the freeze and refrigerator was not sealed and was open to air. Findings include: On 3/13/22 at 10:15 AM, an initial tour of the kitchen was conducted. The following item was observed to be unsealed and open to air: 1. In the refrigerator: an unsealed box of beef patties. On 3/16/22 at 10:58 AM, a second walk-through of the kitchen was conducted. The following items were observed to be unsealed and open to air: 1. In the refrigerator: an unsealed box of pre-made omelets. 2. In the dry-storage room freezer: an unsealed box of Salisbury steak patties. On 3/16/22 at 11:00 AM, an interview was conducted with the facility Dietary Manager (DM). The DM accompanied the surveyor on the second walk-through of the dry storage area. The box of Salisbury steak patties was brought to the attention of the DM. The DM stated she had educated her staff about sealing food in the refrigerator and freezer and would need to re-educate the staff to ensure food items were sealed when stored.

Based on interview and record review it was determined that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 35 sampled residents, the facility administered hypertensive medications when the blood pressure measurements were outside of the physician ordered parameters and administered insulin outside of physician ordered parameters. Resident identifier: 37 Findings included: Resident 37 was initially admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/15/22, resident 37's medical record was reviewed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . And a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the January and March 2022 Medication Administration Record (MAR) documented the following entries when resident 37's vital signs were below the physician ordered parameters and the [MEDICATION(S)] and [MEDICATION(S)] were administered: a. On 1/30/21, B/P 95/51 b. On 3/6/21, B/P 104/57 c. On 3/7/21, B/P 102/50 A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the January 2022 Medication Administration Record (MAR) documented the following entries when resident 37's blood glucose levels were below the physician ordered parameters and the [MEDICATION(S)] Insulin was administered: a. On 1/22/21 at 12:03 PM, BG 125 b. On 1/22/21 at 4:45 PM, BG 133 On 3/15/22 at 9:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated when passing medications, the doctors' orders should always be followed. The orders and parameters are in the MAR and you can see them when you are passing out medications. On 3/16/22 at 11:15 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses should check the MAR when passing medications to residents. The orders that are given from the doctor would be in the MAR and each nurse can find them, if there was a question they should check with the doctor before giving the medication. It was expected that the nurses will follow the orders given by the physician.

Based on interview and record review it was determined that the facility did not provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene to residents who were unable to carry out activities of daily living (ADLs). Specifically, for 4 out of 35 sampled resident, residents that were dependent on ADLs did not receive showers or bathing assistance in a timely manner and according to the facility schedule for showers. Resident identifiers: 6, 16, 22, and 48. Findings included: 1. Resident 16 was admitted to the facility initially on 7/10/2020 and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/13/22 at 2:54 PM, an interview was conducted with resident 16. Resident 16 stated she would like to get a shower at least once per week. Resident 16 stated she had a bath 3 days ago, however, she stated her baths were not consistent. On 3/15/22 at 11:24 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated resident 16's shower days were on Tuesday, Thursday, and Saturday in the evenings. CNA 2 stated when resident 16 went to the toilet the staff would wipe her down. CNA 2 stated if resident 16 does not turn her call light on the staff would go ask when she wanted a shower. CNA 2 stated resident 16 had refused some showers. CNA 2 stated if resident 16 refused a shower the policy was that the CNA would tell the nurse on duty and the nurse would have to sign the refusal. CNA 2 stated during rounds the staff coming on shift would be told that the resident had missed or refused a shower and the CNAs would try the next day. CNA 2 stated when the facility is short staffed, they do the best they can. CNA 2 stated that during the day if staff were unable to get to all the showers, they would move those showers to the PM (evening) shift, or sometimes showers would be done on Sundays. CNA 2 stated if help was needed, additional staff members would be called in to help with showers. On 3/16/22 resident 16's electronic medical record (EMR) was reviewed, including shower sheets provided by the facility. Resident 16's most recent Minimum Data Set (MDS) was reviewed and revealed that (Section F) resident 16 felt it was very important to choose between a bath, shower, bed bath or sponge bath, (Section G) resident 16 needed extensive 1 person assistance with hygiene, and (Section GG) resident 16 required maximum assistance with showers. Resident 16's shower task was reviewed for the previous 4 months. For the month of March, as of the 14th day, resident 16's shower sheet did not document any showers. For the month of February, showers were documented on 2/4/22, 2/7/22, 2/11/22, 2/18/22 (7-day gap), 2/25/22 (7-day gap that included a refusal on 2/21). Resident 16 received 5 showers in the month of February. In January, resident 16 received a shower on 1/3/22, 1/12/22 (a 9-day gap with 1 refusal on 1/10), 1/24/22 (a 12-day gap with refusals on 1/14, 1/17, and 1/21). Resident 16 refused showers on 1/28 and 1/31 and received no other showers the remainder of the month. Resident 16 received a total of 3 showers in the month of January. 2. Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/14/22, resident 6 was interviewed and stated she was lucky to shower two times a week but only got 1 shower last week. They used to have a shower aide to do the showers now it was just the certified nursing assistants (CNA's). Resident 6 stated she would like to shower 3 times a week and that she has made the staff aware of this. On 3/15/22, resident 6's medical record was reviewed. An Admission Minimum Data Set (MDS) dated [DATE] revealed resident 6 was totally dependent with 2 person physical assist for bathing. A form titled Showers located behind the nurses' desk on the pin board revealed that the resident room numbers were separated into two columns. One column labeled Mon, Wed, Fri (Monday, Wednesday, Friday) and the other column labeled Tues, Thurs, Sat (Tuesday, Thursday, Saturday). Resident 6 resided in room [ROOM NUMBER]-B and was in the column to shower on Mon, Wed, Fri in the morning. A Care Plan dated 12/6/21 revealed the resident had a potential for self care deficit related to pain, weakness and [CONDITION(S)] with a goal to have all basic self care needs met at all times through the review date. An intervention developed was Teach techniques with adaptive equipment to help make bathing, hygiene and ADL tasks easier. Certified Nursing Assistant (CNA) documentation for showers in the tasks section of resident 6's medical record revealed showers from 12/2/21 until 3/14/22. Resident 6 went 7 days without a shower from 12/13/21 until 12/20/21 and 12/20/21 until 12/27/21. In January, resident 6 went without a shower from 12/30/21 until 1/12/22, which was 13 days. And from 1/21/22 until 1/28/22, which was 7 days. In February, resident 6 went without a shower from 1/28/22 until 2/4/22 and 2/22/22 until 2/28/22. And in March, resident 6 went without a shower from 2/28/22 until 3/7/22. 3. Resident 22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/13/22 at 2:08 PM, an interview was conducted with resident 22. Resident 22 stated she would like to have more showers. Resident 22 stated she would like a shower every other day but usually only got them twice a week if that often. They are bad at giving us showers. On 3/15/22, resident 22's medical record was reviewed. An Annual MDS dated [DATE] revealed resident 22 required substantial maximal assist with bathing. A Care Plan dated 12/20/19 revealed the resident had a potential for self care deficit related to [CONDITION(S)], weakness and [CONDITION(S)] with a goal to have all basic self care needs met at all times through the review date. An intervention developed was Teach techniques with adaptive equipment to help make bathing, hygiene and ADL tasks easier. The form titled Showers revealed resident 22 was to be showered on Monday, Wednesday, and Friday according to the location of her room. Certified Nursing Assistant (CNA) documentation for showers in the tasks section of resident 22's medical record revealed showers from 12/2/21 until 3/14/22. Resident 22 went 7 days without a shower from 12/13/21 until 12/20/21. In January, resident 22 went 5 days without a shower from 1/5/22 until 1/10/22. In March it was noted resident 2 received showers twice a week. 4. Resident 48 was initially admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/13/22 at 1:54 PM, an interview was conducted with resident 48. Resident 48 stated he did not get to bathe when he would like to, which was 3 times a week. He stated he only got to bathe 1 time a week and sometimes none. Resident 48 stated it had been like this for a while because the facility was low on staff. On 3/15/22, resident 48's medical record was reviewed. A Care Plan dated 11/1/21 revealed the resident had a potential for self care deficit related to incontinence, pain weakness and developmental delay with a goal to have all basic self care needs met at all times through the review date. An intervention developed was Teach techniques with adaptive equipment to help make bathing, hygiene and ADL tasks easier. The form titled Showers revealed resident 48 was to be showered on Monday, Wednesday, and Friday according to the location of his room. Certified Nursing Assistant (CNA) documentation for showers in the tasks section of resident 22's medical record revealed showers from 12/2/21 until 3/14/22. Resident 48 went without a shower from 2/21/22 until 2/28/22. And 3/9/22 until 3/16/22, which was 7 days. On 3/15/22 at 12:00 PM, an interview was conducted with CNA 2. CNA 2 stated showers are done according to the shower schedule on the form at the nurses' desk. CNA 2 stated they try hard to get everyone's showers completed, but it can get difficult. On 3/16/22 at 12:06 PM, an interview was conducted with the Director of Nursing (DON). The DON stated it was company policy to ask the residents to shower but we cannot force them. It was expected of the staff to assist residents to shower if they would like, the residents tell us their shower preference on admit. The DON stated the 90 percent of the time we have enough CNAs to get the showers done, but weekends have been hard. Most showers are done during the week.

Based on interview and record review the facility did not develop and implement a comprehensive person-center care plan for 1 of 35 sampled residents, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident did not have a care plan to attain or maintain the highest practicable physical, mental and psychosocial well-being when receiving [CONDITION(S)] medications. Resident Identifier: 62 Finding include: Resident 62 was initially admitted on [DATE] and again on 2/21/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/15/22, Resident 62's medical record was reviewed. Resident 62's 12/19/21 Admitting Minimum Data Set (MDS) revealed he had an active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 62's Care Plan was updated on 3/15/22 with a new Focus, which read, [NAME] has Potential for complications r/t (related to) [CONDITION(S)] medication use for depression with [CONDITION(S)], anxiety This Focus area included a Goal and multiple Interventions, which were also initiated on 3/15/22. Note: This new Focus area in resident 62's Care Plan was added two days after starting the Recertification Survey on 3/13/22. On 3/15/22 at 12:45 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1 and Registered Nurse (RN) 2. The two nurses stated that they initiate a Care Plan when a resident is first admitted . They stated that a skin check is performed, and the resident is asked about their health care issues. RN 2 stated that when a resident has orders for [CONDITION(S)] medications, she has the resident or the resident's representative sign a consent to receive the [CONDITION(S)] medications and then adds a Focus area for the [CONDITION(S)] medications in the resident's Care Plan. On 3/15/22 at 1:01 PM, an interview was conducted with the facility's Director of Nursing (DON). The DON stated that if a resident had received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 62's [CONDITION(S)] medications were ordered on 2/22/22 and 2/24/22, but a Focus area for receiving [CONDITION(S)] medication was not added to his Care Plan until 3/15/22.

Based on interview and record review, it was determined for 1 of 7 sample residents, that the facility did not ensure the resident was free of significant medication errors. Specifically, a resident's blood thinning medication was not discontinued per the physician's orders [REDACTED]. Based on corrective measures taken by the facility, the noncompliance was determined to be past-non-compliance. Corrective measures were implemented by 4/21/17. Corrective measures included: 1. On 4/18/17 a Quality Assuarnce Meeting was held for [MEDICATION NAME]. The facility identified probelms with: a. Failure to enter new order in (electronic medical record (EMR)) when [MEDICATION NAME] was to be discontinued on (4/10/17). A progress note was entered by the nurse about the discontinuation of [MEDICATION NAME] but nurse failed to (discontinue) medication in (EMR) so the medication remained in the MARS (Medication Administration Records) and was given for additional 7 days. [MEDICATION NAME] dose changed on (4/13/17) following new PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) values. Due to entry error above, [MEDICATION NAME] continued to be administered with [MEDICATION NAME] until (4/17/17). b. Administration of two anticoagulant medications led to internal bleeding and transfer of resident to the (emergency room ) on (4/17/17). The facility implemented the following plan of correction on 4/18/17: a. Discontinued medications must be removed from the medication cart immediatley after the order has been given to the nurse either on a (Telephone Order) or verbally. b. A new [MEDICATION NAME] and [MEDICATION NAME] tracking log has been created. Unit clerk to start tracking log audit for residents on [MEDICATION NAME] and [MEDICATION NAME] on (4/18/17). This audit will continue daily with no end date. c. Unit clerk to audit PT/INR and (Telephone Orders) daily effective (4/19/17) with no end date, as this will be a part of the facility daily practice. d. DON (Director of Nursing) in-serviced nurses on (4/18/17) and another in-service to be held on (4/20/17) by DON. e. Disciplinary action held for the nurse involed in this incident on (4/21/17). f. DON to review findings, audits and in-services in the next QA meeting on (5/8/17). Note: During the facility's recertification survey on 7/27/17, no deficient practice was identified related to the administration of blood thinning medications or significant medication errors. During the abbreviated survey on 11/29/17, no deficient practice was identified related to the administration of blood thinning medications or medication errors. Findings include: Resident 2 was admitted to the facility on admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. A review of resident 2's medical record was completed on 11/19/17. Resident 2's Physician order [REDACTED]. a. 50 milligrams (mg) [MEDICATION NAME] subcutaneously (sq) daily. Started 4/7/17. To be discontinued when INR is therapeutic. (Note: Resident 2's hospital discharge orders revealed that [MEDICATION NAME] should have been discontinued when resident 2's INR was greater than 2.5.) b. 2.5 mg [MEDICATION NAME] at bed time, start 4/13/17. c. 2 mg [MEDICATION NAME] at bedtime every Sunday, Tuesday, Thursday, and Saturday. Started 4/8/17 and discontinued 4/13/17. d. 3 mg [MEDICATION NAME] at bedtime every Monday, Wednesday, and Friday. Started 4/8/17 and discontinued 4/13/17. Resident 2's laboratory results dated [DATE] revealed the following significant laboratory values: a. Red Blood Cells (RBC) 3.58, reference range 4.0-10.4. b. Hemoglobin (Hgb) 11.4, reference range 12.0-18.0. c. Hematocrit (Hct) 35.0, reference 26.0-50.0. d. PT 26.6 seconds, Reference range 12.3-14.5. e. INR 2.4, Reference range 0.0-3.0. A Telephone Order (TO) dated 4/10/17 revealed that resident 2's [MEDICATION NAME] was to be discontinued. A review of resident 2's Medication Administration Record [REDACTED]. Resident 2's laboratory results dated [DATE] revealed the following significant laboratory values: a. RBC 2.15 b. Hgb 6.9 c. Hct 21.4 A secure conversation dated 4/16/17 at 12:00 PM between a facility nurse and the Medical Director (MD) revealed that the facility nurse had found the laboratory results from 4/15/17 at the nurses station and notified the MD at 10:00 AM. The MD asked the facility nurse where the resident was bleeding from. The facility nurse replied that there was no visible bleeding at this time. she has some extensive brusing at her surgical site, but it doesn't seem to have worsened since I initially checked it out on Thursday (4/13/17). The MD ordered for the Complete Blood Count (CBC) to be redrawn in the morning, to have the wound nurse assess the wound the folloiwng morning, and for another CBC to be drawn on 4/20/17. A nurses's note dated 4/17/17 at 7:47 AM, revealed that resident 2's [MEDICATION NAME] was held and that the MD was notified related to an INR of 7.1. A discharge note dated 4/17/17 at 10:59 AM, revealed that resident 2 was sent to the ER related to resident 2's complaints of incontractable pain to right lower extremity and her daughters requests to discharge the resident to the hospital. Resident 2's laboratory results dated [DATE] at 1:01 PM, revealed the following significant laboratory values: a. RBC 1.72 b. Hgb 5.6 c. Hct 17.7 d. PT 57.8 e. INR 6.61 On 11/29/17 at 12:30 PM, the Director of Nursing (DON) was interviewed. The DON stated that he was not at this facility in April 2017, however he was aware that there was an issue with resident 2's [MEDICATION NAME] during her stay. The DON provided copies of the quality assuarance meeting that was held on 4/18/17 after the medication error was identified. The quality assuarnce meeting minutes confirmed that resident 2's [MEDICATION NAME] was not discontinued on 4/10/17 as ordered and that she received [MEDICATION NAME] in error for six additional days. The minutes revealed that resident 2 was found to have internal bleeding at the hospital.

Based on interview and medical record review it was determined for 2 sampled residents that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, a resident had an acute onset or change in condition that was not evaluated nor treated by facility staff for 13 days and a resident had her newly fractured foot with an external fixation device "bumped" into a facility door frame on the day of admission to the facility, subsequently facility staff did not report the incident to the medical director nor surgeon thus allowing an opportunity to make changes to the resident's plan of care. Resident identifiers: 287 and 289. Findings include: 1. Resident 287 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/30/11 resident 287's medical record was reviewed. Review of the physician's admission orders [REDACTED]. Review of the facility nursing admission assessment revealed that upon admission to the facility, resident 287 was alert and oriented X 3 (person, place and time) cooperative and friendly. Review of facility "Daily Skilled Nurse's Notes" revealed that resident 287 was alert and oriented and pleasant and cooperative with treatments from admission 3/7/11 through 3/16/11. On 3/16/11 it was documented by a facility nurse on the "Daily Skilled Nurse's Note" that resident 287 was alert but more sleepy. On 3/17/11 it was documented by a facility nurse on the 'Daily Skilled Nurse's Note" that resident 287 had refused to shower, refused therapy, refused to brush teeth and refused Q-tips to ears and nose. The facility nurse also documented that resident 287's UA (urinalysis) was positive and had been faxed to the doctor. (Note: The UA was done two days after it was ordered to be done). Review of facility laboratory values revealed that resident 287 had a UA collected on 3/16/11. Review of that laboratory value revealed that the physician had been notified of the results of the UA on 3/18/11 and was awaiting the culture and sensitivity report. According to facility documentation the results of resident 287's urine culture where called to the facility on [DATE] at 10:40 AM and then faxed to the physician. It was documented on the laboratory results that there were no new orders for resident 287 as of 1:30 AM on 3/19/11. (Note: The results of the UA showed that the urine specimen had been contaminated upon obtainment of the sample, meaning the lab was unable to culture the urine). Review of the CBC and CMP obtained on 3/16/11 revealed that the medical director was notified of the results and ordered for a repeat CBC and CMP to be done on 3/23/11. Review of facility "Daily Skilled Nurse's Notes" revealed that resident 287 remained confused and uncooperative with cares from 3/17/11 through 3/27/11. On 3/27/11 it was documented by a facility nurse that resident 287 had pulled out his feeding tube. Facility staff received a physician's orders [REDACTED]. It was documented on the physician's orders [REDACTED]. ([MEDICAL CONDITION]) tube ASAP (as soon as possible). Review of "Daily Skilled Nurse's Notes" revealed that resident 287 pulled his IV out twice. A facility nurse documented that the family was aware of resident 287 pulling out the IV and was, "okay if we left IV out until his feeding tube replacement if it was okay with doctor. ... Doctor notified and was okay if we left IV out." Facility staff received a physician's orders [REDACTED]. According to the "Daily Skilled Nurse's Note" resident 287 pulled the second IV around dinner time. According to facility posted meal times, dinner is served from 4:30 PM until 6:00 PM. Review of the IV medication flow sheet revealed that resident 287's IV fluids were not started until 3:00 PM on 3/27/11. (Note: If the resident was started on the IV at 3:00 PM and was receiving 150 cc per hour and resident 287 pulled out his IV at approximately 6:00 PM, then resident 287 only received 450cc of fluid before the IV was discontinued). Review of the "Daily Skilled Nurse's Note" dated 3/28/11 revealed that resident 287 returned from having his NG tube replaced at 3:30 PM on 3/28/11 at which time the facility resumed resident 287's tube feeding. ( Note: Resident 287 went 301/2 hours with no nutrition and 211/2 hours with no water or hydration and only received 450cc of fluid in 30 1/2 hours). On 3/30/11 at 1:25 PM, an LPN (Licensed Practical Nurse) facility case manager was interviewed regarding obtaining a UA. The case manager stated that the facility would only obtain a UA after the doctor had given the order to obtain the UA. The case manager further stated that if the report indicated that the sample was contaminated and the resident was still exhibiting symptoms the facility would collect another UA. On 3/30/11 at 4:38 PM, the facility medical director (MD) was interviewed. The MD stated if a UA comes back contaminated the facility will recheck the UA if the patient is symptomatic. The MD further stated that he usually treats the patient for the positive UA before the culture comes back, if the resident is symptomatic, and then adjusts the antibiotics based on the results of the laboratory culture. The MD stated that the UA done on 3/16/11 was faxed to him but he did not recall that lab result specifically. The MD further stated that he did not know why he did not start antibiotics on resident 287. On 3/31/11 at 10:30 AM, resident 287's daughter was interviewed. The daughter stated that she knew her father had a UTI (Urinary Tract Infection) because that was the only time he got confused and pulled out his feeding tube. The daughter further stated that she had requested the facility do a UA on 3/27/11 due to her father's confusion. The daughter stated that she knew her father well and had gone through this before. The daughter stated that every time her father got a UTI he became confused and difficult to care for. It was documented on a facility incident report dated 3/29/11 at 3:30 AM, that resident 287 was, "Found on floor by BR (bathroom) per CNA (certified nursing assistant). Awake and talking. Has been more confused. C/O (complaints of) headache. Abrasions Lft (left) fore head, eyebrow, Lft shoulder, sm (small) abrasion rt. (right) cheek. PERL (pupils equal responsive to light).... Urine dipped lg. (large) leukocytes and [MEDICATION NAME]. ..." Review of facility nurses notes revealed an entry dated 3/29/11 at 5:00 AM. A facility nurse documented that resident 287's color was "somewhat flushed. Skin warm and slightly moist. Attempts to open eyes. No verbal response except for moaning. Dr. (name of Doctor) notified. Family notified. Family request to be sent to (name of local hospital)." Review of the medical record revealed that resident 287 was sent to the local hospital on [DATE] at 5:30 AM. On 3/30/11 the admission Hospital History and Physical for resident 287 was reviewed. Review of the admission History and Physical revealed that resident 287 was admitted to the hospital on [DATE] with Altered Mental Status secondary to Urinary Tract Infection and Dehydration. 2. Resident 289 was admitted to the facility on [DATE] discharged [DATE], admitted to the facility 3/1/11 discharged [DATE], then readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 289 also had [DIAGNOSES REDACTED]. Resident 289's medical record was reviewed on 3/30/11. Review of resident 289's closed medical record for the admit of 2/18/11 revealed that resident 289 sustained a fracture of her left ankle at home on 2/15/11. Resident 289 was admitted to the facility on [DATE] status [REDACTED]. According to the nursing admission assessment resident 289 told facility staff that she had left leg [MEDICAL CONDITION] and could usually not feel pain. Review of admitting physician's orders [REDACTED]. Review of facility incident reports revealed an incident report dated 2/18/11 at "4-5ish" PM. A facility Physical Therapist (PT) documented on the incident report that, "pt. (patient) was sitting in w/c (wheel chair) L LE (left lower extremity) supported by an elevated leg rest. Pt.s lateral border of left foot came into contact with door frame sausing slight (5 degree inversion) movement but no displacement of leg on leg rests. Pt. had c/o (complaints of) minimal pain upon contact which quickly <1minute subsided. PT/ OT (Physical Therapy/ Occupational Therapy) were present and observed incident. No other information was contained on the incident report. No documentation could be found to show the physician, nursing staff, or other facility staff members were notified of the incident. On 2/19/11 it was documented by a facility nurse on the "Daily Skilled Nurse's Note" that resident 289 had a small amount of blood on the gauze of the fixator. On 2/22/11 it was documented by a facility nurse that resident 289 had an orthopedic (sic) appointment on 2/22/11 and at 3:30 PM on 2/22/11 resident 289's spouse had returned to the building to tell staff that resident 289 would not be returning because she was currently in surgery. On 3/29/11 at 10:45 AM, resident 289 was interviewed regarding her ankle. Resident 289 stated that after she was admitted an aide or some facility staff member wheeled her down the hall to get her weight. Resident 289 stated that the scale was in a closet type area and had a little ramp on it. Resident 289 stated that the staff member had to give her a "good shove" to get the wheel chair up the ramp on the scale and when he pushed her, her foot was "rammed" into the door frame of the closet. Resident 289 stated that the pins around the fixator device began to bleed and she felt some pain. Resident 289 further stated that when she went to the doctor after the incident she then had to go back to surgery because the dislocation and fracture of her ankle had been displaced after the facility had "rammed" her leg into the door frame. On 3/28/11 at approximately 10:00 AM, RN 4 was interviewed regarding resident 289. RN 4 stated that resident 289 had sustained a fracture when an aide had "bumped her foot into a door frame at the facility." No documentation could be found in resident 289's medical record to show facility staff notified resident 289's surgeon or the facility medical director of the incident on 2/18/11, thus allowing the physician's to intervene with resident 289's plan of care. Review of the Orthapaedic Clinic Note dated 2/22/11 revealed the following entry: "(Resident 289) is her for a follow-up on expanding the [DEVICE] of her ankle. ... (Resident 289) reports that while she was in a wheel chair at the care facility, someone ran her forefoot into a wall and the pin sites bled for a while and it hurt a little bit at the time, but she is not capable of hurting very much because she is so neuropathic." Radiographic Interpretation: "Three views of the ankle demonstrate that she is significantly displaced laterally as well as posteriorly." Review of the Orthapaedic Clinic Note dated 2/22/11 revealed that resident 289 was admitted to the hospital on 2/ 22/11 and underwent an open reduction and internal fixation of left trimalleolar ankle fracture with open reduction and internal fixation of the distal fibula as well as the medial malleolus on 2/26/11.

Based on observation, interview and record review, the facility did not ensure that 1 of 17 sample residents received appropriate treatment and services to promote healing and prevent infection of a toe wound. Resident identifier: 17. Findings include: 1. Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 17's Nursing Admission Assessment, completed 2/9/09 at 2:20 PM, included a facility nurse's notation that the resident's right "middle toe is red (and) raised". On the 2/10/09 and the 2/11/09 Daily Skilled Nurse's Note, facility nurses had documented their assessments of resident 17's skin. The nurses identified that resident 17 had a surgical wound and discoloration on her coccyx. The nurses did not document that resident 17 had any skin condition on her foot. On 2/12/09, a facility nurse documented on the Daily Skilled Nurse's Note that resident 17 had a pressure ulcer between her toes and a "tiny scab on top fourth toe." On 2/12/09, a physician's orders [REDACTED]. Licensed Practical Nurse 2 (LPN 2) performed weekly skin assessments for resident 17. On 2/12/09, LPN 2 documented a Wound Tracking Report for a superficial pressure ulcer on resident 17's right third toe. LPN 2 measured the "open sore" to be 0.3 cm (centimeters) by 0.2 cm. LPN 2 documented the toe was swollen and reddened. LPN 2 documented resident 17's level of pain was "4" on a scale of 1 - 10 with "1" representing little or no pain. Resident 17's next Wound Tracking Report was dated 3/2/09. LPN 2 documented that the pressure ulcer on resident 17's right third toe measured 0.4 cm by 0.1 cm. LPN 2 documented resident 17's toe was swollen and reddened with a scant amount of clear drainage. LPN 2 documented that resident 17's pain level was "7". The 3/2/09 Wound Tracking Report included new Treatment Notes. LPN 2 documented that the first and second toes on resident 17's right foot had been taped together by a podiatrist. LPN 2 documented: "Bandaid on 3rd toe daily Fluff lamb;s (sic)wool between 2nd and 3rd toes for comfort. Keep right foot dry in shower". On 3/9/09, LPN 2 documented resident 17's Wound Tracking Report that the resident's right third toe had no open area and the redness and swelling had decreased. LPN 2 documented that resident 17 continued to complain of toe pain at a level of "7". On 3/12/09, LPN 2 documented resident 17's Wound Tracking Report that the right third toe had reopened and the "tape holding 1st and 2nd toe was removed by nurse." LPN 2 documented the ulcer measured 0.4 cm by 0.2 cm. LPN 2 documented the toe was reddened and swollen and the resident had increased pain and tenderness. The 3/12/09 Wound Tracking Report included Treatment Notes that an antibiotic had been started for resident 17 and the resident's toe would be amputated. The physician ordered the antibiotic for resident 17 on 3/13/09. Resident 17's family member / Power of Attorney (POA) was interviewed by telephone on 9/22/09 at 8:40 AM. The POA stated that resident 17 had a reddened, intact, pressure area on the third toe of her right foot before she was admitted to the facility. The POA stated resident 17 reported to her, on 2/27/09, the toe had become extremely painful. The POA stated she removed the protective bandaid from resident 17's right 3rd toe. The POA stated she found the resident's toe to be bright red, swollen and draining from an open wound. The POA stated the facility nurses had not notified her of any change in the condition of resident 17's toe. The POA stated she called her podiatrist the next morning to assess resident 17's open wound. During the telephone interview with resident 17's POA, the POA stated the podiatrist assessed resident 17's right foot at the facility on 3/2/09. The POA stated she was present when the podiatrist dressed the wound, and when he verbally instructed the facility nurse that only the bandaid was to be changed. The POA stated the podiatrist informed the nurse the rest of the dressing he placed was not to be touched. Resident 17's POA stated the facility removed the dressing despite the podiatrist's instructions. A physician progress notes [REDACTED]. foot. The podiatrist described the ulcer on resident 17's right third toe as medial by the second toe, 4 to 5 millimeters in diameter and 1 millimeter deep. The podiatrist documented there was no evidence of infection, no [DIAGNOSES REDACTED] or malodor. The podiatrist documented that clear fluid was draining from the wound. The podiatrist documented resident 17 reported her pain at a level of 6 on a scale of 1 to 10 (1 is little or no pain). The podiatrist's notes described the dressings he applied to resident 17's toes, to include lambs wool placed between toes one and two, and the first and second toes taped together to reduce pressure on the third toe. The podiatrist placed additional "pressure-off" padding to the second toe and a bandaid to the wound on the third toe to further reduce pressure to the wound. The podiatrist placed fluffed lamb's wool between the second and third toes. The podiatrist documented orders that the tape was not to be removed but the bandaid was to be changed daily and the "ulcer inspected for sign of improvement vs. (versus) worsening". The podiatrist provided his phone number with the order. In addition, the podiatrist wrote the following Physician's Telephone Order to reiterated the orders in his notes: 1 - Keep right foot dry 2 - Leave tape on first and second toes 3 - Change bandaid on third toe right foot daily 4 - Fluff lamb's wool between second and third toes to comfort "5 - Report Signs of infection to (podiatrist's name) (telephone number)." The Treatment Record (TAR) included the physician's orders [REDACTED]. between the toes. The balance of the physician's orders [REDACTED]. and second toes. Resident 17's podiatrist was interviewed by telephone on 9/21/09 at 4:10 PM. Resident 17's podiatrist stated that resident 17 had sandwiched toe syndrome, with a lot of arthritis, and her toes were all scrunched together. The podiatrist explained the procedure he used to dress the toes on resident 17's right foot. The podiatrist stated his dressing splinted the resident's first and second toes to relieve pressure from the third toe without separating them too far. He stated he left an open area over the third toe wound which was to be covered with a bandaid. He said the bandaid was to be changed daily by the nurses to allow daily visual assessment of the wound. The podiatrist stated he had placed fluffed lambs wool between the toes to further reduce pressure and provided comfort to the resident. The podiatrist stated "(resident 17) had a toe that needed to be amputated because the nurses did not follow my directions." The podiatrist stated he could not understand why, after he had spoken directly to the nurses, his orders were not followed. The podiatrist stated that, when he first assessed resident 17's toes, he left specific instructions for the nurses to monitor for infection and he left his phone number for them to call him. The podiatrist stated he was "positive there was no malice, but they caused the toe to be amputated." The podiatrist stated, just prior to his next assessment on 3/13/09, he had been informed resident 17's toe was healed. When he did the follow up assessment, on 3/13/09, he found resident 17's bandage had been removed and replaced incorrectly. He stated the resident's toes were padded with gauze. The podiatrist stated resident 17's toe had deteriorated, was extremely painful and appeared to be infected. The podiatrist stated he prescribed an antibiotic for resident 17 on 3/13/09. The podiatrist stated he had to amputate the toe a couple of days later to prevent the infection from spreading. The podiatrist stated resident 17's third toe was amputated Monday, 3/16/09. The physician stated further that resident 17's foot had healed completely within 10 to 12 days after the amputation of her toe. Resident 17's POA provided additional information regarding the progression of resident 17's wound. Resident 17's POA stated the podiatrist told her, on 3/2/09, that the pain in resident 17's toe needed to be much better within a week or he may have to amputate the toe. She stated that the ulcer was still causing resident 17 "a lot of pain" on 3/9/09. The POA stated she notified the podiatrist and surgery was scheduled for 3/19/09. The POA stated she found resident 17 to be in "much more pain" on 3/11/09. The POA stated she observed the podiatrist's dressing had been removed. The POA described resident 17's wound as having thick pus colored drainage and the third toe was swollen and colored almost purple. She stated that the bottom of resident 17's foot had become reddened. The POA stated that someone had called the podiatrist on 3/11/09 and reported resident 17's wound had healed. Resident 17's POA stated the podiatrist was able to see the resident on 3/13/09. The podiatrist stated resident 17's toe had become infected. Resident 17's POA stated the podiatrist reported he would have to perform the surgery on Monday (3/16/09) to prevent infection from spreading into the resident's bones. An interview was conducted with RN 1 on 9/22/09 at 1:10 PM. RN 1 worked with resident 17 on 3/11/09 and removed the resident's right foot dressings. RN 1 stated she was not aware the tape was not to be removed from resident 17's first and second toes. RN 1 stated she thought she was following the podiatrist's order when she removed the dressing to assess the resident's wound. RN 1 stated she did not contact the podiatrist. An interview was conducted with LPN 1 on 9/22/09 at 2:00 PM. LPN 3 frequently provided care to resident 17 and was aware of the podiatrist's orders. LPN 3 worked the two days following removal of resident 17's dressing. LPN 3 stated she did not contact the podiatrist to notify him the dressing had been removed or to get new orders. An interview was conducted with RN 3, on 3/22/09 at approximately 1:45 PM. RN 3 frequently provided care to resident 17 and was aware of orders to leave the resident's splint-type bandage untouched. RN 3 stated that resident 17's toe had become very painful when touched. RN 3 stated that she had never contacted the podiatrist regarding resident 17's wound. An interview was conducted intermittently with LPN 2 on 9/22/09 beginning at 1:05 PM. LPN 2 stated she had observed resident 17's toe wound to be healed on 3/11/09 or 3/12/09. LPN 2 stated she contacted the podiatrist at that time, but wasn't certain of the date. LPN 2 stated she called to ask the podiatrist if he was still going to amputate resident 17's toe since it was healed. She stated the podiatrist told her he would have to reassess the wound before deciding what was to be done. The LPN 2 was asked to describe the healed wound. LPN 2 stated resident 17's wound was scabbed over with no drainage. LPN 2 stated that within two days, the wound had reopened. After the bandage was removed against the podiatrist's orders, no one from the facility contacted the podiatrist to get new treatment orders. As the wound on resident 17's toe worsened, no one contacted the podiatrist to notify him.