Every finding on record at Life Care Center of Gwinnett

Based on observations, staff interviews, and review of the facility policy titled, Food Safety, the facility failed to label, date, and discard expired food items in the refrigerator, freezer, and dry food storage. This deficient practice created the potential for 86 of 87 residents who received meals from the kitchen to contract food borne illnesses. Findings Include:A review of facility's policy titled, Food Safety, revised May 26, 2026, revealed under Policy: Food is stored and maintained in a clean, safe, and sanitary manner following federal, state, and local guidelines to minimize contamination and bacterial growth. The policy further states under Dry Storage: 2. Opened packages of food are sealed tightly to prevent contamination of the food item and use by date will be used when applicable. Under Procedure: 2. Pre-packaged food is placed in a leak-proof, non-absorbent, sanitary (NSF) container, with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). Use by Date is noted on the label of product when applicable.During an initial tour of the kitchen on 06/17/2026 at 8:48 AM with the Dietary Manager (DM), it was verified that food items were open with no open, use by date, or expiration date in the dry pantry to include grits, quick oats, cocktail sauce, creamy peanut butter, white distilled vinegar, vegetable olive oil, baking powder, tri-color pasta/ spaghetti noodles, tortilla chips, and bread. Also, food items in the freezer included biscuits, mixed vegetables, pancakes, breakfast sausage, and pork chops were not in the original box nor labeled with food item name, open, or use by date. It was noted in the refrigerator that puree canned fruit, chocolate pudding, yellow mustard, and chicken base were expired and eggs were not in a box nor dated. The DM verified open food containers in dry storage, refrigerators, and freezer were not properly labeled with food item name, open date, or use by date, and expired foods. He stated that his expectations of the kitchen staff were to check all food items daily and a negative outcome would be that residents could get sick.During an interview on 06/18/2026 at 4:45 PM with the Administrator revealed his expectations of the kitchen staff were to follow the policies and a negative outcome could be contamination of food and residents could get a food borne illness.

Based on observations, staff interviews, record review, and review of the facility policies titled, BiPAP/CPAP Administration and Associate Conduct and Dress Code, the facility failed to ensure infection control was maintained, to ensure CPAP was appropriately stored when not in use, to label and properly store distilled water for one of 14 residents (R) (R44) reviewed for respiratory therapy, and failed to ensure dietary staff wore a beard covering. The deficient practice had the potential of food contamination by beard hair in the kitchen and to place R44 at increased risk of cross contamination, respiratory complications and adverse clinical outcomes. Findings include: Review of the facility policy titled, BiPAP/CPAP (bilevel positive airway pressure/continuous positive airway pressure) Administration, revised February 3, 2026, revealed under Policy: The facility will ensure that each resident receives necessary respiratory care and services (BiPAP/CPAP) that are in accordance with professional standards of practice, the resident's care plan, federal, and state regulations. Under Infection Control revealed: 1. To reduce the risk of waterborne illnesses associated with BiPAP/CPAP machines, the CDC (Centers for Disease Control) recommends that open containers of water in nursing homes should be covered, labeled, and used within 2 hours to prevent contamination. Water should be stored in clean, sealed containers, and any unused water should be discarded to reduce the risk of waterborne illnesses. Single use 100 ml containers of sterile water are recommended. Review of the facility policy titled: Associate Conduct and Dress Code, with revised date of April 28, 2025, states The facility will ensure all food service adhere to the company's established code of conduct and dress code. Procedure 4 of the policy states: The Food and Nutrition services associates should wear hair restraints which cover all unpinned hair, including all facial hair while on duty. 4a of the policy states: According to the Food Code, food service staff must wear hair restraints such as hair coverings or hair nets, beard restraints, and clothing that covers body hair when cooking, preparing, or assembling food to prevent food contamination. Hair restraints must be designed and worn to effectively keep hair from contracting food. 1. Review of the electronic medical record (EMR) for R44 revealed admission to the facility diagnoses including, but not limited to type 2 diabetes, obstructive sleep apnea (adult), asthma, dependence on supplemental oxygen, and dependence on other enabling machines and devices. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for R44 revealed in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 9, indicating a moderate cognitive impairment. Section GG (Functional Abilities and Goals): No Impairment of Functional ROM (range of motion) Upper extremity, Uses walker for mobility; Eating: Set Up or Clean Up assistance, Oral Hygiene: Supervision or Touching Assistance, Toileting Hygiene: Substantial/maximal Assistance, Shower/Bathing, Self: Partial/Moderate Assistance, Upper Body Dressing: Partial/Moderate Assistance, Resident is legally blind and has low vision. Review of the physician orders for R44 revealed: CPAP/BIPAP: Pressure setting EPAP (expiratory positive airway pressure): 8, Size and type of mask: airfit p30i, frequency of use : nightly at bedtime for sleep apnea with expectations to document each shift. Care Plan last reviewed 06/15/2026 revealed R44 is at risk for alterations in her respiratory status/difficulty breathing due to diagnosis of asthma. Since 08/31/2023, she has used a C-PAP machine at bedtime. The resident will have no signs or symptoms of poor oxygen absorption through the review date. Administer medication/puffers as ordered. Administer oxygen as ordered. BIPAP/CPAP/VPAP (variable positive airway pressure) settings as ordered. Elevate head of bed for comfort. Observe for changes in orientation, increased restlessness, anxiety, and air hunger. Observe for signs and symptoms of respiratory distress and report to MD (medical doctor) PRN (as needed): increased respirations; decreased pulse oximetry; increased heart rate (tachycardia); restlessness; diaphoresis (sweatiness); headaches; lethargy; confusion; hemoptysis (coughing up blood); cough; pleuritic pain; accessory muscle usage; skin color changes to blue/grey. observe/ report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring. An observation on 06/16/2026 at 10:04 AM, during the initial screening and interview with R44, revealed a CPAP machine/supplies were uncovered and unbagged and a gallon of distilled water on the bedside table was not labeled or dated. Observation on 06/17/26 at 4:57 PM, in R44's room, revealed the CPAP machine was not covered and a gallon of distilled water was unlabeled and undated. Observation on 06/17/2026 at 9:28 AM, revealed the equipment on the nightstand and mask not covered. The bottle of distilled water was not dated or labeled. Interview with DON on 06/18/2026 at 1:37 PM, the DON revealed licensed nurses were responsible for cleaning filters, ensuring orders were clear, and masks were kept in bags when not in use. Nursing staff would also wash masks and change oxygen tubing. Distilled water should be stored in the Medication Room and include an open date. There should be no medications at the bedside. Settings should match the physician's orders. 2. During an initial observation of the kitchen on 06/16/2026 at 8:48 AM, revealed that the Dietary Manager (DM) had a beard and was not wearing a beard net. During an interview with the Administrator on 06/17/2026 at 10:28 AM, the Administrator stated that all kitchen staff with beards should wear a beard net. The Administrator confirmed at 10:30 AM that the DM was not wearing a hair net. He provided the policy that stated food service staff must wear hair restraints such as hair nets and clothing that covers body hair when cooking, preparing, or assembling food to prevent food contamination. He revealed he expected the kitchen staff to follow the policy, and a negative outcome could be contamination of the food. During an interview with the DM on 06/17/2026 at 4:47 PM, the DM stated that his expectation of the dietary staff, including himself, was to wear proper PPE (personal protective equipment) consistently and a negative outcome was that food could get contaminated.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Indwelling Urinary Catheter (Foley) Management, the facility failed to provide the resident with appropriate catheter tubing management and securement for one of two residents (R) (R2) reviewed for catheter care. This deficient practice had the potential to cause urine backflow, bacterial infection, and excessive tension on the catheter, which could lead to urethral tears or catheter dislodgment. Findings include:Review of the facility's policy titled, Indwelling Urinary Catheter (Foley) Management, revised September 4, 2025, revealed under General Urinary Catheter Maintenance Guidelines: . 2. b. Keep the collecting bag below the level of the bladder at all times. Do not rest the drainage bag on the floor. Under Additional Care Practices Related To Catheterization: . 5. Keeping [sic] the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter . Review of the electronic medical record (EMR) revealed R2 was admitted to the with pertinent diagnoses, including but not limited to, urinary tract infection, hemiplegia, type 2 diabetes, acute kidney failure, schizophrenia, benign prostatic hyperplasia, and kidney stones.Review of R2's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated R2 had moderate cognitive impairment. Section GG, functional status, revealed R2 required moderate assistance from staff for most ADLs (activities of daily living), can feed and position himself in bed, but requires assistance from staff for transfer and bathing. Section H, Bladder and Bowel, R2 is incontinent of bowel movements and has an indwelling Foley catheter for urinary output.Review of the R2's care plan, dated 06/02/2026, indicated a problem with an indwelling catheter with a diagnosis of obstructive uropathy, BPH (benign prostatic hyperplasia). Interventions included, but were not limited to, antibiotics as ordered and catheter care every shift. Catheter: The resident has a position catheter bag and tubing below the level of the bladder. Check tubing for kinks each shift. Enhanced barrier precautions. Observe for and document pain/discomfort due to the catheter. Observe for and report to MD (medical doctor) for s/sx (signs/symptoms) UTI (urinary tract infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul-smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observe for s/sx of discomfort on urination and frequency.Review of the Physician's Orders for R2 included, but was not limited to:Order dated 04/24/2026: Secure catheter with an anchoring device to prevent tension.Order dated 04/24/2026: Change catheter bag as needed for infection, obstruction, or when the closed system is compromised.Order dated 04/24/2026: Catheter care every shift, keep the catheter bag placed below the level of the bladderOrder dated 04/24/2026: Indwelling catheter to straight drainage bag size 16Fr. (French) With a 10cc (cubic centimeter) bulb. Change for infection, obstruction, or when the closed system is compromised.An observation on 06/16/2026 at 11:02 AM of R2 and Certified Nursing Assistant (CNA) FF revealed that R2 had a Foley catheter; and CNA FF was applying a privacy bag to the drainage bag. The catheter bag was on the floor when the CNA left the room.An observation on 06/17/2026 at 10:56 AM of R2 revealed his Foley catheter drainage bag was in a privacy bag, but the entire bag was lying on the floor. The urine in the tubing was cloudy and red-tinged. The resident lifted his sheet to reveal his right leg and the catheter tubing, which was not secured with a securement device and was laying under his leg.An observation made on 06/17/2026 at 3:08 PM of R2 revealed that the resident was asleep, but the urinary drainage bag was still lying on the floor in the same position.An observation on 06/17/2026 at 5:17 PM noted CNA GG performing foley catheter care; the Foley bag was again on the floor, unchanged from earlier in the day. When asked about the drainage bag position, CNA GG confirmed that it was on the floor and that it should be positioned off the floor. CNA GG confirmed that the catheter tubing was under the resident's leg and that there should be a securement device in place. On closer inspection, there was a leg-strap securement device on the resident's left leg, but the Foley tubing was under the right leg. CNA GG confirmed that the tubing was under the right leg and should be routed over it and secured with the securement device.An interview with Licensed Practical Nurse (LPN) HH on 06/18/2026 at 11:20 AM confirmed that the drainage bags should be off the floor, hung on the bed frame, and have a dignity cover bag. An interview with the Director of Nursing (DON) on 06/18/2026 at 1:37 PM revealed that she expected the indwelling Foley bags to be hung/positioned on the bedframe with a privacy bag, and off the floor. If the resident has an order for a securement device, the resident should wear it to prevent pulling and trauma.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Infusion Therapy-Intravenous (IV Fluids), the facility failed to properly date and initial one midline dressing for one of two residents (R) (R46) reviewed for IV therapy. This deficient practice had the potential to cause confusion about when to change the dressing next and to lead to infection. Findings include: Review of the facility's policy titled, Infusion Therapy-Intravenous (IV Fluids), revised May 5, 2026, revealed under Procedure: .2. The facility will utilize the [NAME] (manual of Nursing Practice is a comprehensive, evidence-based guide for nursing students and practicing nurses, offering practical guidance across all major areas of patient care) procedures: . IV therapy.Review of the electronic medical record (EMR) revealed resident R46 was admitted to the facility with pertinent diagnoses, including, but not limited to, moderate protein-calorie malnutrition, dependence on supplemental oxygen, anxiety disorder, and depression.Review of R46's significant change Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating R46 had moderate cognitive impairment. Section GG, functional status, revealed R46 was independent with meals, requires setup and cleanup assistance with oral care, partial assistance from staff with bathing, dressing, and footwear. She can reposition herself in bed and requires the assistance of one staff member for transfer to a wheelchair. Section H, Bowel and Bladder, Resident is frequently incontinent of bowel and bladder. Section O, Special Treatments and Programs, the midline IV is not mentioned in this area.A review of R46's care plan dated 06/05/2026, indicated a problem with a urinary tract infection on antibiotics. Interventions included, but not limited to, lab/ diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. Observe for and report to MD (medical doctor) PRN (as needed) for s/sx (signs/symptoms) of UTI (urinary tract infection): Frequency, Urgency, Malaise, foul-smelling urine, dysuria, Fever, nausea and vomiting, flank pain, Suprapubic pain, Hematuria, Cloudy urine, Altered mental status, Loss of appetite, Behavioral change.Review of a Nursing Progress note dated 06/13/2026 revealed: Central Line placed by IV team. Patent no s/s of infection to Left arm.Review of the Physician's Orders for R46 included, but not limited to:Order dated for 06/13/2026 revealed IV: Device - Midline Catheter - Non-Valved Brand: Gauge Total length cm. Site every shift for 5 DaysMay use 1% (percent) lidocaine intradermal up to 1ml (milliliter) to insertIV: Observe the site before and after administration of intermittent medications and during dressing changes.Confirm observation every shift for 5 DaysIV: Observe every shift for 5 Days with intermittent therapy or when not in useIV: Midline Cath (catheter) - Measure the circumference of the upper arm(10 cm (centimeters) above antecubital (space in bend of elbow)) as needed for 5 Days with transparent dressing change.IV: Midline Cath - With PPN (peripheral parenteral nutrition) - Change needles every 24 hours for 5 DaysAn observation made on 06/16/2026 at 12:57 PM of R46 revealed that the resident had midline vascular access located on the upper inner aspect of her left arm. The dressing was wrinkled, and there was no date or initials on the dressing.An observation made on 06/17/2026 at 10:30 AM of R46 revealed that the midline dressing remained undated or initialed.An observation made on 06/18/2026 at 11:45 AM showed that R46 was sitting in the dining area, and an observation of the midline dressing revealed no date, time, or initials on it. Licensed Practical Nurse EE confirmed that there were no dates or initials on the dressing and that the dressing was becoming very wrinkled.An interview with LPN EE on 06/18/2026 at 11:55 AM revealed that the midline was placed by the IV team after she left shift last week. She stated that the standard for midline dressings was to include a date, time, and initials, and if the IV team did not do this, the nurse on the hall should have done so.An interview with the Director of Nursing (DON) on 06/18/2026 at 1:27 PM revealed that her expectations for all IV, midline, and peripherally inserted central catheters (PICC) line dressings should be dated and timed, and if the IV team did not do it, then the nurse on the floor should do it.

Based on observations, resident and staff interviews, and review of the facility policy titled, Resident Rights, the facility failed to post notice of the availability of the State survey results so that facility residents (R), including four of 38 sampled R's (C1, C2, C3, C4) and/or visitors were aware of its location. Findings include:Review of the facility policy titled, Resident Rights, revised September 26, 2025, indicated under section, Procedure: .39. The resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility.Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/01/2026, for C1, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive decline.Review of the comprehensive MDS assessment, dated 05/28/2026, for C2, revealed a BIMS score of 15, indicating intact cognition.Review of the comprehensive MDS assessment, dated 04/17/2026, for C3, revealed a BIMS score of 15, indicating intact cognition.Review of the comprehensive MDS assessment, dated 03/27/2026, for C4, revealed a BIMS score of 15, indicating intact cognition.Observation during the initial tour on 06/16/2026 at 8:42 AM revealed that the survey book was not found in the front entrance lobby where the book was designated to be kept.Observation on 06/17/2026 at 7:50 AM revealed that the survey book was not found in the front entrance lobby.Observation on 06/18/2026 at 12:23 PM revealed that the survey book was not found in the front entrance lobby.Interviews during the Resident Council Meeting on 06/18/2026 between 2:00 PM and 3:00 PM, it was revealed that four residents (C1, C2, C3, C4) present, who were alert and oriented, stated they did not know where the State inspection results were located, and that this was something they would be interested in reviewing.Review of the Resident Council minutes revealed that the location of the survey results had not been discussed with the residents. Interview on 06/18/2026 at 3:15 PM with Receptionist AA revealed the survey book used to be located on a table behind the backside of the sofa. She stated the survey book was moved to a secure place in the drawer of the lobby table and then moved again later to the Administrator's office. She further stated that the renovation period took place at the end of last year around the fall season.Interview on 06/18/2026 at 3:26 PM with Administrator confirmed the survey results book had been moved into his office since the start of the renovations of the front lobby area and the book was still in his office. The Administrator acknowledged that residents and visitors would not be able to readily access the survey book without having to ask for it or go into his office to review it.

52126 Based on observations, interviews, record review, and review of the facility's policy titled, Bed Rails - Safe and Effective Use of Bed Rails, the facility failed to develop a baseline care plan specific to the use of side rails for three of nine Residents (R) (R290, R14, and R287) reviewed for physical restraints. In addition, the facility failed to develop a baseline care that identified the use of an indwelling urinary catheter for one of one resident (R236) reviewed for indwelling urinary catheter. The failure created the potential for the residents to have unmet care needs, safety needs, and to not meet their highest levels of functional abilities. Findings include: Review of the facility's policy titled, Bed Rails - Safe and Effective Use of Bed Rails revised 9/6/2024 indicated, Procedure: A person-centered care plan will be developed within 48 hours of admission to address the bed rail(s), if indicated. The interdisciplinary team will review and revise the care plan, if indicated, upon completion of the comprehensive, significant change and quarterly MDS for the need to continue the use of bed rail(s). 1. Review of R290's Admission Record located under the Profile tab in the electronic medical record (EMR) noted R290 was admitted on [DATE] with diagnoses that included fracture of unspecified part of neck of right femur, generalized muscle weakness, age-related physical debility, and dysarthria following cerebral infarction. Review of the Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/19/2025 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R290 was cognitively intact. Observation and interview on 4/8/2025 at 9:34 am revealed, R290 in bed with two 1/8 side rails up. When asked about the side rails, R290 stated I hold onto when turning in bed and getting up. Review of R290's Baseline Care Plan located under the Assessments tab in the EMR dated 3/19/2025, revealed, The resident is at risk for falls. Review of R290's entire Baseline care plan revealed side rails were not addressed or the potential safety concerns. 2. Review of R14's Admission Record located under the Profile tab in the EMR noted R14 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, generalized muscle weakness, and osteoarthritis. Review of R14's admission MDS with an ARD of 3/14/2025 revealed a BIMS score of eight out of 15 which indicated R14 was moderately cognitively impaired. Observation and interview on 4/8/2025 at 9:33 am revealed, R14 in bed with two 1/4 side rails up. When asked about the side rails, R14 was unable to state what the side rails was used for. Review of R14's Baseline Care Plan located under the Assessments tab in the EMR, dated 3/13/2025 revealed, Resident is at risk for falls. Review of R14's entire Baseline Care Plan revealed side rails were not addressed or the potential safety concerns. 3. Review of R287's Admission Record located under the Profile tab in the EMR noted R287 was admitted on [DATE] with diagnoses that included fracture of left leg, generalized muscle weakness, and osteoarthritis. Review of R287's Admission MDS with an ARD of 4/1/2025, revealed a BIMS score of 12 out of 15 which indicated R287 was moderately cognitively impaired. Observation and interview on 4/8/2025 at 9:32 am revealed, R287 in bed with two 1/8 side rails up. When asked about the side rails, R287 stated they were used to help him get out of bed. Review of R287's Baseline Care Plan located under the Assessments tab in the EMR, dated 3/26/2025, revealed, Resident is at risk for falls. Review of R287's entire Baseline care plan revealed side rails were not addressed or the potential safety concerns. During an interview on 4/10/2025 at 12:29 pm, Licensed Practical Nurse (LPN)1 stated that side rails should be included on the baseline care plan. During an interview on 4/10/2025 at 1:04 pm, LPN2 stated that side rails should be included in the baseline care plan. During an interview on 4/10/2025 at 1:47 pm, the Director of Nursing (DON) confirmed that the side rails were not addressed on R290, R14 or R287's baseline care plan. The DON stated side rails should be care planned when then resident is evaluated for side rails, and they have been implemented for bed mobility assistance. The nurse on the floor or the admitting nurse would be responsible for adding side rails to the care plan. 4. Review of R236's EMR located under the Assessments tab revealed a base line care plan dated 4/4/2025 did not indicate R236's use of an indwelling catheter. Review of R236's EMR located under the Orders tab a physician order dated 4/4/2025 which indicated, Indwelling catheter to straight drainage. Size:16 Bulb: 10 cc (cubic centimeter). Change for infection, obstruction or when the closed system is compromised and a physician order dated 4/4/2025, to keep catheter bag below the level of the bladder. During an interview on 4/10/2025 at 12:54 pm, LPN4 stated that if a resident admits to the facility with an indwelling urinary catheter, it should be included on the base line care plan to help communicate the basic care needed for that resident. During an interview on 4/10/2025 at 1:15 pm, the MDS Coordinator (MDSC) stated that the indwelling urinary catheter should be on the base line care plan so that all direct care staff know the basic information needed to provide the proper for the resident. During an interview on 4/10/2025 at 2:40 pm, the DON stated that an indwelling urinary catheter should have been on R236's base line care plan to let the staff know the basic needs for that resident. DON stated the baseline care plan let's all nursing staff know the basic needs on how to properly take care for a resident.

Based on observations, interviews, record review, and review of the facility's policy titled, Bed Rails - Safe and Effective Use of Bed Rails, the facility failed to develop a comprehensive care plan specific to the use of side rails for six of nine Residents (R) (R58, R290, R14, R25, R48, and R52) reviewed for physical restraints. The failure created the potential for the residents to have unmet care needs, safety needs, and to not meet their highest levels of functional abilities. Findings include: Review of the facility's policy titled, Bed Rails - Safe and Effective Use of Bed Rails revised 9/6/2024 indicated, Procedure: A person-centered care plan will be developed within 48 hours of admission to address the bed rail(s), if indicated. The interdisciplinary team will review and revise the care plan, if indicated, upon completion of the comprehensive, significant change and quarterly MDS for the need to continue the use of bed rail(s). 1. Review of the Admission Record located under the Profile tab in the Electronic Medical Record (EMR) noted R58 was admitted on [DATE] with diagnoses that included unspecified convulsions and unspecified dementia. Review of the Physician Orders located under the Orders tab in the EMR identified R58 was prescribed Oxcarbazepine tablet 150 MG [milligram] Give 1 tablet by mouth two times a day for seizures. The order was initially prescribed on 1/10/2024 and remained current as of the 4/2025 physician orders. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/9/2025 revealed a Brief Interview for Mental Status score of three out of 15 which indicated R58 was severely cognitively impaired. The MDS noted bedrail not used. Observation and interview on 4/8/2025 at 9:52 am revealed, R58 in bed with two 1/2 rails up. When asked about the side rails, R58 stated Oh these, I like them. I can hold on. Observation on 4/9/2025 at 1:15 pm revealed, R58 in bed with two 1/2 rails up. Review of R58's Comprehensive Care Plan located under the Clinical tab in the EMR with a revision date of 2/3/2025, revealed, [R58] is at risk for falls r/t [related to] Muscle weakness . Review of R85's entire care plan revealed 1/2 side rails were not addressed or the potential safety concerns. 2. Review of R290's Admission Record located under the Profile tab in the EMR noted R290 was admitted on [DATE] with diagnoses that included fracture of unspecified part of neck of right femur, generalized muscle weakness, age-related physical debility, and dysarthria following cerebral infarction. Review of the Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/19/2025 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R290 was cognitively intact. Observation and interview on 4/8/2025 at 9:34 am revealed, R29 in bed with two 1/8 side rails up. When asked about the side rails, R290 stated I hold onto when turning in bed and getting up. Review of R290's Comprehensive Care Plan located under the Care Plan tab in the EMR with a revision date of 3/31/2025 revealed, [290] is at risk for falls and other related injuries d/t [due to] Muscle weakness .[R290] had a recent GLF [ground level fall] resulting in a R [right] hip Fx [fracture]. Review of R290's entire care plan revealed side rails were not addressed or the potential safety concerns. 3. Review of R14's Admission Record located under the Profile tab in the EMR noted R14 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, generalized muscle weakness, and osteoarthritis. Review of R14's Admission MDS with an ARD of 3/14/2025 revealed a BIMS score of eight out of 15 which indicated R14 was moderately cognitively impaired. Observation and interview on 4/8/2025 at 9:33 am revealed, R14 in bed with two 1/4 side rails up. When asked about the side rails, R14 was unable to state what the side rails were used for. Review of R14's Comprehensive Care Plan located under the Care Plan tab in the EMR with a revision date of 3/24/2025 revealed, [R14] had an ADL [activity of daily living] self-care performance deficit r/t [related to] impaired mobility. Review of R14's entire care plan revealed side rails were not addressed or the potential safety concerns. 4. Review of R25's Admission Record located under the Profile tab in the EMR noted R25 was admitted on [DATE] with diagnoses that included cerebral infarction and generalized muscle weakness. Review of the Significant Change MDS with an ARD of 1/17/2025, revealed a BIMS score of nine out of 15 which indicated R25 was moderately cognitively impaired. Observation and interview on 4/8/2025 at 9:35 am revealed, R25 in bed with two 1/4 side rails up. When asked about the side rails, R25 was unable to state what the side rails were used for. Review of R25's Comprehensive Care Plan located under the Care plan tab in the EMR with an initiated date of 2/27/2025, revealed, [R25] has an ADL self-care performance deficit r/t [related to] Disease Process . Review of R25's entire care plan revealed side rails were not addressed or the potential safety concerns. 5. Review of R48's Admission Record located under the Profile tab in the EMR noted R48 was admitted on [DATE] with diagnoses that included contracture of the left knee, generalized muscle weakness, epileptic seizures, and contracture of the left hand. Review of R48's Quarterly MDS with an ARD of 3/11/2025, revealed a BIMS score of 12 out of 15 which indicated R48 was moderately cognitively impaired. Observation and interview on 4/8/2025 at 9:38 am revealed, R48 in bed with two 1/4 side rails up. When asked about the side rails, R48 stated I hold onto these when I'm turning in bed. Review of R48's Comprehensive Care Plan located under the Clinical tab in the EMR with a revision date of 3/22/2024, revealed, [R48] has self-care deficits due to mobility and cognitive deficit; secondary to diagnosis of Schizoaffective disorder, CVA with hemi, depression, and L [left] wrist and L knee contracture. Review of R48's entire care plan revealed side rails were not addressed or the potential safety concerns. 6. Review of R52's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/7/2025 and located in the electronic medical record (EMR) under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 07 out of 15 which indicated the resident was severely cognitively impaired. The MDS revealed the resident was admitted on [DATE] with diagnoses to include cerebral infarction, non-Alzheimer's dementia, depression, and spondylosis. The MDS also revealed that R52 requires moderate assistance with bed mobility. Observation on 4/8/2025 at 9:20 am revealed R52's bed had 1/4 size side rails on both sides of the bed in the up position. Review of R52's EMR located under the Care Plan tab a comprehensive care plan dated 1/2/2024 did not indicate the use of side rails. During an interview on 4/10/2025 at 12:54 pm, Licensed Practical Nurse (LPN)4 stated that the side rails should be on the care plan to help communicate the care needed for that resident. During an interview on 4/10/2025 at 1:15 pm, the MDS Coordinator (MDSC) stated that side rails should be on the care plan so that staff know the needs of the resident. We just missed it. During an interview on 4/10/2025 at 12:29 pm, Licensed Practical Nurse (LPN) 1 stated that side rails should be included in the comprehensive care plan. During an interview on 4/10/2025 at 1:04 pm, LPN2 stated that side rails should be included in the comprehensive care plan. During an interview on 4/10/2025 at 1:47 pm, the Director of Nursing (DON) confirmed R290, R14, R25, R48, R58 and R52's care plans did not address the use of side rails. The DON stated that side rails should be care planned when then resident is evaluated for side rails, and they have been implemented for bed mobility assistance. The nurse on the floor or the admitting nurse would be responsible for adding side rails to the care plan. 46319 52126

Based on observation, interview, record review, and review of the facility's policy titled, Bed Rails - Safe and Effective Use of Bed Rails, the facility failed to complete initial and quarterly assessments for the use and safety of side rails for six of nine Residents (R) (R290, R14, R25, R48, R49, R287) reviewed for physical restraints. This failure had the potential for the residents to be injured or restrict movement of residents. Findings include: Review of the facility's policy titled, Bed Rails - Safe and Effective Use of Bed Rails revised 9/6/2024 indicated, Assess the resident for risk of entrapment from bed rails prior to installation. Procedure: Residents will be assessed upon admission, readmission, or upon initiation utilizing the Evaluation for use of bed rails assessment. If bed rails are determined to be appropriate for use with a resident, a reassessment of rail(s) use will be assessed at a minimum of quarterly and potentially with a change of condition utilizing the Evaluation for use of bed rails form. 1. Review of R290's Admission Record located under the Profile tab in the Electronic Medical Record (EMR) noted R290 was admitted on [DATE] with diagnoses that included fracture of unspecified part of neck of right femur, generalized muscle weakness, age-related physical debility, and dysarthria following cerebral infarction. Review of the Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/19/2025 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R290 was cognitively intact. Continued review of the MDS revealed R290 required partial/moderate assistance with bed mobility and transfers. Observation and interview on 4/8/2025 at 9:34 am revealed, R290 in bed with two 1/8 side rails up. When asked about the side rails, R290 stated, I hold onto when turning in bed and getting up. Review of R290's Evaluation for use of side rails located under the Assessments tab in the EMR, dated 3/18/2025, revealed Is resident being considered for side rail or assistive device for the bed was marked No. Review of R290's Consent for Use of Bed Rails located in the R290's paper chart, revealed I do consent to the use of bed rail(s) recommended above and was signed on 3/29/2025. 2. Review of R14's Admission Record located under the Profile tab in the EMR noted R14 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, generalized muscle weakness, and osteoarthritis. Review of R14's Admission MDS with an ARD of 3/14/2025 revealed a BIMS score of eight out of 15 which indicated R14 was moderately cognitively impaired. Continued review of the MDS revealed R290 required partial/moderate assistance with bed mobility and transfers. Observation and interview on 4/8/2025 at 9:33 am revealed, R14 in bed with two 1/4 side rails up. When asked about the side rails, R14 was unable to state what the side rails were for. Review of R14's Evaluation for use of bed rails located under the Assessments tab in the EMR, dated 3/12/2025, revealed Is resident being considered for Bed Rail or assistive device for the bed was marked No. Review of R14's Consent for Use of Bed Rails located in the R14's paper chart, revealed I do consent to the use of bed rail(s) recommended above and verbal consent was obtained from the power of attorney (POA) on 3/12/2025. 3. Review of R25's Admission Record located under the Profile tab in the EMR noted R25 was admitted on [DATE] with diagnoses that included cerebral infarction and generalized muscle weakness. Review of the Significant Change MDS with an ARD of 1/17/2025, revealed a BIMS score of nine out of 15 which indicated R25 was moderately cognitively impaired. Continued review of the MDS revealed R290 required dependent assistance with bed mobility and transfers. Observation and interview on 4/8/2025 at 9:35 am revealed, R25 in bed with two 1/4 side rails up. When asked about the side rails, R25 was unable to state what the side rails were used for. Review of R25's Evaluation for use of bed rails located under the Assessments tab in the EMR, dated 3/28/2024, revealed Is resident being considered for Bed Rail or assistive device for the bed was marked No. Review of R25's Consent for Use of Bed Rails located in the R25's paper chart, revealed I do consent to the use of bed rail(s) recommended above and verbal consent was obtained from the power of attorney (POA) on 3/31/2024. 4. Review of R48's Admission Record located under the Profile tab in the EMR noted R48 was admitted on [DATE] with diagnoses that included contracture of the left knee, generalized muscle weakness, epileptic seizures, and contracture of the left hand. Review of R48's Quarterly MDS with an ARD of 3/11/2025, revealed a BIMS score of 12 out of 15 which indicated R48 was moderately cognitively impaired. Continued review of the MDS revealed R290 required substantial/maximal assistance with bed mobility and transfers. Observation and interview on 4/8/2025 at 9:38 am revealed, R48 in bed with two 1/4 side rails up. When asked about the side rails, R48 stated I hold onto these when I'm turning in bed. Review of R48's Evaluation for use of bed rails located under the Assessments tab in the EMR, dated 6/7/2022, revealed Is resident being considered for Bed Rail or assistive device for the bed was marked Yes. The recommended type was 1/4 partial rails. Further review of the Assessments tab revealed R48 was not evaluated quarterly for the continued use of side rails. Review of R48's Consent for Use of Bed Rails located in R48's paper chart revealed, I do consent to the use of bed rail(s) recommended above and consent was obtained on 6/7/2022. 5. Review of R49's Admission Record located under the Profile tab in the EMR noted R49 was admitted on [DATE] with diagnoses that included fracture of left leg, hemiplegia and hemiparesis following cerebrovascular disease, and acquired deformity of lower leg. Review of the Quarterly MDS with an ARD of 2/28/2025, revealed a BIMS score of 12 out of 15 which indicated R49 was moderately cognitively impaired. Continued review of the MDS revealed R290 required substantial/maximal assistance with bed mobility and transfers. Observation and interview on 4/8/2025 at 9:37 am revealed, R49 in bed with two 1/4 side rails up. When asked about the side rails, R49 stated that she used them to help her turn over in bed. Review of R49's Evaluation for use of bed rails located under the Assessments tab in the EMR, dated 8/27/2024, revealed Is resident being considered for Bed Rail or assistive device for the bed was marked No. Further review of the Assessments tab revealed R49 was not evaluated quarterly for the continued use of side rails. Review of R49's Consent for Use of Bed Rails located in R49's paper chart revealed, I do consent to the use of bed rail(s) recommended above and verbal consent was obtained from the power of attorney (POA) on 08/27/24. 6. Review of R287's Admission Record located under the Profile tab in the EMR noted R287 was admitted on [DATE] with diagnoses that included fracture of left leg, generalized muscle weakness, and osteoarthritis. Review of R287's Admission MDS with an ARD of 4/1/2025, revealed a BIMS score of 12 out of 15 which indicated R287 was moderately cognitively impaired. Continued review of the MDS revealed R290 required substantial/maximal assistance with bed mobility and transfers. Observation and interview on 4/8/2025 at 9:32 am revealed, R287 in bed with two 1/8 side rails up. When asked about the side rails, R287 stated that they are used to help him get out of bed. Review of R287's Evaluation for use of bed rails located under the Assessments tab in the EMR, dated 3/26/2025, revealed Is resident being considered for Bed Rail or assistive device for the bed was marked No. Review of R287's Consent for Use of Bed Rails located in R287's paper chart revealed, I do consent to the use of bed rail(s) recommended above and verbal consent was obtained from the POA on 3/29/2025. During an interview on 4/10/2025 at 12:29 pm, Licensed Practical Nurse (LPN) 1 stated that every resident had side rails when they are admitted and were to be evaluated at the time of admission. If the resident did not want the side rails then the side rails would be removed. The admitting nurse or the nurse on the next shift was responsible for completing the side rail evaluation. LPN1 stated side rail evaluations for the continued use of side rails would be automatically scheduled in the computer. LPN1 stated that residents would not qualify for use of side rails if they were not cognitive or were not able to use the side rails. LPN1 stated that it was important to evaluate residents for the use of side rails because they could be a restraint, or the resident could become entrapped in the side rail. During an interview on 4/10/2025 at 1:04 pm, LPN2 stated that residents are assessed upon admission and quarterly. LPN2 stated that all residents have bed rails when they are admitted . If they are not needed, then they are removed. LPN2 stated residents are evaluated for bed mobility, turning side to side, ability to hold onto the bed rail, getting up out of bed, and safety so that they don't fall out of bed. LPN2 stated that the admitting nurse was responsible for completing the side rail evaluation. LPN2 stated that it was important for residents to be evaluated for the use of bed rails for their safety as they could get caught in the rail. During an interview on 4/10/2025 at 1:47 pm, the Director of Nursing (DON) confirmed that R290, R14, R25, R48, R49, and R287 were not assessed for the use of side rails. The DON stated that residents would be evaluated for the use of bed rails upon admission. If bed rails were appropriate, then they would be put in place once consent was obtained. The DON stated side rails would not be implemented if they impeded movement or if the resident did not want them. The admitting nurse or the next shift was responsible for completing the side rail evaluation. Bed rail evaluations should be completed quarterly for the continued use of side rails. It is important for residents to be evaluated for the use of bed rails due to safety, risk of entrapment, and risk for injury.

Based on record review, staff interviews, and review of the facility policies titled, Administration of Medications, and Receipt of Interim/Stat/Emergency Deliveries the facility failed to maintain professional nursing standards of quality. Specifically, one (1) Licensed Practical Nurses (LPN) and 1 Registered Nurse (RN) administered R#401 narcotic medication, using another resident's medication. The sample size was 34. Findings include: Review of facility policy titled, Administration of Medications, revised [DATE], under subtitle Procedure revealed: B. Staff who are responsible for mediation administration will adhere to the 10 Rights of Medication Administration. 2. Right Resident. Use two identifiers. Ask the resident his or her full name and compare it to the name on the medication or treatment administration record (MAR/TAR) and compare the resident's photo to the resident. Review of facility's policy titled Receipt of Interim/Stat/Emergency Deliveries revised [DATE], under subtitle Procedure revealed: 4. Facility should not borrow medications from another resident. Review of the clinical record revealed R#401 diagnoses included but not limited to unspecified fracture of upper end of left humerus, subsequent encounter for fracture with routine healing, multiple fractures of pelvis with unstable disruption of pelvic ring subsequent encounter for fracture with routine healing, muscle weakness, unspecified fracture of sacrum, pain in left shoulder, chronic pain syndrome, age related osteoporosis without current pathological fracture, edema, history of falling. Review of R#401's Quarterly Minimum Data Set (MDS) dated [DATE], revealed Section C-Cognitive Patterns: Brief Interview Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Section G- Functional Status revealed the resident required assistance for Activities of Daily Living (ADLs). Section J indicated the use of scheduled pain medications. Review of care plan dated [DATE] revealed R#401 was at risk for pain due to multiple fractures. Interventions included but not limited to: Evaluate the effectiveness of pain interventions, pain meds as ordered and sling to left arm as ordered. Review of Order Summary Report dated [DATE] revealed R#401 had orders for Hydrocodone-Acetaminophen ,d+[DATE] (milligram) mg. Give one (1) tablet by mouth every eight (8) hours for pain, Pain level every shift. Document pain scale zero (0)-10 dated [DATE]. Review of the Medication Administration Record (MAR) for [DATE] revealed Hydrocodone-Acetaminophen ,d+[DATE] mg was scheduled for administration at 6:00 am, 2:00 pm and 10:00 pm. Further review of the record revealed the scheduled 2:00 pm dose was left blank. Doses scheduled for [DATE] at 10 pm and [DATE] at 6 am were signed with a code of (seven) 7 - indicating Hold/See Progress Note. The dose scheduled for [DATE] at 2:00 pm was signed with a code 10 - indicating Other - See Progress Note. Record review revealed a Health Status Progress note dated [DATE] at 4:58 pm that read: Nurse Practitioner (NP) was contacted for prescriptions for lorazepam and Norco. Prescriptions received from the hospital were without Medical Doctor (MD) signature. NP called lorazepam prescription and MD contacted times (x) two (2) to call Norco prescription. Review of the prescription dated [DATE] for Hydrocodone-acetaminophen ,d+[DATE] mg oral tablet revealed the script did not have a physician's signature. Review of the facility's grievance log revealed R#401's family filed a grievance on [DATE] related to the facility not having the residents scheduled pain medications at the facility. Review of Controlled Drug Record for the resident who discharged on [DATE] revealed doses were signed out by two nurses on [DATE] and [DATE]. Review of the Control Substance Sheet for R#401 revealed the 2 tabs of Hydrocodone ,d+[DATE] mg pulled from the Omnicell were signed out [DATE] at 2 pm and 10pm. Review of the Omnicell Authorization from the facility's pharmacy verified the pharmacy gave the facility an authorization code to pull Hydrocodone ,d+[DATE] mg 2 tablets from the facility's Omnicell on [DATE] at 2:41 pm. During a telephone interview on [DATE] at 10:17 am with the facility's Pharmacy Service Technician (PST)AA revealed that the medication (hydrocodone) left the pharmacy on [DATE] and arrived at the facility [DATE] at 1:00 am and was signed by the receiving nurse at the facility. During an interview on [DATE] at 11:00 am with LPN FF revealed that it is never acceptable to borrow medications from one resident to administer to another resident. LPN FF further stated that the medications can be pulled from the Omnicell. If not available to pull from the Omnicell then the physician should be notified and get an alternate order and/or order to hold the medication. LPN FF stated in addition, the pharmacy should be informed of the need for the medication to ensure that it arrives at the facility on the next delivery. LPN FF stated that the pharmacy delivers to the facility twice daily. During a telephone interview on [DATE] at 11:52 am with the facility's pharmacy Pharmacist BB in charge revealed she is the pharmacist in charge of handling narcotics and the facility's Omnicell authorizations. Pharmacist BB stated that the pharmacy received a prescription for R#401's Hydrocodone on [DATE] it did not contain a physician's signature, so the pharmacy was not able to dispense the medication on [DATE] upon R#401's arrival to the facility. Pharmacist BB further stated that the pharmacy received a signed script for the Hydrocodone on [DATE]. Authorization was given to LPN BB to pull 2 tabs from the Omnicell on [DATE] at 2:41 pm for the 2 pm and 10 pm doses to be administered. Pharmacist BB further stated that the supply of medication was received at the facility on [DATE] at 1:12 am. During an interview on [DATE] at 12:14 pm with LPN CC revealed that residents typically are admitted to facility with active scripts for narcotics. LPN CC stated that if there is an active script and the medication is not on the medication cart, she calls the pharmacy to get an authorization code to pull the narcotic from the Omnicell. LPN CC further stated that if the script is not active that she is responsible for calling the physician to inform of the need for the script. LPN CC stated that if pain medication is needed to manage the pain, she would activate the PRN standing order and administer Tylenol. LPN CC stated that the Tylenol order would be uploaded into the electronic record and documented as administered on the record. LPN CC stated that she does not pull medications from one resident to administer to another resident ever. During a telephone interview on [DATE] at 8:12 pm with RN DD revealed that she made sure R#401 received the scheduled pain medication on [DATE]. She stated that she pulled the Hydrocodone from another resident that was deceased , but the medication was still in the narcotic bin on the medication cart. RN DD further stated that R#401's family were irate and adamant that resident received the scheduled pain medications. RN DD further stated that the family did not want R#401 to receive Tylenol (PRN) per the standing order. RN stated that she assessed the resident, resident rated her pain at 4 on a pain scale of ,d+[DATE]. RN DD stated that the family did not want the R#401 to be sent to the hospital due to pain so she phoned the physician and was told that the facility needed to administer the medication as ordered even though the medication was not at the facility. RN DD stated that she called the Administrator and was instructed to pull the medication from another resident. RN DD stated that her goal at this point was taking care of the residents and getting residents pain under control. During an interview [DATE] at 10:22 am LPN LL revealed that she does not recall administering the pain medication to R#401 from another resident's supply of medications. LPN LL stated that if she documented it as administered on the medication administration record, then she administered the medication. LPN LL verified the signature on the narcotic sheet for another resident for [DATE] was her signature. During an interview on [DATE] at 11:06 am with the Director of Nursing (DON) and Administrator revealed that they had spoken with the nurses who were involved with the care of R#401 when she was first admitted and learned that the routine pain medications were administered but were pulled from a deceased resident medication. The administrator stated that this is not the practice the facility fosters but the nurses instructed her that the previous Administrator instructed the RN Supervisor to do so. The Administrator stated that she and DON will begin to educate the licensed staff on the process of obtaining narcotics for administration.

Based on observations, record review and staff interviews, the facility failed to develop a care plan for a diagnosis of Post Traumatic Stress Disorder-chronic (PTSD), for one Resident (R) R62 of 25 sampled residents. The deficient practice increased the potential for R62 not to receive treatment and/or care according to the resident's needs. Findings include: Review of the facility policy titled Comprehensive Care Plans and Revisions review date 8/22/2023 revealed the policy statement The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed or individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. Procedure states: 1. The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. 2. When these changes occur, the facility should review and update the plan of care to reflect the changes to care deliver, this can include: a. Additional interventions on existing problems, b. Updating goal or problem statements Record review revealed R62's Admission Minimum Data Set (MDS) assessment dated [DATE] did not reflect a diagnosis of PTSD upon admission. Review of the psychiatric provider note dated 6/23/2022 revealed an initial psychiatric evaluation with no indication of PTSD. Pertinent psychiatric diagnoses included schizoaffective disorder (SCAD) and generalized anxiety disorder (GAD) only. Review of the psychiatric provider note dated 12/15/2022 revealed the addition of a PTSD diagnosis to the significant findings under the psychiatric heading and remained listed on all subsequent psychiatric notes. Review of R62 care plan revealed there was no focus, goals, or interventions to eliminate or mitigate triggers that may cause re-traumatization related to the diagnosis of PTSD at the time of admission, or any subsequent care plan revisions. Interview on 9/14/2023 at 1:48 p.m. with the MDS Coordinator KK and the Medical Record Director, confirmed the Admission MDS dated [DATE] did not have PTSD indicated on the assessment, however, the MDS dated [DATE] indicated the resident had a history of PTSD. Subsequent MDS assessments for 12/14/2022, 3/14/2023, 6/14/2023, and 8/21/2023 also indicated a continued diagnosis of PTSD. MDS Coordinator KK and the Medical Record Director confirmed that R62's care plan did not include a PTSD focus with interventions. A review and confirmation of the Physician Order Report dated 5/19/22-5/19/22 from a long-term facility R62 had previously resided, revealed a diagnosis of post-traumatic stress disorder, chronic. The Medical Record Director confirmed that she had entered the medical diagnosis of F43.12, POST-TRAUMATIC STRESS DISORDER, CHRONIC on 7/8/2022 and had copied the diagnosis from the records sent from the resident's previous long-term facility. Interview on 9/14/2023 at 2:59 p.m. with Licensed Practical Nurse (LPN) CC revealed that R#62 seems to get more anxious with bright lights or noises. LPN CC reported, if someone visits her and talks to her about a different medication for anxiety or any other issue she may have, she gets fixated on it and becomes more agitated. Interview on 9/14/2023 at 3:05 p.m. with the Director of Nursing confirmed that R#62 did not have a PTSD diagnosis on any psychiatric evaluations from admission until 12/15/2022. She confirmed that a care plan including PTSD should have been developed if the resident had PTSD. She stated that she would contact the psychiatric provider to determine if R#62 did indeed have PTSD upon the initial psychiatric evaluation on 6/23/2022 and was possibly inadvertently omitted from the record, or if the resident had developed PTSD as indicated on 12/15/2022 psychiatric provider note. Interview on 9/14/2023 at 3:18 p.m. with Certified Nursing Assistant (CNA) HH revealed she knows that lights and loud noises get R#62 more anxious. She said that if there is a lot of talking in the hall by her room, she seems to become more nervous, so they try to keep it calm around R#62's room.

Based on staff interviews, record review, and review of the facility policy titled, Pre-admission Screening and Resident Review (PASARR), the facility failed to submit an application for a Level II PASARR for evaluation and determination of specialized services for one of three sampled residents (R) (R#30). The deficient practice increased the potential for R30 not to receive treatment and/or care according to the resident's needs. Findings include: Review of the facility policy titled, Pre-admission Screening and Resident Review (PASARR) revised 10/6/2022 revealed: 4) A positive level I screen necessitates an in-depth evaluation of the individual by the state designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility. 13) Any resident with a newly evident or possible serious mental disorder, Intellectual Disorder (ID) or a related condition must be referred, by the facility to the appropriate state designated mental health or intellectual disability authority for review. Review of the diagnoses for R#30 revealed diagnoses including but not limited to mood affective disorder, anxiety disorder, and depression. Review of records revealed an approved PASARR Level I dated 10/10/2016. Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section A-Identification Information (1500): indicated no PASARR; Section C-Cognition Patterns: Brief Interview of Mental Status (BIMS) score of 11 indicating moderate cognitive impairment; Section D-Mood: mood assessment score of three indicating minimal depression. Review of care plan dated 5/24/2023 revealed: Resident at risk for drug related side effects due to use of psychotropic drugs and indication for use for mood disorder and anxiety; Resident has a mood problem related to diagnosis of mood affective disorder with noted episodes of sadness, suicidal thoughts, and refusing to eat or drink. Review of Physicians Orders include but not limited to: - duloxetine HCl Capsule delayed release particles 60 milligrams (MG), give one (1) capsule by mouth at bedtime for depression start date 6/23/2023, buspirone HCl tablet 15 MG, give 1 tablet by mouth two times a day start date 6/23/2023, aripiprazole tablet five (5) MG, give 1 tablet by mouth one time a day 6/24/2023. Review of records revealed R#30 was not receiving psych services. Interview on 9/11/2023 at 3:40 pm with Social Services Director revealed she had never received education on the PASSAR Level II process, nor does she have access to enter information in the system. She also revealed that Admissions is responsible for the PASSAR process. Interview on 9/11/2023 at 3:50 pm with Admissions revealed she is responsible for verifying that residents have a PASSAR Level I, then documents are sent to the business office. Interview on 9/13/2023 at 2:45 pm with Director of Nursing revealed the process for PASSAR Level II is, the facilities liaison in the hospital should be verifying that the PASARR Level I information is correct, if not, the liaison will contact admissions with correct information. At this point, the admissions and social services will work together to verify corrected information and determine if a PASSAR Level II is warranted. If yes, social services should then enter all necessary information and documents to the proper state entity for determination. She also revealed that the facility is aware that the process is broken, and they are working on the education in-service for all staff that are responsible for the PASARR process. Interview on 9/13/2023 at 2:50 pm with the Regional Nurse revealed they know the PASARR Level II process is not working. He reported he has started gathering materials to begin education for all staff responsible for the PASARR process and they would begin in-services as soon as possible.

Based on record review, staff interviews and review of facility policy titled, 3.8 Psychotropic Medication Use the facility failed to limit as needed (PRN) psychotropic medications to no more than 14 days with documentation in the medical record for use after the 14-day time frame for one of five Residents (R) (R49) reviewed for unnecessary drugs. This failure had the potential to create unnecessary adverse side effects or adverse neurological effects. Findings include: Review of the facility policy titled, 3.8 Psychotropic Medication Use last revised October 24, 2022, under subsection, Procedures revealed: 8. PRN psychotropic medications should be ordered for no more than 14 days. Each resident who is taking a PRN psychotropic drug will have his or her prescription reviewed by the physician or prescribing practitioner every 14 days and by a pharmacist every month. 9. For psychotropic medications, excluding antipsychotics, that the attending physician believes a PRN order for longer than 14 days is appropriate, the physician can extend the prescription beyond 14 days for the resident by documenting their rationale in the resident's medical record. 9.1. The facility should not extend PRN antipsychotic orders beyond 14 days. Record review of Physician Orders and Medication Administration Record (MAR) revealed orders for: Ativan oral tablet one (1) milligram (mg) (Lorazepam), give 1 tablet by mouth every four hours as needed for anxiety, agitation, seizures by mouth or under the tongue. The physician order was dated 7/17/2023 with an indefinite end date. Lorazepam 1mg/ diphenhydramine 25mg/ haloperidol 1 mg. Apply four clicks (1ml) to inner wrists, every six hours as needed for agitation. Wear gloves. The physician order was dated 8/22/2023 with an indefinite end date. Haloperidol tablet 1 mg, give one tablet by mouth every four hours as needed for agitation/ hallucination. The physician order was dated 7/19/2023 with an indefinite end date. Record review revealed no documentation by the provider that included rationale for extending the PRN medication orders for lorazepam, haloperidol, or Lorazepam/diphenhydramine/haloperidol combination medication greater than 14 days. Record review revealed the last gradual dose reduction (GDR) for the haloperidol was dated July 19, 2023, and the lorazepam was dated July 19, 2023. Record review on 9/13/2023 revealed that the three PRN psychotropic medication orders that had an indefinite end date for the physician orders printed on 9/11/2023, had since been updated on 9/12/2023 at 1:00 p.m. to now reflect a 14-day end date. Interview with the Director of Nursing on 9/14/2023 at 11:44 a.m. revealed that if a PRN psychotropic medication is ordered, they would enter the order and an end date of no more than 14 days if not ordered differently. Interview on 9/14/2023 at 11:43 a.m. with Licensed Practical Nurse (LPN) GG revealed that if a psychotropic medication is ordered PRN, it would possibly need an end date, but wasn't sure of the amount of time.

Based on observations and staff interview, the facility failed to maintain a safe, clean homelike environment for two of 14 rooms on the B Hall. Specifically, the facility failed to maintain clean air filters in the Packaged Terminal Air Conditioners (PTACs) in rooms [ROOM NUMBERS]. In addition, room [ROOM NUMBER] contained a stained and broken blade on the window blind. The facility sample was 34 residents. Findings include: Observation of the B Hall on 9/11/2023 beginning at 5:00 pm revealed PTAC filters in rooms [ROOM NUMBERS] that were covered in dust. In addition, the window blind in room [ROOM NUMBER] was stained and had a broken blade. Observation on the B Hall with the Housekeeping Supervisor (HS) on 9/13/2023 beginning at 3:25 pm, revealed the PTAC filters in rooms [ROOM NUMBERS] remained covered in dust. Interview conducted during this time with the HS confirmed the PTAC filters were dusty and stated they should be cleaned at least monthly. He stated that was the responsibility of the Maintenance Department and the facility was currently looking to hire a director. In addition, he stated the Maintenance Assistant was away on vacation, so he could not produce any monitoring documents or facility policy kept by the Maintenance Department. He confirmed the window blind in room [ROOM NUMBER] was broken and stained. He stated the housekeeping staff was responsible for cleaning the window blinds.

Based on observation, interview, record reviews, and review of facility's policy Infection Prevention and Control Program (IPCP) and Plan, the facility failed to provide a urine sample to the lab in a timely manner for Resident #1 (one) who had a (Urinary Tract Infection) UTI from a sample of five residents reviewed for this complaint survey. Findings include: The facility could not provide a policy related to UTI or labs. Review of the facility's policy entitled, Infection Prevention and Control Program (IPCP) and Plan, dated 1/21/19 and revised 9/2/2020, revealed the organization-wide Infection Prevention and Control Program is comprehensive in that it addresses detection, prevention, and control of infections among residents and personnel. Goals: Monitor for any occurrences of infection and implement appropriate control measures. Identify and correct problems relating to infection prevention and control practices. Optimize the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility utilizes the Federal Regulations: 483.80 (a) Infection prevention and control the facility must establish an infection control program that includes a minimum, of the following. 483.80 (a) (1) A system for preventing, identifying, reporting, investigating, and controlling infections for all residents under a contractual arrangement based upon the facility assessment and following accepted national standards. 483.80 (a) (4) A system for recording incidents under the facility's IPCP and the corrective actions taken by the facility. Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. The resident was assessed on the Quarterly Minimum Data Set (MDS) assessment, dated 3/14/21, to have diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment identified the resident's functional status for activities of daily living (ADLs) as indicating required total assistance from staff including toileting. A review of the Nurses Progress Notes, dated 4/16/21, revealed R#1 confused and agitated, complained of burning with urination. Medical Doctor (MD) notified, new orders for UA (urinalysis) with C&S (culture and sensitivity). Responsible Party made aware. There was no written documentation dated 4/16/21 on the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician Orders, dated 4/20/21, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Nurses Progress Notes, dated 4/21/21, revealed, urine specimen obtained on 4/21/21 at 3:00 a.m. to rule out (r/o) UTI. Specimen in unit one refrigerator awaiting pick up by lab resident complaining of (c/o) dysuria (painful or difficult urination) while being toileted. A review of the Nurses progress Notes, dated 4/22/21, revealed Physician notified of UA/Culture results, cultured showed >100,000 gram negative rods, and sensitivity still pending. Physician wanted to wait until sensitivity is back to develop and implement appropriate antibiotic therapy following antibiotic stewardship guidelines and protocols. Will continue to monitor. A review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Nurses Progress Notes dated 4/24/21 revealed, antibiotic in progress for UTI, resident encouraged to drink more fluids. Resident denies pain or discomfort at this time. Will continue to monitor. A review of the facility's I power-doc daily log dated 4/21/21 revealed, urinalysis was obtained for R#1 to be sent out to the lab. There was no documentation that the lab (urine for Culture and Sensitivity) was drawn on 4/16/21, 4/19/21 or 4/20/21. Observation on 6/22/21 at 12:00 p.m. revealed the resident resting quietly in bed low position, with two cokes, chips, crackers, waffle cake on nightstand along with a pitcher of water. The phone and call light in reach. Observation on 6/22/21 at 3:26 p.m. with R#1 awake alert and pleasant. Phone and call light in reach. Observation on 6/23/21 at 9:00 a.m. revealed the resident resting in her room on her back with the call bell and phone within reach. Observation and interview on 6/23/21 at 9:20 a.m. of peri-care for R#1 revealed no concerns, the resident's skin without redness or breakdown. Resident stated she is doing good and slept well and is able to let staff know when she needs changed or if she is having burning with urination. An interview on 6/22/21 at 1:34 p.m. with treatment License Practical Nurse (LPN) AA revealed that she calls the family member weekly with treatment updates. LPN AA revealed that she did talk to the family member about the resident's UTI. LPN AA recalled the family member calling on 4/16/2021 and mentioned something about the resident having a UTI. LPN AA passed the information to the floor nurse, LPN BB, and thought she would follow through. LPN AA spoke with LPN BB on her next working day, 4/19/21, who stated that she and the family member thought that she had collected a urine specimen. LPN AA stated that is the responsibility of the floor nurse. LPN AA stated, I have no idea who collected the urine sample. An interview was conducted on 6/22/21 at 1:48 p.m. License Practical Nurse (LPN) BB revealed that on 4/20/21 the resident asking for her green pill, but the resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN BB confirmed that it is the responsibility of the floor nurse to collect urine specimens. An interview was conducted on 6/22/21 at 2:13 p.m. with Certified Nurse Aide (CNA) CC revealed R#1 needs assistance to bathroom, she wears depends, pull ups and a diaper at night. I check her every two hours to ensure she is dry, she is able to use the call light and ask for assistance, I've never known her to be soiled for a long time without getting assistance to keep her clean. I don't recall anything about a UTI. An interview with the resident on 6/22/21 at 3:26 p.m. revealed the resident felt her care is good at times, the staff come and change me; I let them know when I'm wet or soiled, I get UTI's often and have for years, it's chronic at one time I was seen by a urologist; they keep telling me to drink more water I don't like it and should, but I prefer to drink coke my family members bring it to me. An interview with the family member of R#1 on 6/22/21 at 6:39 p.m. revealed it's been a nightmare for us. R#1 had issues with UTI's for years and prior to being admitted to the facility. When she has a UTI, I can tell because she gets disoriented. She feels the DON, Assistant Director of Nursing (ADON) and unit managers were good at having meetings and spouting policy. She has a chronic UTI problem that you can't wait four days to treat. I spoke to LPN AA and thought she was going to get the urine sample; unfortunately the urine sample was called in late and I found out the sample was not sent; by the time R#1 got treatment it was the middle of the following week, this was not handle in a timely manner, and since she is a person with chronic UTI's they need to come up with another plan to help. My issue is not that she has chronic UTI's it's that they wait too long to do cultures and start treatment. A telephone interview with the laboratory used by the facility on 6/23/21 at 10:15 a.m., revealed the phlebotomist picks up the labs (including urine specimens) daily at the facility and that no labs for R#1 were picked until Wednesday April 21, 2021. The Lab confirmed the culture results were sent to the facility on Friday April 23, 2021. An interview with LPN BB on 6/23/21 at 11:00 a.m. revealed that the lab picked up the urine specimen 4/19/21 and they stated it was not a good specimen because it was left in the refrigerator over the weekend. The specimen was found Tuesday morning, 4/20/21 when we called for the lab results. We collected a fresh urine sample on 4/20/21 to be picked up by the lab that morning. She could not remember why the urine specimen was not picked up until 4/21/21. An interview with the Nurse Practitioner (NP) on 6/23/21 at 11:11 a.m. with revealed that anytime I am informed of symptoms relating to a UTI, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She doesn't know why the treatment was delayed. An interview with the Medical Director on 6/23/21 at 1:28 p.m. revealed that either he or the NP could have been called, which the staff usually call me right away. Unfortunately, the nurse at the time did not put the order in the system, our process is we would start the resident on an antibiotic but with this resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . When I received the call on Friday 4/16/21, I would have at least expected the urine specimen to be sent out that Monday 4/19/21, I'm not sure why the lab was sent out late and I would expect the urine specimen to be sent out when ordered.

Based on staff interview, record review, review of staff assignment sheets and the facility policy entitled, Guide to Infection Prevention and Control Coronavirus (COVID-19), the facility failed to follow the established policy to maintain consistent staffing on two (2) of two (2) care units (Non-COVID-19 care unit and COVID-19 care unit). These failures occurred during a COVID-19 pandemic. The findings include: Review of the staff assignment sheets from 6/1/20 through 6/10/20 revealed the following: Certified Nursing Assistant #1 (CNA #1) worked on the COVID-19 care unit eight (8) out of ten (10) days starting on 6/1/20. On 6/2/20 she worked on the Non-COVID-19 care unit during the Evening Shift (3:00 p.m. - 11:00 p.m.) and on the COVID-19 care unit during the Night Shift (11:00 p.m. - 7:00 a.m.). On 6/10/20 CNA #1 was again scheduled to work on the Non-COVID-19 care unit. CNA #2 worked on the COVID-19 care unit six (6) out of ten (10) days and on the Non-COVID-19 care unit four (4) out of 10 (10) days. This included switching from the COVID-19 to the Non-COVID-19 care unit starting on 6/5/20. She worked three (3) more days on the Non-COVID-19 care unit. On 6/10/20 was again scheduled to work on the COVID-19 care unit. CNA #3 worked on the COVID-19 care unit seven (7) out of ten (10) days and on the non-COVID-19 care unit three (3) out of 10 days. This included switching from the COVID-19 care unit to the non-COVID-19 care unit starting on 6/2/20 and again on 6/7/20. CNA #4 worked on the COVID-19 care unit five (5) out of ten (10) days and on the Non-COVID-19 care unit five (5) out of ten (10) days. This included switching from the COVID-19 starting on 6/5/20 and again on 6/7/20. CNA #5 worked on the Non-COVID-19 care unit six (6) out of eight (8) days and then worked on the COVID-19 care unit starting on 6/9/20 for two (2) consecutive days. CNA #6 worked on the COVID-19 care unit three (3) out of ten (10) days and on the Non-COVID-19 care unit four (4) out of ten (10) days. This included switching from the COVID-19 care unit starting on 6/4/20 and again on 6/9/20. CNA #7 worked on the COVID-19 care unit five (5) out of ten (10) days and on the non-COVID-19 care unit one (1) out of ten (10) days. This included switching from the COVID-19 care unit to the Non-COVID-19 care unit on 6/6/20. Licensed Practical Nurse #1 (LPN #1) worked on the COVID-19 care unit seven (7) out of ten (10) days and on the Non-COVID-19 care unit one (1) out of ten (10) days. This included switching from the COVID-19 care unit to the non-COVID-19 care unit on 6/3/20. LPN #2 worked on the COVID-19 care unit five (5) out of ten (10) days and on the non-COVID-19 care unit two (2) out of ten (10) days. This included switching from the COVID-19 care unit to the Non-COVID-19 care unit on 6/6/20. Allowing staff to work on both units increased the risk for COVID-19 transmission between the units. During a telephone interview with CNA #5 on 6/9/20 at 2:15 p.m., she said when she arrived at work each day she entered through the front door to get screened and clock-in for her shift. She was also able to check the staff assignments at that time, to see if she would be working on the COVID-19 care unit or the Non-COVID-19 care unit. CNA #5 added she had been working on the Non-COVID-19 care unit over the weekend but was working on the COVID-19 care unit on 6/9/20. CNA #5 said that some staff worked on the COVID-19 care unit all the time but she worked on both units. She also said the COVID-19 care unit had a separate entrance she would go to after being screened. Once on the unit the staff working there stayed on the unit for the remainder of their shift and took breaks in the designated break area. Review of the facility policy entitled, Guide to Infection Prevention and Control Coronavirus (COVID-19) and last revised 5/22/20 revealed Assign dedicated HCP (Health Care Providers) to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistant (NA's) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility. During an interview with the Regional Clinical Director (RCD) on 6/9/20 at 11:00 a.m., he stated the intention was to have consistent staff on the COVID-19 care unit. He added that some staff had to be moved from the non-COVID-19 care unit as the number of cases increases and the unit grew larger. The RCD said since some of the Residents with COVID-19 were starting to recover and test negative, they expected to be able to move more residents off the unit and for the unit to start getting smaller. During an interview with the Administrator and RCD on 6/9/20 at 5:30 p.m. the Administrator acknowledged there were occasions when staff had switched from working on the COVID-19 care unit to working on the Non-COVID-19 care unit. He added that although CNA #1 was scheduled to work on the Non-COVID-19 care unit on the Evening Shift on 6/10/20, after working on the Non-COVID-19 care unit on 6/9/20; that had been a clerical error and was corrected so she would be working on the COVID-19 care unit instead. The RCD said that he had been working with the scheduler to ensure consistent staffing on each unit and thought she had been keeping the staffing consistent so had not reviewed the most recent staff assignments.

Based on observation, record review, and staff interview, the facility failed to perform catheter care in a manner to prevent a potential urinary tract infection [MEDICAL CONDITION] due to fecal contamination. For one of three Residents (R) #1 resident reviewed for with history urinary tract infections [MEDICAL CONDITION], or urinary catheter use, and the sample size three (3) residents. Findings include: Review of R #1 clinical record revealed that she had [DIAGNOSES REDACTED]. Review of her Quarterly Minimum Data Set (MDS) dated Quarterly 5/17/19 revealed that she had a Brief Interview for Mental Status (BIMS) score a 1 indicates severely-impaired cognition; however, the resident had a recent decline in physical and mental status and was not able to answer screening questions. Further review of this MDS revealed the resident needed extensive assistance by two staff for bed mobility and transfers. MDS assessment on 2/14/19 and 7/19/19 section H bowel and bladder revealed R#1 was assessed as having an indwelling catheter. According to hospital discharge summaries revealed that on 5/27/19 resident was admitted to the hospital with [REDACTED]. The second admission to the same hospital on [DATE] final [DIAGNOSES REDACTED]. Her most recent hospitalization on [DATE] states resident again had a [DIAGNOSES REDACTED]. A urine culture pending upon discharge from hospital following a broad-spectrum antibiotics therapy. Observation of R #1 catheter care conducted on 8/8/19 revealed that R#1 had a bowel movement and the CNA AA repeatedly introduce feces into the resident periurethral and meatal area. Further observation revealed that AA failed to inspect and clean the catheter tubing during care. During an interview with Certified Nursing Assistant (CNA) AA on during the catheter care observation 8/8/18 she stated that she been a CNA for 8 years and attended training for catheter care x 1 month ago. She stated that she was trained to perform the catheter care always first before attending to resident soiled brief to prevent feces contamination. During an interview with the Director of Nursing (DON) on 8/9/19, revealed that the facility use Lippincott 2019 Skills check list procedure to train staff catheter care and AA was taken off direct care temporarily until she was properly trained for peri care and catheter care. She also revealed that the facility had recently hired Staff developer and was unable to locate training record for AA and other staff. She further revealed that AA should have stopped catheter care and performed incontinent care for the resident's bowel first and resumed the catheter care. Review of the facility Lippincott procedure 2019 Skill checklist Indwelling urinary catheter and management which instruct to cleanse the periurethral and meatal area using soap and water OR perineal cleanser, cleansing front to back.

Based on observation, record review, resident, staff interview, facility training Indwelling urinary catheter (foley) care and management the facility failed to develop and implement the care plan related to caring for a urinary catheter as appropriated of one resident (R) R#1; of three (3) residents with indwelling urinary catheter. Finding include: Review of R #1's Admission Minim Data Set (MDS) assessement dated 2/14/19 revealed that she had an indwelling catheter, and indwelling catheter triggered as an area of concern on the Care Area Assessment Summary. Review of her MDS dated [DATE] revealed that she still had an indwelling catheter. Comprehensive care plan developed on 2/7/19 and revised on 4/2/19 did not address resident indwelling catheter. The care plan did not address the resident ' s foley catheter and interventions included to care for the catheter as appropriate. During observation of catheter care by CNA AA on 8/8/19 at 9:55 a.m. revealed continuous use of the wet cloth use to provide care was soiled with feces in which she continuous introduction of feces into the resident periurethral and meatal area while providing care. Further observation revealed the catheter tubing was not inspected or cleaned during the care. Interview with Certified Nursing Assistant (CNA) AA on during the catheter care observation 8/8/18 she stated that she been a CNA for 8 years and attended training for catheter care x 1 month ago. She stated that she was trained to perform the catheter care always first before attending to resident soiled brief to prevent feces contamination. According to the facility skills checklist- Indwelling urinary catheter (foley) care and management state: Develop an individual care plan based on assessment findings and revise as needed and identify approaches to minimize the risk of infection by providing catheter/tubing/bag care. Review of hospital discharge summaries revealed that on 5/27/19 resident was admitted to the hospital with [REDACTED]. The second admission to the same hospital on [DATE] final [DIAGNOSES REDACTED]. Her most recent hospitalization on [DATE] states resident again had a [DIAGNOSES REDACTED]. A urine culture pending upon discharge from hospital following a broad-spectrum antibiotics therapy. Cross-reference F690

Based on observation, interviews, record review, review of the facility policies titled Reducing the Risk [MEDICAL CONDITION] Residents from Hot Beverages and Feeding a Resident, the facility failed to provide adequate supervision when offering hot beverages for three residents (R) (#85, #99, and #33) of 38 sampled residents. The three residents [MEDICAL CONDITION] their body which resulted in actual harm. Findings include: Review of the undated facility policy titled Reducing the Risk [MEDICAL CONDITION] Residents from Hot Beverages revealed: [MEDICAL CONDITION] result from hot liquids that are 120 degrees F (Fahrenheit) or above, supervision is required to provide a safe environment in which our residents can enjoy a good-tasting cup of coffee or other hot beverages. Hot beverages should be available to residents only in areas that are supervised at all times. Evaluate each resident's ability to manage hot beverages and provide needed assistance. Develop a process to ensure that all associates involved with dining, activities, etc., are aware of who needs this special supervision. Review of the facility policy titled Feeding a Resident effective 11/26/18 revealed that it was the responsibility of all nursing staff to provide assistance to residents who are unable to feed themselves or need assistance with meals and snacks. This facility will ensure that properly trained personnel supervised by nursing assist residents as needed with meals and snacks and feed residents who are unable to feed themselves. 1. R#85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment for R#85 dated 4/9/19 revealed a Brief Interview for Mental Status (BIMS) score of 8 (a BIMS score of 8 to 12 indicates moderately-impaired cognition). Section G - Functional Status documented the resident requires one-person extensive assistance with eating. Resident #85's baseline care plan dated 4/2/19 notes resident skin was intact and states resident requires assistance with activities of daily living (ADL) and mobility. During an interview on 4/23/19 at 10:33 a.m., R#85 stated he wanted to go home but the burn wound on his thigh was keeping him from going home. During wound care observation on 4/24/19 at 10:34 a.m., Licensed Practical Nurse (LPN) II and LPN Wound Care Nurse HH provided the dressing change to R#85's right thigh. LPN II stated the wound was a healing burn and that the resident fell asleep and spilled hot coffee on his leg. A review of Nurse's Note for 4/5/19 offered an event note timed 23:45 (military time) which stated Resident observed with lesion on his right upper thigh. Resident stated, The coffee spilled on me and burned me. Physician (MD) notified, resident's family notified. New order for [MEDICATION NAME] ointment applied to area. Resident is stable. No acute distress noted. The Weekly Skin Integrity Data Collection forms for R#85 documented the following: On 4/5/29, resident has lesion from burn to right front thigh. On 4/6/19, resident has a burn to right front inner thigh, skin blistering. On 4/9/19, burn to the right front thigh continues with decreased scarring. No signs and symptoms of infection. On 4/12/19, right front thigh blister intact. On 4/17/19, right front thigh burn noted with layer of yellow tissue at wound surface. R#85 was seen by Wound Physicians starting 4/9/19 and review of the latest Wound Evaluation and Management Summary dated 4/23/19 revealed a wound 8.3 centimeters (cm) in length (L), 12.5 cm in width (W) and 0.1 cm in depth (D) to the right thigh caused by a coffee burn was unchanged with 50% necrotic tissue. Resident received excisional debridement. During an interview on 4/24/19 at 3:33 p.m., the Administrator stated the burn incident occurred around 5:30 p.m. on 4/5/19. He completed an investigation which revealed Certified Nursing Assistant (CNA) MM served hot coffee to R#85. R#85 was lying in bed and the coffee spilled, burning his leg. After completion of the investigation, CNA MM was terminated due to failure to follow facility policy on serving hot beverages. Administrator stated facility policy is that temperature checks are completed on all hot liquids leaving the kitchen. He further stated that the coffee company came to the facility to lower the coffee machine temperatures to less than 165 degrees. An interview on 4/24/19 at 3:47 p.m. with Assistant Director of Nursing (ADON) revealed R#85 requested a cup of coffee. CNA MM went to the kitchen, requested a cup of coffee and was told by dietary staff to serve herself. CNA MM obtained the coffee and provided it to the resident. ADON further stated that after the incident, all coffee pots were removed from the pantries and thermoses are now in their place. An interview on 4/25/19 at 4:00 p.m. with DON revealed there have been two other burn incidents in the facility. On 10/1/18, R#33 was burned after CNA heated soup, upon request, on the night shift. At that time all staff were educated and banned from heating any beverages for residents. DON further stated CNA violated policy when she retrieved coffee without the knowledge of dietary staff. Since this incident, the kitchen is now locked. Any staff requesting entrance must be let in by the dietary staff. An interview on 4/25/19 at 4:24 p.m. with Food Service Director (FSD) revealed there were three employees on duty the evening of the incident. All employees denied allowing access to the kitchen. FSD stated the kitchen usually closes around 8:30 - 9:00 p.m. The coffee had not yet been sent out in thermoses to the floor pantries. FSD further stated it is the facility's policy to check the temperature on all hot beverages before they leave the kitchen. The temperatures are taken and then logged. If the temperatures are greater than 150 they are cooled down with water; and that only dietary staff should be in the kitchen. No beverages were logged in that evening. During further interview on 4/26/19 at 1:21 p.m., R#85 stated he could recall the incident where he was burned. He stated he requested a cup of coffee from the CNA. She brought it in and placed it on the table next to the bed. When he attempted to bring the table closer, the coffee turned over on his lap. An interview with Wound Care Physician on 4/26/19 at 3:28 p.m. revealed he was unable to assign a degree of burn to R#85's wound due to the amount of necrotic tissue present and the wound has some full to partial thickness involvement. The wound is healing as expected and requires some debridement. The wound is superficial in nature. He further stated that if the wound was a third degree burn, the resident would have been sent to a wound clinic. 2. Review of a [DIAGNOSES REDACTED].#99 had [DIAGNOSES REDACTED]. Review of R#99's completed MDS revealed that she had Entry Tracking Records on 12/7/18, 12/18/18, 3/1/19, and 3/15/19. Further review of her MDS revealed Discharge Assessment-Return Anticipated completed on 12/9/18, 1/26/19, 3/9/19, and 3/26/19. Review of R#99's Admission MDS dated [DATE] revealed that she had a BIMS score of 9, needed extensive one-person assist for eating, and had no burns. Review of her Medicare 5-day MDS dated [DATE] revealed these items were coded the same as on the Admission MDS, except her BIMS score was 8. Review of a care plan initiated 12/7/18 revealed that R#99 needed ADL assistance and therapy services to maintain or attain highest level of function. Review of the Interventions/Tasks of this care plan included assist with ADLs as needed. Review of a care plan developed 3/24/19 revealed R#99 sustained a burn to the right breast and right flank. Interventions/Tasks to this care plan included to refer to therapy for assistive device for hot beverage. Review of a Speech Therapy SLP (Speech Language Pathologist) Evaluation and Plan of Treatment dated 3/19/19 revealed R#99 was referred to ST (Speech Therapy) services for dysphagia due to decline in ability to respond to cues/instruction, ability to use compensatory strategies, signs/symptoms of dysphagia, pneumonia, oral/pharyngeal function, need for assistance from others and safety awareness. Clinical Impressions: Based on the evaluation only, patient is at risk for aspiration pneumonia and a diet downgrade. Patient exhibits increased confusion, limited verbal output, lack of mastication, and poor tongue strength. Patient also exhibits similar s/s (signs and symptoms) of a stroke or TIA, but hospital tests came back negative. Patient not appropriate for ST services due to recent medical decline and increased inability to participate. Review of Nursing Progress Notes revealed the following: 3/17/19 10:33 p.m. Health Status Note: Resident weak and non-verbal. 3/19/19 8:38 a.m. Health Status Note: Resident unable to swallow. Will not open mouth or speak at this time. 3/24/19 10:18 a.m. Event Note: Pt. (patient) found in bed by nurse with coffee spilled on bedside table, gown and bed. Skin noted to be red on abdomen, right breast area and right flank. [MEDICATION NAME] 1% cream to be applied to right abdomen, right flank daily until healed. Treatment carried out by wound care nurse. Pain assessment rendered. OT (Occupational Therapy) screen ordered for device needed for hot beverages. New order for wound MD to evaluate and treat if appropriate. 3/24/19 2:19 p.m. Health Status Note: Skin assessed, red area on abdomen and right breast. No blisters noted. No complaints of pain but upon assessment and palpation around the area, resident begin to frown. 3/24/19 3:22 p.m. Skin/Wound Note: Reported new skin issue, area assessed. Patient has newly burn site to right upper quadrant of abdomen extended to right flank, redness to the area noted no drainage, new order for [MEDICATION NAME] cream to apply daily and prn (as needed) until resolved. 3/26/19 1:00 p.m. Event Note: Skin to abdomen is intact with slight redness noted. No blistering or open areas. (R#99) denies pain. Review of a Weekly Skin Integrity Data Collection dated 3/24/19 revealed a new finding of burn to abdomen and right rear iliac crest, treated per wound care. Review of an incident report dated 3/24/19 revealed: Writer went to resident's room and saw coffee spilled on the bedside table and on resident's gown and on resident, skin red on right breast area around to right flank. Therapy to screen for device for hot beverages, wound care MD to evaluate. Mental status oriented to person and place. Predisposing Physiological Factors: recent illness. No witnesses. Review of a physician phone order dated 3/24/19 revealed to cleanse right abdomen and flank burn site with normal saline, apply [MEDICATION NAME] cream and leave area open to air daily. Review of a Wound Evaluation & Management Summary dated 3/26/19 revealed: Patient presents with a wound on her right, anterior flank. There is no exudate. There is no indication of pain associated with this condition. Burn wound of the right, anterior flank. Wound size: 3.0 x 12.0 x not measurable (centimeters). Primary dressing: Silver [MEDICATION NAME] apply once daily for 30 days. During interview with the DON on 4/25/19 at 5:32 p.m., she stated that CNA LL was the staff member who had served R#99 the coffee the day the resident was burned. She stated during further interview that the CNA had made coffee from the single-serve coffee maker in the pantry but did not know what the temperature of the coffee maker was set to. During interview with CNA LL on 4/25/19 at 7:05 p.m., she stated that when she was passing breakfast trays on the unit on 3/24/19, she offered R#99 a cup of coffee, which was stored on top of the breakfast carts. She stated during further interview that she added some cold milk to the coffee cup, placed a straw in the cup, remained with the resident as she took her first sip, and then placed the cup on the overbed table. The CNA further stated that the resident had no difficulty drinking the coffee, so she left the room and continued passing breakfast trays to other residents on the unit. CNA LL stated during continued interview that when she had reached the end of the hall, she was told that R#99 had spilled the coffee on herself. She stated that she had received education several times, both before and after this incident, about the handling of hot beverages, and that staff were not allowed to heat up a resident's coffee. CNA LL added that when working with a resident she was not familiar with, she asked the nurse about what the resident's care needs and level of assistance were. During interview with the DON on 4/26/19 at 9:22 a.m., she stated that when she interviewed CNA LL after R#99 was burned, the CNA said that R#99 was alert when served the coffee. The DON further stated that the CNA told her that she supervised R#99 when she took her first sip with a straw, and then left the room to continue to pass the breakfast trays. The DON stated during continued interview that R#99 had been in and out of the hospital several times and could not remember what her physical status was at the time of the burn. During interview with LPN MDS Coordinator NN on 4/26/19 at 10:08 a.m., she stated that if a resident was coded as needing extensive assistance for eating with one-person physical assist, that staff should be present when the resident was eating or drinking. During interview with the Director of Rehabilitation Services on 4/26/19 at 10:12 a.m., she stated that they did not have an assistive device for hot beverages (as per intervention in R#99's burn care plan), but rather looked more at a supervision and positioning aspect for drinking hot beverages. Continued interview revealed that the last time R#99 was on therapy caseload was from 3/15/19 to 3/26/19 for general strengthening and mobility, as the resident had a decline with physical mobility and weakness after a hospitalization for pneumonitis. The Rehabilitation Director further stated that ST assessed R#99 as supervision for self-feeding, and that the ST evaluation dated 3/19/19 had a recommendation for upright position during feeding with an emphasis more on swallowing than ability to feed herself safely. She further stated that on the OT evaluation dated 3/16/19, R#99 was assessed as independent for eating. During interview with SLP OO on 4/26/19 at 10:56 a.m., she stated that she screened R#99 for skilled ST services after a hospital readmission. She further stated that there was a change in the resident's medical status and cognition, and she was not as aware of her surroundings. She stated during continued interview that when she evaluated R#99 on 3/19/19, she recommended that the resident required supervision with eating due to changes in cognition and medical status. SLP OO further stated that she did not feel that R#99 was safe to feed herself after 3/19/19 because of this decline and periods of varying awareness and needed to be supervised when eating and drinking. During interview with LPN Wound Care Nurse HH on 4/26/19 at 1:25 p.m., she stated that she recalled R#99's burn, and that the resident's skin was intact and just reddened, but not blistered. Review of a Quality Assurance and Performance Improvement Plan for Hot Beverage (undated but with the first goals dated 3/24/19) revealed that a resident (R#99) sustained a burn to right breast and flank area. Actions included wound care MD to evaluate and treat; therapy screen for device and self-feeding of hot liquids; one cup coffee maker immediately taken out of use and removed from nutrition room. Staff to be educated on pouring and set-up of hot beverages with post-test on reducing the risk [MEDICAL CONDITION] hot beverages. Establish times that coffee tea and cocoa will be available to residents with supervision. Coffee will be made from equipment located inside the food service department only and transferred to carafes to be served on unit. Hot liquids will be checked and recorded on the food temp log to ensure guidelines are met before leaving the department. 3. Review of the clinical records revealed R#33 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS assessments revealed a Quarterly MDS of 8/3/18 which revealed R#33 had BIMS score of 15, indicating that the resident was cognitively intact. The assessment also documented that the resident needed extensive assistance with bed mobility and one-person limited assistance with eating (an assessment that a resident needs limited assistance in this area means that, while the resident is able to eat by herself/himself, staff must set up the tray and assist with needed items such as cutting meat, opening containers, and handing utensils. At times, such as when the resident is tired, staff may also need to guide the resident's hand so she/he will get the utensils to his/her mouth). During an interview with R#33 on 4/26/19 at 12:28 p.m., it was revealed that she sustained a burn in (MONTH) or (MONTH) of (YEAR) during the 11:00 p.m. to the 7:00 a.m. shift. This occurred after she asked a CNA to heat up some soup she could have as a late snack. The resident said she placed the soup in a Styrofoam cup and gave it to the CNA to be heated in the microwave. When the CNA returned with the heated soup, she cautioned the resident to be careful because the soup was hot. The resident said she was very hungry so she immediately put the soup to her mouth, but when it burned her lips, she must have squeezed the cup, reflexively, causing the hot soup to spill on her chest. The CNA came in immediately when she called and placed some cold, wet towels on the burned area. The resident said she later learned that the CNA had been reprimanded and that the staff were advised that they were no longer able to heat/reheat food items on her behalf. Review of an incident report dated 9/30/18 at 1:00 a.m. revealed the resident had sustained a burn to her breast during the night shift. The nurse was called to the room by the resident (R#33) who stated that she had wasted her soup cup on her chest that the CNA had just warmed up for her. The resident was listed as being in bed and alert and oriented to her surroundings when the incident occurred. The physician was notified and gave orders to monitor the resident's chest for signs and symptoms of infection every shift related to a thermal burn allegedly caused by food to chest area. The incident report also documented that the resident's care plan was reviewed and updated and that the resident and staff were educated on handling hot objects. Review of a physician's telephone order form of 9/30/18 revealed that the staff received orders to cleanse the resident's sternum with normal saline, pat dry, apply [MEDICATION NAME] cream, and cover with a protective dressing daily and as needed. Review of an Initial Wound Evaluation and Management Summary of 10/2/18 revealed that the resident was referred by the physician for assessment and evaluation of a burn wound of the anterior chest of at least three days duration. The area was described as having a light serous exudate with a partial thickness wound related to the resident spilling hot noodles on the chest. The wound size was described as being 22 cm L x 21 cm W x 0.1 cm D with 60% dermis/40% skin affected. The recommended treatment was for silver [MEDICATION NAME] to be applied once daily for 30 days. The Rehab Services Screen of 10/5/18 documented that R#33 sustained a burn to the chest over the previous weekend while eating hot soup in bed. The screen also documented that nursing staff had reported that the resident frequently ate in bed with the head of the bed at a 35-degree elevation. The resident was assessed as having no changes in the areas of self-feeding, swallowing, cognition, communication, and range of motion/strength. The therapy staff recommended that it was appropriate for the resident to continue to eat as before but, because she normally ate in bed, it was recommended that the head of the bed be positioned at 60 degrees to prevent future burn injury, spillage, etc. Review of the care plans for R#33 revealed a plan of care for ADLs initiated 2/22/18 and updated on 9/30/18 for noncompliance with upright positioning while eating. A review of staff education documents of 10/2/18 revealed more than 100 members of staff were provided education related to Reducing the Risk [MEDICAL CONDITION] Residents from Hot Beverages. Post-tests elicited responses that: hot beverages were to be served at 145 to 155 Fahrenheit; staff should never warm up liquids if they were not part of the dietary staff; and all hot beverages should be served in a mug. However, residents were still [MEDICAL CONDITION] to hot liquids despite the facility staff education of (MONTH) (YEAR). A review of the pantry areas on the resident hallways revealed copies of posted signs which read: Liquids shouldn't be warmed up by staff. Any Liquids to be warm should be taken to dietary to be warmed by Dietary Staff ONLY. An interview on 4/19/19 at 2:46 p.m. with the DON revealed that R#33 sustained a burn to her chest after she asked a CNA to warm some soup on her behalf and, subsequently, dropped said soup on her person when she discovered it was too hot. The DON said that the facility immediately educated all staff that non-dietary staff are not to heat/reheat liquids for residents. If residents need liquids heated/reheated, dietary staff must perform this action and must take the temperature of the heated food item before it is served to the resident. The DON said the management team determined that only dietary staff had the training and equipment needed to reheat food items on behalf of residents because these food items must be a certain temperature before being presented to the resident. A therapy screen determined that R#33 was appropriate to have hot liquids/items without supervision if she was sitting upright during its consumption. The CNA involved in the incident also received the relevant training.

Based on observation, record review, and staff interviews, the facility failed to follow Physician order [REDACTED].#67 and R#42) related to wearing TED hose (compression stockings) of 38 sampled residents. Findings include: 1. Review of the clinical record revealed R#67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) coded as 10, indicating moderate cognitive impairment. Section G - Functional Status documented that the resident requires extensive assistance with dressing including donning and removing TED hose. Review of the Physician order [REDACTED]. Observation on 4/23/19 at 11:40 a.m. revealed R#67 sitting in the wheelchair with no TED hose on. The resident wore regular red socks. The Medication Administration Record [REDACTED]. During an interview on 4/24/19 at 3:06 p.m., Certified Nursing Assistant (CNA) DD stated that she was not aware that R67 has an order to wear TED hose and has never put TED hose on the resident. During an interview on 4/24/19 at 3:30 p.m., CNA FF stated that R#67 wore regular socks and the charge nurse never gave them report for R#67 to wear TED hose. 2. Review of the clinical record revealed R#42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Annual MDS assessment dated [DATE] revealed a BIMS coded as 03, indicating severe cognitive impairment. Section G - Functional Status documented that the resident requires extensive assistance with dressing including donning and removing TED hose. Review of the POF dated 3/20/19 revealed an order for [REDACTED]. Observation on 4/23/19 at 1:15 p.m. revealed R#42 sitting in the wheelchair. The resident was not wearing TED hose. Review of the MAR for (MONTH) 2019 and (MONTH) 2019 revealed that the order was not transcribed. During an interview on 4/24/19 at 4:00 p.m., Licensed Practical Nurse (LPN) GG stated that she received the orders for the TED hose and forgot to enter them on the MARs.

Based on record review, resident and staff interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment after declines in cognition, five areas of ADL (Activities of Daily Living), and in bladder and bowel continence between the Quarterly MDS assessments of 1/9/19 and 4/11/19 for one resident (R) (#94). In addition, the facility failed to do a Significant Change MDS for one resident (R#65) who had been placed under Hospice services. The sample size was 38 residents. Findings include: Review of the facility's Resident Assessment Instrument & Care Plan policy last revised 11/28/16 revealed the following: The MDS uses assessment, patient observation, staff, family and patient interviews to form the foundation of the comprehensive assessment. MDS assessments are completed at a minimum upon admission, quarterly, annually, and with a significant change in patient status. The Care Area Assessment provides a systematic method to further assess the patient and determine if the Care Area that triggered requires interventions and care planning. The information identified using the MDS and Care Area Assessment process is used to develop an individualized person-centered Care Plan that includes the patient's voice, the patient's goals while residing in the facility and for discharge that assist the patient to attain and/or maintain their highest practicable level of well-being. 1. Review of R#94's Quarterly MDS dated [DATE] revealed that she had a BIMS (Brief Interview for Mental Status) score of 12 (a BIMS score between 8 and 12 indicates moderate cognitive impairment); needed limited assistance by two persons for transfers; needed extensive assistance by one person for dressing, toilet use, and personal hygiene; needed supervision only for eating; and was frequently incontinent of bowel and bladder. Review of R#94's Quarterly MDS dated [DATE] revealed that she had a BIMS score of 00 (a BIMS between 0 and 7 indicates severe cognitive impairment); was totally dependent by two persons physical assist for transfers; was totally dependent by one person physical assist for dressing, toilet use, and bathing; needed extensive physical assistance by one person for the ADL of eating; and was always incontinent of bowel and bladder. During interview with the Director of Rehabilitation Services on 4/25/19 at 1:28 p.m., she stated that R#94 had been on rehab caseload in the past for functional intervention, but was not currently. She further stated that if a resident had a decline in their ADL, therapy would want to know this so that they could screen them for skilled services, but had not gotten a referral from nursing for R#94. During interview with Licensed Practical Nurse (LPN) MDS Coordinator KK on 4/25/19 at 1:36 p.m., a Significant Change MDS would be done if a resident had two or more significant events, such as going on hospice services, a new wound, weight loss, or decline in ADL. She verified that R#94 had areas of decline from the (MONTH) and (MONTH) MDS in areas of cognition, transfers, dressing, toilet use, bathing, eating, and continence, and that a Significant Change assessment would have been appropriate after the (MONTH) MDS. During interview with R#94 on 4/26/19 at 2:24 p.m., she stated that she did not feel that physical or occupational therapy would be beneficial for her. 2. Review of the clinical records for R#65 revealed she was admitted to the facility on [DATE] and, after a hospital stay beginning on 10/3/18, was readmitted on hospice services with [DIAGNOSES REDACTED]. A review of the MDS assessments revealed the last comprehensive assessment completed for the resident was an admission MDS of 9/19/18. After her admission to hospice services on 10/9/18, two quarterly assessments were completed on 12/20/18 and 3/22/19, respectively. However, there was no evidence that a comprehensive assessment had been completed to reflect the significant change the resident experienced at the time of her admission to hospice services. Interview on 4/19/19 at 10:45 a.m. with LPN MDS Coordinator NN revealed that a significant change assessment should be completed when a resident has significant changes in at least two areas of functioning. A significant change assessment should have been completed for R#65 after she was admitted to hospice which signaled that she had a significant decline in several areas. That such an assessment was not completed for the resident was an oversight and one would be completed immediately.