Every finding on record at Johnson Cntr/Falcons Landing

Based on clinical record review, staff record review, staff interview and facility documentation review, the facility staff failed to offer and/or provide up to date COVID-19 immunization for 5 residents, Residents #2, #16, #19, #39, and #96, in a survey sample of 7 residents reviewed for COVID-19 vaccination. The findings include: 1. The facility staff failed to offer and/or provide a COVID-19 bivalent booster vaccine for Residents #2, #16, #19, #39, and #96. On 5/3/23, clinical record reviews were performed and revealed the following: A. Resident #2 completed a primary COVID-19 vaccine series on 4/30/21, however there was no evidence that Resident #2 had been offered or received a COVID-19 bivalent booster dose. B. Resident #16 completed a primary COVID-19 vaccine series on 1/21/21, however there was no evidence that Resident #16 had been offered or received a COVID-19 bivalent booster dose. C. Resident #19 completed a primary COVID-19 vaccine series on 2/10/21, however there was no evidence that Resident #19 had been offered or received a COVID-19 bivalent booster dose. D. Resident #39 completed a primary COVID-19 vaccine series on 2/27/21 and a monovalent booster on 5/9/22, however there was no evidence that Resident #39 had been offered or received a COVID-19 bivalent booster dose. E. Resident #96 was admitted to the facility on [DATE]. There was no evidence that facility staff assessed the COVID-19 immunization status for Resident #96, including primary COVID vaccination and/or booster doses. On 5/3/23, an interview was conducted with the Director of Nursing (DON) and the Infection Preventionist (IP), both of whom confirmed the facility policies and procedures follow CDC (Centers for Disease Control and Prevention) guidance and recommendations for resident COVID-19 immunization. The DON stated there were no concerns with the facility's ability to provide COVID immunizations to residents. The DON stated that it is expected for all residents to be provided the opportunity to be up to date with COVID-19 immunizations, including the bivalent COVID booster. On 5/3/23, the DON accessed the clinical records for the residents sampled and verified the findings. The facility's COVID vaccination policy for residents was requested and received. On 5/4/23, review of the facility's policy titled, COVID-19 Vaccine, date reviewed 1/9/2023, subheading Policy, was conducted and read, To reduce morbidity and mortality from Coronavirus disease 2019 (COVID-19), [facility name redacted] will offer vaccination to all residents and employees . The CDC (Centers for Disease Control and Prevention) document titled, Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States, updated March 16, 2023, page 3, Recommendations for COVID-19 vaccine use, subtitle, Booster vaccination, read, People ages 6 months and older are recommended to receive 1 bivalent mRNA booster dose after completion of any FDA-approved or FDA-authorized primary series or previously received monovalent booster dose(s). The CDC (Centers for Disease Control and Prevention) document titled, Stay Up to Date with COVID-19 Vaccines Including Boosters, updated March 2, 2023, page 2, COVID-19 Boosters, subtitle, Updated Boosters, read, The updated boosters are called 'updated' because they protect against both the original virus that causes COVID-19 and the Omicron variant BA.4 and BA.5 .Updated COVID-19 boosters became available on: September 2, 2022, for people aged [AGE] years and older .You are up to date with your COVID-19 vaccines when you have completed a COVID-19 vaccine primary series and got the most recent booster dose. The CDC (Centers for Disease Control and Prevention) document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 23, 2022, page 2, item 1, read, 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Encourage everyone to remain up to date with all recommended COVID-19 vaccine doses .HCP [Healthcare Personnel], patients, and visitors should be offered resources and counseled about the importance of receiving the COVID-19 vaccine. On 5/4/23, the Facility Administrator and Director of Nursing were made aware of the findings. No further information was provided.

Based on staff interview, clinical record review and facility documentation review, the facility staff pre-selected the option on the SNF ABN notice (Skilled Nursing Facility Advance Beneficiary Notice) issued to 2 Residents (Resident #25 and #27) in a survey sample of 3 Residents, reviewed for such notices. The findings included: On 5/3/23, the facility Administrator was asked to provide a listing of Residents who were discharged from Medicare Part A services. From this listing a sample was selected which consisted of Resident #25 and #27. The notices issued to these Residents were reviewed and revealed the following: 1. For Resident #25, the facility staff provided a SNFABN notice prior to skilled care services ending, and below the options box had typed in, Additional information: I am choosing Option 3. Resident #25 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services, as the facility had pre-selected/indicated the Resident chose option 3. Review of the clinical record revealed that Resident #25 was readmitted to the facility on [DATE], for skilled care, Medicare part A services. When skilled services were scheduled to end on 1/25/23, the Resident remained in the facility. The facility staff issued a NOMNC (Notice of Medicare Non-Coverage) form on 1/23/23. The facility staff provided Resident #25 with the second required notice, a SNF ABN, which allows the resident an option to continue to receive services, be notified of the expected cost, and have Medicare make the coverage determination once a bill is submitted to Medicare. 2. For Resident #27, the facility staff provided a SNFABN notice prior to skilled care services ending, with option 3 noted/pre-filled in, therefore eliminating the Resident's opportunity to have Medicare make the coverage determination. Review of the clinical record for Resident #27's skilled care ended on 12/21/22, and the Resident remained in the facility for long-term care. 5/4/23 at approximately 10 AM, an interview was conducted with Employee G, the facility social worker. Employee G was asked to explain the NOMNC and ABN forms and explain when they are issued. Employee G stated, For the ABN, if they stay long term care it is option 2. Option 3 is for people who don't want to stay here, and it is kind of irrelevant. Employee G had difficulty verbalizing what each of the 3 options on the ABN form represented and how that would affect the services provided to the Resident based on their selection. Employee G provided Surveyor C with a blank ABN form that is used by the facility. It was noted that under the 3 options for Residents to make a selection, it was pre-filled/typed with, Additional information. I choose option 3. Employee G said, option 3, Says you don't want our care and don't want to pay for it. Employee G also stated, That was on the form I was given, and I don't touch that. The facility policy titled, Advance Beneficiary Notice of Non-Coverage, was reviewed. This policy read, . Blanks (G)-(I) must be completed by the beneficiary when the ABN is issued and should not be pre-filled . The ABN may not be modified except as specifically allowed by these instructions. Notifiers must exercise caution before adding any customizations beyond these guidelines, since changing ABNs too much could result in invalid notice and healthcare provider or supplier liability for non-covered charges . In the CMS document, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN). This instruction sheet read, .There are 3 options listed on the SNFABN with corresponding check boxes. The beneficiary must check only one option box. If the beneficiary is physically unable to make a selection, the SNF may enter the beneficiary's selection at his/her request and indicate on the notice that this was done for the beneficiary. Otherwise, SNFs are not permitted to select or pre-select an option for the beneficiary as this invalidates the notice . Accessed online at: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-SNF-ABN- On 5/4/23 at approximately 10:30 AM, the facility Administrator was made aware of the above findings. No further information was provided.

Based on record review, staff interview, and facility documentation review, the facility staff failed to ensure that one Resident (Resident #145) was free from a significant medication error, where insulin was administered and was not ordered, in a survey sample of 25 Residents. The findings included: On 5/3/23, at approximately 8:30 AM, Resident #145 was visited in his room. During the interview, Resident #145 expressed concern over his blood sugars and said that he had several occurrences of hypoglycemia and was having difficulty managing his blood sugars. On 5/4/23, a clinical record review was conducted of Resident #145's chart. This review revealed that Resident #145 had orders for sliding scale insulin. The physician order read, Humalog Kwik Pen Insulin 100 unit/mL subcutaneous, Administer Humalog insulin per blood sugar sliding scale. Sliding scale subcutaneous 4 times a day at 7:30 AM; 11:30 AM; 4:30 PM and 10 PM as follows: Less than 70 follow hypoglycemic protocol and call MD. For BS [blood sugar] 70-150= No Insulin; 151-200= 3 units; 201-250= 6 units . Review of the Medication Record for Resident #145 for the month of April revealed that on 4/26/23, Resident #145's blood sugar was 137 at 7:30 AM. The nursing staff administered 3 units of insulin. According to the physician order, insulin was not to be administered with a blood sugar reading of 137. On 5/4/23 at approximately 10:30 AM, an interview was conducted with LPN B. LPN B stated that it is important to manage a person's blood sugar because you don't want them to get hypoglycemic, they can go into shock, or a coma and their kidneys can shut down as well. On 5/4/23 at 12:36 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that when a person's blood sugar is too low, they can go into a coma and could die. The ADON was shown Resident #145's medication record and confirmed that on 4/26/23, with a blood sugar of 137 no insulin should have been administered. On the afternoon of 5/4/23, Surveyor C met with the attending physician of Resident #145, who was also the medical director for the facility. The doctor confirmed that Resident #145 had some challenges in managing his blood sugars at stable levels. When shown the orders for sliding scale the doctor confirmed that with a blood sugar of 137, no insulin was to be administered. The doctor also confirmed that this could cause the blood sugar to drop to dangerous levels that could be life threatening. A review was conducted of the facility policy titled, Blood Glucose Monitoring/Treatment. This policy read, . 2.2 The blood glucose will be obtained as ordered by physician or PRN [as needed] when the resident demonstrates symptoms of hypoglycemia or hyperglycemia . Review of the policy titled; Administration of Drugs was also reviewed. This policy read, .2.1 All medications shall be administered in accordance with the physicians' instructions and consistent with the standards of practice outlined in the current A Resource Guide for Medication Management for Persons Authorized Under the Drug Control Act, approved by the Virginia Board of Nursing . On the afternoon of 5/4/23, the Administrator and Director of Nursing were made aware of the above concerns. No additional information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from unnecessary medications for 1 Resident in a survey sample of 25 Residents. The findings included: For Resident #37 the Medical Director ordered several narcotic medications including duplicate orders for PRN Oxycodone. On 5/2/23 at approximately 3:30 PM an interview was conducted with Resident #37 she stated that she used to go to pain management but no longer wants to go there. She stated that the doctor at the facility will manage her pain medications now. Resident #37 had been recently readmitted to the facility after a hospital stay. Resident #37 had diagnosis that included but were not limited to cervical spinal stenosis causing upper body pain, and osteoarthritis. On 5/3/23 a review of the clinical record was conducted, and it was found that Resident #37 was prescribed the following medications for pain when readmitted back to the facility after a hospital stay. 5/1/23 - Lyrica - (Pregabalin) 75 mg by mouth three times daily for pain. (Lyrica is a seizure medication used for treatment of neuropathic pain) 5/2/23-Methocarbamol 500 mg tablet by mouth 4 times a day as needed for muscle spasm (Methocarbamol is a muscle relaxer) 5/1/23 - OxyContin 20 mg. tablet, crush resistant extended release, 1 tablet by mouth 3 times per day for pain (OxyContin is a narcotic pain medication) 5/3/23 - Oxycodone-acetaminophen 5/325 mg. one tablet by mouth twice daily (Oxycodone is a narcotic pain medication) 5/2/23 - Oxycodone acetaminophen 5/325 mg one tablet by mouth every 4 hours as needed for pain (Oxycodone is a narcotic pain medication) 5/2/23 - Oxycodone acetaminophen 5/325 mg one tablet by mouth every 6 hours as needed for pain (Oxycodone is a narcotic pain medication) 5/2/23 - Nucynta 75 mg 1 tablet by mouth every 6 hours PRN pain (Nucynta is a narcotic pain medication. On 5/4/23 at 3:00 PM an interview was conducted with the Medical Director who was asked about the duplicate medication therapy of narcotic pain medications. The Medical director explained that prior to coming to the facility the Resident was at another nursing facility and not happy with the care. He stated that she was seeing a Pain Management specialist however did not want to continue seeing them. The medical director stated that he would manage her pain however he did recommend that she see a neurosurgeon for her spinal stenosis and that she see another pain management specialist, and a rheumatologist. When asked about the duplicate Oxycodone orders he stated that he noticed Resident # 37 not making use of the PRN medication and suggested that LPN B offer it to her twice a day. He stated that the nurse must have put in the order for twice a day scheduled. He stated that he would discontinue the routine dose. The Medical Director also stated that he had discontinued some of her medications, but they restarted them at the hospital. On 5/4/23 at approximately 3:45 PM an interview was conducted with the LPN B who was asked the procedure for a resident who comes from the hospital to the facility. LPN B stated that when a Resident is admitted to the facility the nurse calls the MD or Nurse Practitioner and verifies the orders with them. When asked how the verification process works, she stated that the nurse reads off the medications and the doctor approves or disapproves. She stated at that time the MD has the choice to keep the orders from the hospital or change them. On 5/4/23 during the end of day meeting the Administrator was made aware of the concerns with the narcotic pain medications and no further information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with CDC (Centers for Disease Control) and CMS (Centers for Medicare & Medicaid Services) guidance/requirements during a COVID-19 Outbreak within the facility for 2 out of 3 residential nursing units. The findings included: The facility staff failed to conduct COVID-19 testing on 1/11/23 and 1/13/23 on Nursing Units A and B, following the identification of a COVID-19 Outbreak on 1/9/23. All residents located on Nursing Unit C had tested positive for COVID-19 on 1/9/23. On 5/3/23, a group interview was conducted with the Director of Nursing (DON) and the Infection Preventionist (IP). The IP stated that 2 residents on Nursing Unit C had tested positive for COVID-19 on 1/8/23 and on 1/9/23, all residents located on Unit C had tested positive for COVID. Unit C was quarantined and COVID testing was also conducted on Units A and B on 1/9/23. The DON and IP stated that the facility's infection control program includes following all recommended CDC guidelines for COVID-19 testing. The facility's COVID-19 Outbreak testing records, including a timeline, along with the facility's COVID-19 testing policy was requested and received. On 5/3/23, review of the facility's COVID-19 Outbreak testing records and timeline was conducted and confirmed the COVID-19 outbreak within the facility on 1/9/23. All residents in the facility were tested on [DATE], however residents were not tested again until 1/16/23--7 days following the initial outbreak. The resident testing occurrences were provided and confirmed by the IP and DON on 5/3/23. On 5/4/23, a review of the facility policy titled, COVID-19 Testing Plan, date revised 1/9/2023, subtitle, 1.0--Policy Statement, was conducted and read, .testing will be conducted in a manner consistent with current standards of practice for COVID-19 to facilitate effective interventions for rapidly detecting and preventing the transmission of COVID-19 and The facility's Testing Plan will be reviewed frequently and will be modified as needed to reflect current updated guidance from CMS [Centers for Medicare & Medicaid Services], CDC [Centers for Disease Control and Prevention], and state health department recommendations. The CDC document entitled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 23, 2022, page 11, subheading, Nursing Homes, item 6 Responding to a newly identified SARS-CoV-2 infection in any HCP [Healthcare Personnel] or resident, read, Perform testing for all residents and HCP Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test, this will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. On 5/4/23, the Medical Director, Facility Administrator, DON, and IP were updated on the findings. No further information was provided.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure the environment remained free of potential accident hazards (a portable heater) for one (Resident (R) 3) out of a survey sample of two. There was no evaluation of the resident's cognition, ambulatory status, and potential risks associated with the use of a portable heater completed prior to the use of the heater. Findings include: Review of a policy provided by the facility titled Incidents & Accidents, dated 01/09/23 failed to address potential environmental or equipment hazards. Review of a document provided by the facility titled Profile Face Sheet, indicated R3 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, difficulty walking, and dementia. Review of a document provided by the facility titled Care Plan dated 02/08/20 indicated R3 had impaired physical mobility and required assistance. In addition, the Care Plan indicated the resident had a decline in physical functioning due to weakness. The Care Plan dated 04/23/22, revealed the resident had impaired cognition related to memory impairment. Review of R3's quarterly Minimum Data Set (MDS) provided by the facility with an Assessment Reference Date (ARD) of 04/14/23 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident was moderately cognitively impaired. The assessment indicated the resident required limited assistance of one staff member for bed mobility and transfers. The assessment revealed the resident could ambulate in her room with limited assistance of one staff member. The assessment revealed the resident used a walker or a wheelchair for ambulation. Review of documents provided by the facility titled Guardian Angel Rounding Tool for R3, dated 04/03/23, 04/10/23, 04/17/23, and 04/21/23 indicated the resident's room was cluttered and the resident would refuse assistance from staff to clean and to pick up her personal items. During an observation and interview on 05/02/23 at 11:50 AM, R3 had a portable heater located in her room and across from the foot of her bed. The heater was on. There was no clutter around the portable heating device. The resident stated she had the heater for multiple years. The resident did not want to be interviewed further. During an observation on 05/02/23 at 4:33 PM, R3's door was open, and the portable heater was still present. During an interview on 05/03/23 at 9:34 AM, Certified Nursing Assistant (CNA) B confirmed R3 had a portable heater in her room and stated the resident has directed staff not to touch her personal items and stated the resident turns the heater on herself. During an interview on 05/03/23 at 9:27 AM, Maintenance (Employee (Empl) D) confirmed there was a heater in R3's room and it was placed there when the heating went out. Empl D confirmed the facility purchased the heater. Empl D stated he did not check out the portable heater or monitor the heater after the heater was placed in the resident's room. During an interview on 05/03/23 at 9:46 AM, the Facility Operations Director (Empl F) stated he was not aware there was a portable heater in R3's room. Empl F stated he would expect the portable heater to be checked and inspected. Empl F stated he did not work with nursing to identify residents who may be at an increased safety risk with the use of a portable heater. During an interview on 05/03/23 at 10:15 AM, Empl D and Empl F both stated there were no other portable heaters in any resident rooms. Empl F stated there were no logs which would indicate which resident or residents who received a portable heater. A request was made on 05/03/23 at 10:34 AM for a purchase invoice for the portable heaters from the Administrator. No document was provided prior to the end of the survey. During an interview on 05/03/23 at 12:11 PM, the Facility's Maintenance/Housekeeping Director (Empl H) stated portable heaters were provided as long as they were used per manufacturer guidelines. Empl H stated the portable heaters had no heating elements and were tampered proof. Empl H stated there were no tags attached to the heaters which would indicate safety and inventory. Empl H stated he has not seen any data tracking on the heating devices which would indicate the date of purchase, date of installation, and date of inspection. During an interview on 05/03/23 at 12:54 PM, the Social Worker (Empl G) stated she entered R3's room on a daily basis to check on the resident. Empl G stated she remembered the resident with a portable heater and had reported this verbally to Empl D on a couple occasions. Empl G stated she was concerned about the safety of the heater in the resident's room. During an interview on 05/03/23 at 3:20 PM, the Medical Director (Empl K) stated R3's skin was fragile, had memory issues, and was at risk of falling. Empl K stated the resident did not comply with fall precautions and would not use her walker to assist her with ambulation. During an interview on 05/04/23 at 2:13 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON/Empl C) both confirmed there was no safety evaluation completed for R3 prior to the use of the portable heater. The DON stated the staff were responding to the lack of heat for the residents.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide pharmaceutical services including procedures that assure accurate acquiring and dispensing of medications, for 1 Resident, (#95) in a survey sample of 25 Residents. The findings included: For Resident # 95 the facility staff failed to secure hard scripts for narcotic medications, and they were accessible in the Resident's chart. On 5/3/23 during clinical record review a review of the hard (paper chart) was conducted and it was found that there were prescriptions for Oxycodone (narcotic pain medication and controlled substance), as well as Lyrica (used for neuropathic pain and also a controlled substance) in the chart. On 5/3/23 at 4:00 PM and interview was conducted with LPN B who was asked the procedure for admitting a Resident from the hospital with new prescriptions. LPN B stated that the prescriptions should be faxed to the pharmacy and placed in the folder in the medication room for the pharmacy to pick up. When asked if the prescriptions should be kept in the hard chart, she stated that they should not. When asked why it would not be kept there, she stated that it would prevent diversion of the script. On 5/3/23 at 5:00 PM an interview was conducted with the DON who stated that LPN B was correct the prescription should not be left in the chart for any reason. The prescription should be placed in the folder for pharmacy to pick up. On 5/4/23 during the end of day meeting the administrator was made aware of the concerns and no further information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to post daily staffing information for Residents, staff, and visitors to see, which has the potential to affect all Residents. The findings included: On 5/3/23 at approximately 11:00 AM, a facility tour was conducted to look for daily staffing posted. With the assistance of facility staff, the surveyor was taken to the unit manager office where on a table inside the office door, the daily staff posting was noted. The facility staff stated that the scheduler fills out the daily staffing and puts it in the office daily. On 5/5/23, during the mid-late morning, the Director of Nursing again confirmed that the daily staff posting is completed by the scheduler each day and placed in the unit manager office, which was vacant at the time of survey due to the unit manager position being vacant. The Director of Nursing (DON) further confirmed that the office is locked daily around 4:30-5:30 PM, therefore Residents and/or families have no access to the area in the evenings. A review of the facility policy titled, Nurse Staffing Posting was conducted. This policy read, The nurse staffing sheet will be posted in the nurses' station . The facility must, upon oral or written request, make nurse staffing data available to the public for review. On 5/5/23, during an end of day meeting with the facility Administrator and DON, were made aware of the above findings. No further information was provided.

Based on observations, interviews, record review, and policy review, the facility failed to consistently implement Centers for Disease Control and Disease Prevention (CDC) infection control measures in the quarantine unit for six of six residents (Resident (R) 18, R82, R81, R78, R77, and R79) and failed to keep urinary catheter tubing off the floor for one of one resident (R15) reviewed for urinary catheters out of a sample of 16 residents. These failures increased the risk of transmission of COVID-19 to the residents on the quarantine unit and urinary tract infection to R15. The facility had one positive COVID-19 resident at time of survey. Findings include: 1. Review of CDC guidance, Preparing for COVID-19 in Nursing Homes, updated April 30, 2020, revealed, . Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19 . Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19. Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Review of CDC, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated February 23, 2021, revealed, . The IPC [Infection Prevention and Control] recommendations described below also apply to patients who have met criteria for a 14-day quarantine based on prolonged close contact with someone with [CONDITION(S)]-CoV-2 infection. Patients in this 14-day quarantine period should be isolated in a single-person room and cared for by HCP using all PPE recommended for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection . Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use . Put on clean, non-sterile gloves upon entry into the patient room or care area . Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. Review of the facility policy, Pandemic Disease Policy, revised May 2020, revealed, . b. For residents on standard, contact and airborne isolation: Staff will don gloves, gown, eye protection and respirator (N95 or higher if available) prior to room entry . j. ii. 2. PPE is appropriately removed and discarded after resident care, prior to leaving the room . Review of the facility, Roster-Residents with Room Numbers, dated 03/16/21, provided by the Director of Nursing (DON), revealed six residents were housed on the warm (quarantine) unit due to being new admissions or readmissions. These six residents, R18, R82, R81, R77, R78, and R79, were within the 14-day quarantine and were being monitored for signs and symptoms of COVID-19. On 03/17/21 at 8:55 AM, housekeeper (HSK)1 was observed entering the quarantine unit from the COVID-19 unit through the zippered plastic barrier wall separating the units. HSK1 left the zipper opened in the plastic barrier. HSK1 had on a gown, face shield, N95 mask, and gloves. HSK1 walked past R18, R82, R81, R77, R78, and R79's rooms. The door of each room was open to the hallway. HSK1 proceeded to empty a linen cart placing towels in the clean linen room with the same PPE on that she had worn in the COVID unit. On 03/17/21 at 9:10 AM, HSK1 was observed leaving the quarantine unit through the zippered plastic barrier wall entering the COVID unit. Continued observation revealed HSK1 bringing empty trash containers from COVID unit to the quarantine unit. Continued observation revealed HSK1 placing bags of trash into the containers and taking them back through the zippered barrier wall into the COVID unit and out the exit door. On 03/17/21 at 9:14 AM, HSK1 was observed coming back from the COVID unit into the quarantine unit, walking down the hallway to the housekeeping cart where she removed the gown and gloves. During an interview on 03/17/21 at 9:20 AM, Licensed Practical Nurse (LPN) 2 verified that HSK1 came out of the COVID unit through the zippered plastic barrier wall into the quarantine unit walking through the hallway wearing the same PPE she had on in the COVID unit. LPN2 stated that staff were not to enter the quarantine unit from the COVID unit. Further observations on the quarantine unit on 03/17/21 at 9:30 AM revealed HSK1 entering R82's room wearing a gown, gloves, face shield, and mask to clean the room. On 03/17/21 at 9:40 AM, HSK1 was observed leaving R82's room wearing the same PPE, walking to her housekeeping cart, emptying the container of disinfectant, picking up clean trash can liners, and returning to R82's room. On 03/17/21 at 9:44 AM, HSK1 was observed leaving R82's room, returning to her cart, removing her gown and gloves in the hallway, and using Alcohol Based Hand Rub (ABHR) to sanitize her hands. On 03/17/21 at 9:50 AM, HSK1 was observed putting on a clean gown and gloves and entering R18's room with a container of disinfectant to clean the room. On 03/17/21 at 9:52 AM, HSK1 was observed leaving R18's room wearing the same gown and gloves, walking down the hallway to her cart, retrieving clean trash can liners, and walking back to R18's room. On 03/17/21 at 9:54 AM, HSK1 was observed leaving R18's room, returning to her cart, removing her gown and gloves in the hallway, and using ABHR to sanitize her hands. During an interview on 03/17/21 at 10:15 AM, HSK1 verified that she did enter and exit the quarantine unit from the COVID unit while taking out the containers of trash. HSK1 also verified that she had worn the PPE in and out of resident rooms as she was cleaning the rooms, including the bathrooms. HSK1 verified that she did not remove the gown and gloves prior to leaving R82 and R18's rooms. During an interview on 03/19/21 at 9:10 AM, the Housekeeping Manager (HM) stated that the housekeeping staff have had numerous infection control trainings throughout the COVID-19 pandemic. HM stated that housekeeping staff have been trained on where to don (put on) and doff (remove) PPE and what PPE is required on the quarantine unit. HM stated that housekeeping staff know to doff the gowns and gloves in the resident room and not to wear out into the hallway after cleaning rooms. HM stated that housekeeping staff are not to go on the COVID unit but instead the nursing staff on that unit clean the rooms. HM stated that the trash is to be taken to the double doors of quarantine unit for removal and not through the COVID unit. Review of undated inservice attendance logs, provided by the Housekeeping Manager, revealed HSK1 did receive training on infection control and PPE requirements for the quarantine units. On 03/17/21 at 9:00 AM in the quarantine unit, Certified Nursing Assistant (CNA) 1 was observed pulling the plastic barrier separating the quarantine unit from the COVID unit away from the wall to talk to LPN1 who was the nurse on the COVID unit. On 03/17/21 at 9:17 AM, CNA1 was then observed entering and exiting R79 and R82's rooms picking up breakfast trays wearing a face shield and mask but no gloves or gowns. During an interview on 03/17/21 at 10:00 AM, CNA1 stated that gowns and gloves were not required when picking up meal trays. During an interview on 03/17/21 at 11:30 AM, LPN1 verified that she was the nurse on the COVID unit that day. LPN1 stated that staff were not to go from the COVID unit to the warm unit but instead stay on the COVID unit for their shift and exit through the door on the COVID unit. LPN1 verified that HSK1 came in and out of the quarantine and COVID units to retrieve trash containers. LPN1 also verified that CNA1 pulled the plastic barrier away from the wall to ask her a question. LPN1 stated that the staff is to use a telephone to communicate to one another not to pull the plastic barrier away from the wall. During an interview on 03/17/21 at 2:30 PM, the Infection Control Preventionist (ICP) stated staff on the quarantine unit are to wear all PPE (gowns, gloves, face masks and shields) when entering resident rooms regardless of the amount of resident contact in the room. The ICP stated that included delivering and picking up meal trays. During the interview on 03/17/21 at 2:30 PM, the ICP verified that staff entering the quarantine unit from the COVID unit, wearing gowns and gloves out of resident rooms into the hallway, and pulling the plastic barrier from the wall to talk to staff on the COVID unit did not follow CDC guidance or the facility's infection control policy for resident care in the quarantine unit. 2. Review of the facility policy titled, Prevention of Catheter-Associated Urinary Tract Infections dated 03/16/21, indicated, .4. Procedure, b. vi .Do not rest the bag on the floor. Observation of Resident (R)15 on 03/16/21 at 12:20 PM in the Main Dining Room revealed R15 seated in a wheelchair at a table eating lunch, the tubing from her catheter was noted to be dragging on the floor under the wheelchair. Observation of R15 was perform on 03/16/21 at 12:34 PM in the Main Dining Room with the Director of Nursing (DON), the catheter tubing was noted to be dragging on the floor. On 03/16/21 at 12:34 PM in an interview with the DON the DON confirmed R15's catheter tubing was sitting on the floor, in the Main Dining Room. The DON stated the tubing should not be there. The tubing should not be on the floor due to germs and risk of infection. Observation of R15 on 03/16/21 at 02:50 PM in the Main Dining Room while R15 was participating in an activity revealed the catheter tubing on floor. A review of R15's Profile Face Sheet [a cover sheet to a multipage document that contains demographic information, insurance information, contact information and limited medical information] found in the Electronic Medical Record (EMR) under the profile tab, revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of R15's Care Plan with a start date of 02/22/21, indicated, .Cover drainage bag when up to promote privacy.

Based on observation, policy review, and staff interview the facility failed to store frozen food in accordance with professional standards for food service safety. Findings: On 7/11/2018 at 8:10AM, an observation was made of the walk-in freezer. An open plastic bag containing 6 frozen sausage patties was noted as being unsealed and unlabeled. Employee A (the head Chef) was asked what the bag contained, and he stated it has the sausage from this morning that wasn't used. When asked for his observations of the food, Employee A stated it was on the tray line this morning. It should be put back in the original box, or sealed and labeled. A review of the provider's policy titled PROPER FOOD HANDLING AND SANITATION last revised (MONTH) 2014 showed the following: 3.4 FREEZER STORAGE (walk-in and reach-in) 3.4.2 All stored food must be wrapped, stored in sealed containers or secured in a tied plastic bag. 3.4.3 All stored food must be properly labeled with date and product name. No further information was provided prior to exit.

Based on observation, resident interview, and staff interview the facility failed to post, in a place readily accessible to residents, family members, and legal representatives, the results of the most recent survey of the facility. Findings: On 7/10/2018, an observation was made of the nursing facility. Posted survey results were not found. On 7/11/2018 at 1:45PM, during the Resident Council interview, residents were asked if they knew where to find the most recent survey findings. Of the 6 residents in attendance, none could verbalize where the most recent survey findings could be located. On 7/11/2018 at 2:10PM, Administrative Employee B (the Director of Nursing) was asked where the most recent survey findings were posted. Administrative Employee B showed the surveyor an empty plastic chart holder mounted on the wall near the nurse's station. On observation, the chart holder was not labeled. There was no signage that survey findings were available at the location. Administrative Employee B was asked if a resident could locate the survey findings, and replied No. There isn't a sign. Administrative Employee B was asked where, specifically, the survey findings were located, and she replied They are supposed to be in this plastic holder. I don't know where they are. On 7/12/2018, at 8:00AM, an observation was made of the designated location for survey findings. A binder labeled Survey Results was in the plastic chart holder. The binder needed to be facing out towards the corridor with the top uppermost to read the label, and there was no signage directing residents, family members, and legal representatives to the binder containing the survey findings. Administrative Employee B was asked if a resident could locate the survey findings if the binder was in any other position than upright and facing forward, and replied No. There is a label on only one side. No further information was provided prior to exit.

Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed to follow the professional standards of nursing for medication administration for one resident, Resident #7 in a survey sample of 17 residents. Resident #7 received his physician ordered Vitamin B 12 by oral route , rather than the physician ordered sublingual route. The findings included: Resident #7 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #7's most recent MDS (minimum data set) coded as an admission 5 day assessment, coded the resident with a BIMS (brief interview of mental status) of 15 out of a possible 15, or no cognitive impairment. Resident #7 was coded as requiring standby to limited assistance with ADL's (activities of daily living) such as bed mobility and dressing. On 5/10/17 at 9:05 AM, a medication pass was observed for this resident. LPN (Licensed practical nurse) A poured the medications in a medicine cup. Included was a pill for Vitamin B 12 2500 mcg (micrograms) sublingual (under the tongue). The medications (including the Vitamin B 12) were taken whole with water by mouth. Review of the physician's orders [REDACTED]. On 5/10/17 at 1:30 PM, an interview was conducted with LPN (A). She stated, I put all the pills in a cup and gave it to him (Resident #7). When told she had given it by mouth rather than the ordered sublingual route, she stated, Oh. Review of the facility's policy and procedure (derived from Lippincott and Mosby per the DON (director of nursing) on Medication Administration- General Guidelines revealed: Medications are administered in accordance with written orders of the attending physician.Saunder's Nursing Drug handbook, 2011, page 1312 included: Sublingual: Administer while seated, dissolve sublingual tablet under tongue (do not chew or swallow tablet), and do not swallow until tablet is dissolved. On 5/11/17 at 12:00 PM, the Administrator and DON were notified of above findings.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure Physician orders for recertification were signed timely for one resident (Resident # 4) in a survey sample of 17 residents. For Resident # 4, the facility staff failed to ensure Physicians orders for recertification were signed timely. No signed Physicians Orders for Recertification were noted between 1/18/2017 and 5/10/2017 (at the time of survey) resulting in 111 days since the last signed recertification orders. Findings included: Resident # 4, a [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a Significant Change Assessment with an ARD (assessment reference date) of 2/4/2017. Resident # 4 was coded as having a BIMS (Brief Interview for Memory Status) score of 13 indicating no cognitive impairment. Resident # 4 was coded as requiring minimal to total assistance of one staff person for his ADLs (activities of daily living), except requiring total assistance of two staff persons for transfers. Resident # 4 was coded as being always incontinent of bowel and bladder. Review of Resident # 4's clinical record revealed the most recently signed Certification and Recertification form was dated as having been signed on 1/18/2017 to recapitulate and reinstitute the Resident's medication, and treatment orders. A thorough review of Resident # 4's clinical record revealed the previously signed Certification and Recertification form was dated as signed on 1/7/2017. On 5/10/2017 at 2:42 PM, an interview was conducted with the Director of Nursing who stated the expectation was that the Physicians would sign Physicians Orders for recertification upon admission to Skilled care, then at 14 days, at 30 days and then every 30 days. On 5/10/2017 at 3:45 PM, the Administrator and Director of Nursing were informed that the last signed Physicians Orders Sheet noted in the clinical record was dated on 1/18/2017 and the one prior was dated on 1/7/2017. The Director of Nursing and Administrator stated the physicians visit the facility every week to examine residents and sign to recertify orders every month. The Director of Nursing stated she would look for signed recertification orders for Long Term Care. The surveyor asked for a copy of the most recent signed Physicians Orders for Recertification. On 5/11/2017 at 9:10 AM, the Director of Nursing stated she reviewed Resident # 4's record and noted the physician visited Resident # 4 at least every month and wrote progress notes. The Director of Nursing stated Resident # 4 became a Long Term Care resident in January 2017 but there were no signed recertification orders for Resident # 4 since he became a Long Term Care resident. During the end of day debriefing on 5/11/2017 at 12:20 PM, the facility Administrator and the Director of Nursing were informed of no signed Physicians Orders for recertification for Long Term Care after the last Skilled Care signature on 1/18/2017. No further information was provided.

Based on staff interview, facility documentation and clinical record review, the facility failed for two residents (Resident #9 and Resident #10) in a survey sample of 17 residents, to ensure an effective prevention infection control program. LPN (licensed practical nurse) B did not wash her hands effectively between Resident #9 and Resident #10. The findings included: Resident #9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. septicemia and high blood pressure. Resident #9's most recent MDS (minimum data set) coded 4/16/17 coded as an admission 5 day assessment, coded the resident with a BIMS (brief interview of mental status) of 13 out of a possible 15, or no cognitive impairment. Resident #9 was coded as requiring extended to total assistance with ADL's (activities of daily living) such as bed mobility and dressing. Resident #10 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #10's most recent MDS (minimum data set) dated 2/7/17 coded as a quarterly assessment, coded the resident with a BIMS (brief interview of mental status) of 12 out of a possible 15, or no cognitive impairment. Resident #10 was coded as requiring extended assistance with ADL's (activities of daily living) such as bed mobility and dressing. On 5/10/17 at 9:30 AM, LPN (B) prepared Resident #9's medications and administered both oral medications and eye drops. LPN (B) went to the sink, washed her hands and turned off the faucet with her bare hands. On 5/10/17 at 9:50 AM, LPN (B) prepared Resident #10's medications and again administered both oral medications and eye drops. She went to the sink, washed her hands and turned off the faucet with her bare hand. On 5/11/17, the facility handwashing procedure was reviewed. The last step in the procedure was to Use clean dry paper towel to turn off faucet. On 5/11/17 at 10;10 AM, an interview with the infection control nurse, RN (registered nurse A) was conducted. She stated she taught the following procedure (by CDC- centers for disease control) for handwashing: Turn on faucet wash hands, soap, rub between fingers and up to wrist for 20 seconds. Rinse, get a paper towel and dry hands. Use a paper towel to turn off the faucet. On 5/111/17 at 12:00 PM, the Administrator and DON (director of nursing) were notified of above findings.

Based on staff interview and facility documentation review, the facility staff failed to ensure the Director of Nursing functioned in a full time role. The Director of Nursing held two positions at the facility, the Administrator and the Director of Nursing. The findings included: The initial entrance at the facility took place on 3/31/15 at 1:45 p.m. The survey team was greeted at the door by the Director of Nursing (DON). When asked if the Administrator was available, the DON stated that she was the Administrator. When asked You are the Administrator and DON?, the DON stated yes. The DON explained that the original Administrator had left in August 2014. She stated that they had hired a new Administrator in the mean time who stayed only 3 months. She stated that the State Agency had been notified that she was now the interim Administrator. She provided a copy of the letter. The letter was dated January 22, 2015. It read ______ has been appointed the acting administrator. The name in the letter was the name of the DON. The letter also read _______ last day as the administrator of record was January 23, 2015. The name was the interim administrator. On 3/31/15 at 2:30 p.m., the Administrator/ DON was asked about how she completed her DON duties. She stated that she gave some of her responsibilities to the Assistant Director of Nursing to complete. On 4/2/15 at 3:00 p.m, the Administrator/ DON stated that she spent about half of her time in the DON role and half of her time in the Administrator role. On 4/2/15 at 4:15 p.m., the Administrator/ DON and facility staff were notified that it was required by regulation that the DON and the administrator function in a full time role.

Based on staff interview and clinical record review, the facility staff failed for 4 residents (Resident #9, #4, #6 and #12) of 15 residents in the survey sample to ensure the drug regimen review findings were documented. 1. Resident #9 did not have drug regimen findings documented in the clinical record. 2. For Resident #4, the facility staff failed to ensure monthly medication reviews included findings. 3. For Resident #6, the facility staff failed to ensure monthly medication reviews included findings. 4. Resident #12 did not have drug regimen findings documented on the clinical record. The findings included: 1. Resident #9 did not have drug regimen findings documented on the clinical record. Resident #9, a [AGE] year old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her Initial Minimum Data Set Assessment coded her with a Brief Interview of Mental status score of 3 indicating severe cognitive impairment. She required extensive assistance with her activities of daily living. Resident #9's drug regimen review was reviewed. The clinical record contained the paper form Medication Regimen Review Signature Record. The form read For complete documentation please refer to the electronic record. The form included a signature and date line for the pharmacist. It also read Recommendation made: Yes___ No___. The pharmacist signed the drug regimen review form on 3/23/15. Neither yes or no was checked to indicate if a recommendation had been made. On 4/2/15 at 1:30 p.m., the pharmacy review was discussed with the Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Clinical Coordinator. The DON explained that the pharmacist documented the pharmacy recommendations in the computer. When asked who had access to the pharmacist's computerized recommendations, the DON stated that only the pharmacist had computer access until yesterday when he showed her how to look at the pharmacy recommendations. When asked how the facility staff knew if there was a pharmacy recommendation, the DON stated that the facility staff knew if there was a pharmacy recommendation when the pharmacist provided a printout of the recommendations. She stated the usual process was that the pharmacist printed out the pharmacy recommendations and gave them to her. She forwarded them to the Clinical Coordinator who was responsible for having the doctor address the recommendation. The DON stated that the form with the statement Recommendation made: Yes___ No___ was a new drug regimen review form. She stated that the old form only had a place for the pharmacist's signature. It did not have a check box section for the pharmacist to indicate if a recommendation had been made or not. When asked why the pharmacy had switched to the new form, she stated that she did not know. It was reviewed with the DON that the new form appeared to be used incorrectly. 2. For Resident #4, the facility staff failed to ensure monthly medication reviews included findings. Resident #4, a male, was admitted to the facility 1/14/15. His [DIAGNOSES REDACTED]. Resident #4's most recent MDS with an ARD of 1/27/15 was coded as a five day, admission assessment. He was coded as having no memory deficits and was able to make his own daily life decisions. Resident #4 was coded as needing extensive assistance of one staff member to assist with his activities of daily living. Review of Resident #4's clinical record revealed no indication on the monthly drug regimen review of whether any irregularities or recommendations were identified or made by the pharmacist. Review of the form revealed an area to be checked by the pharmacist that includedRecommendations made: Yes ( ) No ( ). While the pharmacist's initials and a date were evident, no indication was evident whether recommendations were made. The administrator was informed of the failure of the staff to ensure pharmacy monthly drug regimen reviews included whether irregularities were identified and recommendations were made, 4/1/15 at 5:15 p.m. 3. For Resident #6, the facility staff failed to ensure monthly medication reviews included findings. Resident #6, a female, was initially admitted to the facility 3/31/14 and readmitted after a hospitalization [DATE]. Her [DIAGNOSES REDACTED]. Resident #6's most recent MDS (minimum data set) with an ARD (assessment reference date) of 2/5/15 was coded as a quarterly assessment. She was coded as having short and long term memory deficits and required total assistance with making daily life decisions. Resident #6 was coded as needing extensive to total assistance of one to two staff members to perform her activities of daily living. Review of Resident #6's clinical record revealed no indication on the monthly medication review completed by the pharmacist, whether any irregularities were found or recommendations were made by the pharmacist. The form only included a pharmacist signature with a date indicating the Resident's medications had been reviewed. The administrator stated the pharmacist was able to input the findings into a pharmacy computer system, however the findings were not part of Resident #6's clinical record. The administrator was informed of the failure of the staff to ensure pharmacy monthly drug regimen reviews included information regarding any irregularities or recommendations made as a result of the review, 4/1/15 at 5:15 p.m. 4. Resident #12 did not have drug regimen findings documented on the clinical record. Resident #12 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a significant change assessment with an Assessment Reference Date (ARD) of 3/18/15. The MDS coded Resident #12 with short and long term memory problems and required extensive assistance from staff for most activities of daily living. On 4/2/15 at 8:55 a.m., Resident #12's clinical record was reviewed. The review revealed monthly pharmacy medication regimen reviews on a form titled (Name of Pharmacy) Consultant Pharmacist Signature Record of Medication Regimen Review which included the Resident's name, dates of review and pharmacist initials/signature. The form included the statement For complete documentation please refer to the electronic record. With the exception of February 17, 2015, there was no monthly pharmacy documentation of whether or not the pharmacist had recommendations for the physician. On 4/2/15 at 9:55 a.m., the Administrator/Director of Nursing (Admin-A) was informed of the findings.

Based on staff interview and clinical record review, the facility staff failed for one resident (Resident #5) of 15 residents in the survey sample, to notify the physician of oxygen saturation results per physician ordered parameters. For Resident #5, the physician was to be notified if oxygen saturation percentage rates were less than 90% or greater than 92%, however the physician was not notified on 24 occasions when the oxygen saturation was below 90% The findings included: Resident #5 was originally admitted to the facility on [DATE], was discharged then readmitted on [DATE] with the [DIAGNOSES REDACTED]. No Minimum Data Set (MDS) assessment was due to be completed during survey. On 3/31/15 during initial tour of the facility, Resident #5 was observed sitting on the edge of her bed, alert and conversational. She stated she had [MEDICAL CONDITION] and was observed testing her oxygen saturation level with her own pulse oximeter (a device used to measure the proportion of [MEDICATION NAME] hemoglobin in the blood in pulsating vessels, especially the capillaries of the finger or ear). Resident #5's oxygen saturation readings were between 83-88%. When asked if the nurses monitor the pulse oximetry (pulse ox) results, the Clinical Coordinator (Admin-C) stated Yes they do. Resident #5 was observed with oxygen via nasal cannula in use at 4 liters per minute. On 4/1/15 at 11:10 a.m., Resident #5's clinical record was reviewed. The review revealed a physician's orders [REDACTED]. Review of the electronic medication record for March 2015 revealed the pulse ox percentages were below 90% on 20 occasions March 23 through March 31. It was documented only once on 3/25/15 that the physician was notified. The medication record for April 2015 had documented pulse ox percentages below 90% on 4 occasions, however there was no physician notification. On 4/1/15 at 5:05 p.m. the Administrative team was informed of the findings. An interview was conducted with the Director of Nursing/Administrator (Admin-A) on 4/2/15 at 3:20 p.m. Admin-A stated Per the MD, notification should have been discontinued. We will discontinue the order. No further information was provided by the facility staff.

Based on staff interview, facility documentation review, and clinical record review, the facility failed to report and investigate an injury of unknown origin in a timely manner for one Resident (Resident #6) in a survey sample of 15 Residents. For Resident #6, a [MEDICAL CONDITION], diagnosed on [DATE] was not reported to the state agency (SA) until 8/18/14 and was continuing to be investigated during September, 2014 (over 5 days from the day of initial discovery). The findings included: Resident #6, a female, was initially admitted to the facility 3/31/14 and readmitted after a hospitalization [DATE]. Her [DIAGNOSES REDACTED]. Resident #6's most recent MDS (minimum data set) with an ARD (assessment reference date) of 2/5/15 was coded as a quarterly assessment. She was coded as having short and long term memory deficits and required total assistance with making daily life decisions. Resident #6 was coded as needing extensive to total assistance of one to two staff members to perform her activities of daily living. Review of a facility reported incident (FRI) revealed Resident #6 experienced swelling of her left elbow on 8/12/14. Resident #6 was assessed by the staff and the physician was informed. The physician ordered to monitor the area. Resident #6's left elbow was noted on 8/14/14 to be larger in size and after informing the physician, an order was obtained for an X-ray. The X-ray obtained on 8/14/14 showed a fracture on the olecranon (elbow). The physician ordered for Resident #6 to be assessed at the ER (emergency room ). A thorough review of the clinical record revealed no indication for Resident #6 having a fractured elbow, including falls or injury around the time in question. After being seen at the ER, the decision was made to treat her conservatively and a sling was applied. Resident #6 was evaluated by the orthopedist with a recommendation for conservative treatment due to Resident #6's comorbidities and age. Resident #6 was treated with pain management and a sling. Review of the investigation, completed by the facility, revealed while the fractured elbow was diagnosed on [DATE], the injury of unknown origin was not reported to the SA (state agency) until 8/18/14. A final report of the investigation was submitted to the SA on 8/20/14. Documentation within the investigation revealed staff statements were still being obtained on 9/1/14. When interviewed 4/2/15 at 11:15 a.m., the administrator stated while the fracture was identified on 8/14/14, the SA was not informed until 8/18/14 (4 days later) and the final report was submitted on 8/20/14. The administrator seemed unaware of why employee statements were still being obtained on 9/1/14. Review of the facility's policy entitled Reporting of Alleged Abuse included: 3.4 When alleged violation involving resident mistreatment, neglect, abuse, and/or misappropriation of personal property occur,(name if facility) is required to self-report such incidences immediately to the Center for Quality Health Care Services and Consumer Protection (SA), hereafter referred to as the Center and to any other state official as required by state law. 3.6 The Health Services Administrator or designee will initiate the investigation and submit appropriate written information to the proper authorities in accordance with state guideline. 3.7 After an initial report of the incident, (name of facility) must investigate the incident, implement corrective action, as indicated, and file a written report of the completed investigation to the Center within five working days of the incident. These reports are reviewed by Center staff to verify that appropriate corrective action are taken to guard against the incident happening again. 5.2.1 Injuries of unknown origin should be handled the same as an allegation of mistreatment, neglect or abuse and must be reported to the Center if there is reasonable cause to believe or suspect that a facility staff member has inflicted an injury upon a resident. The administrator was informed of the failure of the staff to report to the SA and investigate an injury of unknown origin in a timely manner for Resident #6, 4/1/15 at 5:15 p.m.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed for one resident (Resident #3) of 15 residents in the survey sample to follow the professional standards of nursing. For Resident #3, the facility staff failed to document medications as having been administered on 3/12/15 and 3/30/15 and failed to change an order for [REDACTED]. The findings included: Resident #3, a [AGE] year old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 2/10/15. She was coded with moderate cognitive impairment and required assistance with her activities of daily living. Resident #3's clinical record contained a Medication Regimen Review Sheet from the pharmacist to the physician. The Comments/Suggestions read This resident has an order for [REDACTED]. The recommendation was electronically signed by the pharmacist on 2/17/15. The physician checked the Agree checkbox and signed the form on 3/2/15. The March 2015 Medication Administration Record [REDACTED]. On 4/2/15 at 1:00 p.m., it was reviewed with the Assistant Director of Nursing and the Clinical Coordinator that it did not appear that the physician signed pharmacy recommendation had been implemented. After they had the chance to review the order, both nurses agreed that the order had not been implemented. During the March 2015 MAR indicated [REDACTED]. At the end of day meeting on 4/1/15, the Director of Nursing and Assistant Director of nursing were asked to determine if the medications had actually been administered. The following medications had not been signed and were blank for the 10:00 p.m. administration on the dates of 3/2 and 3/30 on the MAR: [MEDICATION NAME] eye drops (for [MEDICAL CONDITION]) [MEDICATION NAME] (vitamin supplement) [MEDICATION NAME] (for constipation) [MEDICATION NAME] (for [MEDICATION NAME] degeneration) [MEDICATION NAME] (for asthma) [MEDICATION NAME] (for cholesterol) [MEDICATION NAME] (for asthma) Latanoprost eye drops (for [MEDICAL CONDITION]) Refresh Tears (for dry eyes) On 4/2/15 at 9:00 a.m., the Director of Nursing stated that the same nurse worked both dates. She stated that he remembered administering the medications on 3/12/15. She stated that he administered all the medications except 3 different types of eye drops on 3/30/15. She provided written statements from the nurse. The 3/12/15 statement from the nurse read The above medications were administered but not signed off right away + then they disappeared at midnight. I should have filled out the form that night + will do so if this happens again. The 3/30/15 statement from the nurse read Medications were administered except ([MEDICATION NAME], Refresh, [MEDICATION NAME]) for eye drops + she also refused [MEDICATION NAME] rinse. In my haste, I forgot to sign off on the computer + it dropped off at 2400 (12AM). The facility's policy Medication Administration- General Guidelines was reviewed. The Policy section read Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The Documentation section of the policy read a. The individual who administers the medication dose records the administration on the resident's MAR indicated [REDACTED]. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. The facility used Mosbys for a nursing standard reference. Fundamentals of Nursing 7th Edition, Potter and Perry, p.713. After administering a medication, record it immediately on the appropriate record form. Never chart a medication before administering it. Recording immediately after administration prevents errors. The recording of a medication includes the name of the medication, dose, route, and exact time of administration.

Based on observation, staff interview and clinical record review, the facility staff failed for one resident (Resident #2) of 15 residents in the survey sample, to ensure a preventative skin treatment was in place. Resident #2 had a physician's orders [REDACTED]. The findings included: Resident #2 was readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a significant change assessment with an Assessment Reference Date (ARD) of 3/11/15. The MDS coded Resident #2 with short and long term memory impairment; moderately impaired cognition; required extensive assistance from staff for all activities of daily living except bathing which required total assistance; was incontinent of bowel and bladder. On 4/1/15 at 8:35 a.m., Resident #2 was observed lying in bed, eyes slightly open. Oxygen was in use via nasal cannula, protective sleeves observed on bilateral arms and legs, heels were floated on pillows. A private duty sitter was in the room with the resident. An interview was conducted with Registered Nurse-C (RN-C) on 4/1/15 at 9:20 a.m. Protective skin measures for Resident #2 was discussed. When asked if the resident had a pressure ulcer, RN-A stated she Does have an area on coccyx and the treatment is every Monday, but we will check it today. Resident #2's clinical record was reviewed. The review revealed a physician's orders [REDACTED]. Change weekly and PRN (as needed). The electronic treatment record had documentation that the dressing was applied last on 3/30/15. On 4/1/15 at 9:55 a.m., Resident #2's coccyx area was observed with RN-A. When RN-A removed Resident #2's incontinent brief there was no protective dressing in place. RN-A stated she will put a new dressing on. Resident #2's coccyx area was observed to have approximately 5 centimeters by 5 centimeters of blanchable redness. No open areas were present. On 4/1/15 at 11:00 a.m. an interview was conducted with Clinical Coordinator (Admin-C). Admin-C was informed that no protective dressing was in place upon observing Resident #2's coccyx area. Admin-C stated a new dressing was placed and that It must've fallen off. When asked who does the care for Resident #2, Admin-C stated the private sitter helps the nursing assistant but the nursing assistant is responsible. Admin-C then stated The Exuderm treatment is for protection to area. The Administrator/Director of Nursing was informed of the findings on 4/1/15 at 5:05 p.m. No further information was provided by the facility staff.

Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed for one Resident (Resident #4) in the survey sample of 14 Residents to monitor the PT/INR status to prevent a GI ([MEDICAL CONDITION]) and hospitalization . The facility staff failed to monitor Resident #4's PT/INR status after receiving [MEDICATION NAME]. Resident #4 developed a GI bleed due to a supratherepeutic PT/INR requiring hospitalization . The findings included: A PT/INR as defined at www.surgery.com is: PT: "This test is done to evaluate the blood for its ability to clot." INR: "The INR is used to make sure the results from a PT test is the same at one lab as it is at another lab. In the 1980's the World Health Organization determined that patients may be at risk because the results of a PT test would vary from one lab to another, based upon the way the test was done. The "normal" range for one lab would be different than a "normal" value from another lab, creating problems for patients who were being treated in several locations. In order to standardize the results between labs, the INR was created. The INR result should be the same, regardless of the location where the tests are performed." The 2006 Nursing Drug Handbook 22nd edition documented the following: "[MEDICATION NAME] is an anticoagulant or blood thinner that works in the body by inhibiting vitamin K activated clotting factors in the blood. Unmonitored [MEDICATION NAME] can cause life threatening side effects such as hemorrhage. The potential for hemorrhage or bleeding is increased when [MEDICATION NAME] is taken with other blood thinning medications, such as aspirin. PT and INR determinations are essential for proper control of [MEDICATION NAME] dosages to prevent side effects. PT and INR are laboratory test values obtained from measurements of the time it takes for a clot to form, and are usually measured when taking anticoagulants such as [MEDICATION NAME] to assure the clotting time stays within the desired range, and to prevent side effects." According to the Laboratory Test Handbook, 5 th edition, Lexi-Comp, Cleveland, 2001; 327-358, "During the initiation of [MEDICATION NAME], the PT/INR is checked at least weekly, until the dose and INR are therapeutic and stable." "The interval between tests can then be gradually decreased to as infrequently as every 4 weeks." Resident #4, a [AGE] year old male, was admitted to the facility 12/1/11 and readmitted after a hospitalization [DATE]. His [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1/17/12 was coded as a significant change assessment. Resident #4 was coded as having no memory deficits and was able to make his own daily life decisions. Resident #4 was also coded as requiring physical assistance for all of his activities of daily living. His plan of care was reviewed and had written to obtain lab work as ordered. Resident #4 was observed 2/15/12 at 11 a.m. He was lying on his back in bed with the head of the bed slightly elevated. Resident #4 was alert and verbally responsive with encouragement. He was receiving oxygen at 2 liters per minute via nasal cannula. A nasal cannula is a plastic tube that delivers oxygen directly into the nostrils. A Foley catheter was in place draining amber colored urine. Review of Resident #4's clinical record revealed a hospitalization on [DATE] due to vomiting and shortness of breath at the facility. Resident #4 was transported to the hospital and discovered to have a supratherapeutic (extremely elevated) PT/INR with coffee ground emesis, oozing gums, and staining of the teeth and tongue from bleeding. Documentation within his ER visit revealed his PT/INR was 5.4 seconds when admitted to the hospital. A goal of 2-2.5 seconds was documented as a therapeutic PT/INR for Resident #4. Resident #4's hemoglobin, a protein in the red cells in the blood that carries oxygen, was 10.1 g/dl with a normal for males after middle age being 12.4-14.9 g/dl. Resident #4 was also diagnosed with [REDACTED]. Review of the nurse's notes revealed Resident #4 did vomit in the morning of 12/30/11, although no description of the vomitus was documented. Resident #4 was admitted to the hospital and during his hospitalization was treated conservatively for his GI bleed due to wishes, age and comorbities. Documentation within his hospital stay included: "1/31/12 He was brought to the emergency room with worsening shortness of breath and some coffee-ground vomiting with staining of his tongue and teeth with black vomitus. He was having elevated PT/INR as well. REVIEW OF SYSTEMS: He has most likely coffee ground vomiting which is staining his teeth and tongue as well as his elevated INR. DIAGNOSTIC STUDIES: ...hemoglobin 9.4, hematocrit 29.6..." Coffee ground emesis is an indication of bleeding in gut. Within a cardiac consultation by the hospitalist: "RECOMMENDATIONS: 1. ...holding [MEDICATION NAME] for the time being... 3. Resume [MEDICATION NAME] when INR is less than 2.5. Goal will be to keep his INR between 2 and 2.5." Resident #4 was evaluated for "abdominal pain and black stool" on 2/5/12. The physician included in his consultation note, "1. [MEDICAL CONDITION], coffee-grounds, and melena is likely secondary to mucosal oozing from supratherepeutic INR. This appears to be resolving. HISTORY OF PRESENT ILLNESS:A very pleasant [AGE] year old male who presents with increasing abdominal distention, abdominal pain, dark stools, and vague history of coffee-ground emesis." After stabilizing, Resident #4 was transported back to the facility on hospice on 2/10/12. Review of Resident #4's clinical record revealed he was initially admitted to the facility 12/1/11. Included in his admitting orders was "[MEDICATION NAME] 5 mg (milligrams) PO (by mouth) QD (daily)." An order was also evident to obtain a PT/INR on 12/6/11. The PT/INR was obtained on 12/6/12 with a physicians order, "[MEDICATION NAME] 6 mg po qd, PT/INR 12/20/11". [MEDICATION NAME] (generic for [MEDICATION NAME]), according to www.nlm.nih.gov, is: "[MEDICATION NAME] is used to prevent blood clots from forming or growing larger in your blood and blood vessels. It is prescribed for people with certain types of irregular heartbeat, people with prosthetic (replacement or mechanical) heart valves, and people who have suffered a [MEDICAL CONDITION]. [MEDICATION NAME] is also used to treat or prevent venous [MEDICAL CONDITION] (swelling and blood clot in a vein) and [MEDICAL CONDITION] embolism (a blood clot in the lung). [MEDICATION NAME] is in a class of medications called anticoagulants ('blood thinners'). It works by decreasing the clotting ability of the blood. Your doctor will probably start you on a low dose of [MEDICATION NAME] and gradually increase or decrease your dose based on the results of your blood tests. Make sure you understand any new dosing instructions from your doctor." When the PT/INR was obtained on 12/20/11 the results were elevated at 3.3 and Resident #4's [MEDICATION NAME] was held for 12/20/11 and the dosage was decreased to [MEDICATION NAME] 5 mg daily. A PT/INR was to be obtained in 1 week. The PT/INR was obtained and the physician was notified of the results on 12/27/11. As Resident #4 was to have spinal surgery on 1/4/12, his [MEDICATION NAME] had been ordered to to held beginning on 12/28/11. 5 mg of [MEDICATION NAME] were administered on 12/27/11 and the medication was held until after his surgery and subsequent return to the facility on [DATE]. An order was evident for Resident #4 to be administered 6 mg of [MEDICATION NAME] beginning on 1/5/12 with a PT/INR to be obtained on 1/10/12. No documentation was evident that Resident #4 was administered the physician ordered [MEDICATION NAME] on 1/7 or 1/8/12. The PT/INR obtained on 1/10/12 was low at 1.1. The physician ordered [MEDICATION NAME] 10 mg to be given on 1/10 and 1/11/12 and then to resume [MEDICATION NAME] 6 mg on 1/12/12. A PT/INR was ordered to be obtained on 1/16/12. The PT/INR obtained on 1/16/12 was elevated at 3.4 with an order to hold the [MEDICATION NAME] on 1/16 and 1/17/12 and to repeat the PT/INR on 1/18/12. The 1/18/12 PT/INR was even higher at 4.6 so the [MEDICATION NAME] was also held on 1/18 and 1/19/12 with another PT/INR to be obtained on 1/20/12. There was no documentation that the 1/20/12 PT/INR was obtained however on the "Anticoagulant Flow Sheet" a notation was made that the staff was unable to obtain the test. Resident #4's physician was at the facility on 1/20/12 and was informed of the inability to obtain the PT/INR. She included in her progress note, "[MEDICAL CONDITION] on [MEDICATION NAME]. This has been difficult to control since the dose was held prior to surgery. Check INR 1/21/12 and dose accordingly." The PT/INR was obtained on 1/21/12. After obtaining the PT/INR on 1/21/12 with results of 1.7, the facility staff notified Resident #4's physician and she ordered [MEDICATION NAME] 6 mg to be administered daily with a repeat PT/INR to be obtained in 2 weeks. A physician's telephone order was written by the nurse. The evening of 1/21/12, Resident #4's physician came to the facility and reviewed the lab work. A handwritten entry was evident on the lab slip that included "Continue 6 mg QD (check mark-check) INR 1 week (physician's initials) 1/21/12." Documentation revealed Resident #4 was administered 6 mg of [MEDICATION NAME] daily from 1/21/12 until he was admitted to the hospital 1/30/12 with a GI bleed. A thorough review of Resident #4's clinical record revealed no PT/INR was obtained or attempted to be obtained on 1/28/12, 1 week after the order for PT/INR was written on 1/21/12. LPN B stated 2/15/12 at 3:15 p.m., the initials on the lab slip with the order for PT/INR in 1 week was Resident #4's physician's initials. LPN B stated she would have to check on the missing PT/INR results. LPN B did state however that the nurse should have written another telephone or verbal order for the PT/INR to be obtained in a week. When interviewed 2/16/12 at 12:30 p.m., the DON stated the nurse involved in notifying the physician (who was out of the country) regarding the PT/INR on 1/21/12 could not be reached. The DON stated the nurses obtain the PT/INR at the facility using an "InRatio Machine." The night nurse was responsible for obtaining the PT/INR and leaving the results for the day shift to notify the physician. The DON stated if the nurse had seen the second order for the PT/INR in a week, as opposed to the first order for 2 weeks, the nurse should have contacted the physician and clarified the order. The DON further stated the nurse did not see the second order. The DON stated Resident #4's physician was "very good" about reviewing and keeping up with her Residents lab work results. She felt the physician had come in the evening of 1/21/12, reviewed the lab slip, wrote the order, and left it on the desk. The DON was unaware of where the lab slip was when Resident #4's physician reviewed it. The DON did confirm that both the first order for the PT/INR in 2 weeks and the second order for PT/INR in one week were both valid physician's orders [REDACTED]. "The nurses should go by the most recent order," according to the DON. Review of the facility's policy, "GUIDELINES FOR MEDICATION ORDERS" included: "Specific Procedures for Three Types of Medication Orders. The following steps are completed prior to implementing a medication order: a. New Handwritten Orders must be signed by the prescriber. The nurse on duty at the time the order is received notes the order and enters it on the physician order [REDACTED]. If necessary, the order is clarified before the prescriber leaves the nurses' station whenever possible. Documentation of the Medication Order e. After completion, document each medication order noted on the physician's orders [REDACTED]. Example: 'Noted 1:15 p.m. 5/17/05 M. Jones R.N." The DON stated the policy referenced above was applicable to all physician's orders [REDACTED]. Guidance for nursing practice for following physician's orders [REDACTED]. Nurses follow physician's orders [REDACTED]. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary." Same source, p. 709, "The nurse is also responsible for documenting any preassessment data required of certain drugs, such as a blood pressure measurement for antihypertensive medications, or laboratory values, as in the case of [MEDICATION NAME] before giving the drug." Upon interviewing Resident #4's physician, ADM C, 2/17/13 at 3:30 p.m., she stated she had reviewed the lab work and wrote the order for the PT/INR in a week on 1/21/12. ADM C stated that Resident #4 had been sent to the hospital due to shortness of breath and questionable pneumonia not bleeding. ADM C stated she did not feel that the "GI bleed caused his current decline." The administrator and DON were advised 2/16/12 at 5 p.m. and 2/17/12 at 1:30 p.m. of the failure of the staff to obtain a physician ordered PT/INR with subsequent hospitalization and GI bleed.