Every finding on record at Life Care Center of Hixson

Based on interview, record review, document review, and facility policy review, the facility failed to ensure Certified Nursing Assistant (CNA) #1 did not operate outside the scope of a CNA when he flushed Resident #125's peripherally inserted central catheter (PICC) line (a PICC line is a long, thin, flexible tube inserted through a vein in the arm and threaded to a large vein near the heart. A PICC line provides long-term secure intravenous (IV) access for delivering medication, fluids, or nutrition, or for drawing blood, reducing the need for daily needle sticks). It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, serious harm, serious impairment, or death to residents. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, 483.25 F684, Quality of Care, at a scope and severity of J. The Immediate Jeopardy began on 04/27/2026. The IJ began on 04/27/2026 when CNA #1 flushed Resident #125's PICC line. The survey team notified the Executive Director (ED), the Regional Director of Clinical Services, the Regional [NAME] President, and the interim Director of Nursing (DON) of the IJ on 05/01/2026 at 12:47 PM and provided the IJ template on 05/01/2026 at 12:55 PM. A removal plan was requested. The facility's removal plan was accepted by the state survey agency on 05/01/2026 at 7:29 PM. The IJ was removed on 05/02/2026, after the survey team performed onsite verification that the removal plan had been implemented. Noncompliance for F684 remained at a lower scope and severity of D, isolated, no actual harm with the potential for more than minimal harm. The Findings Include: A facility policy titled, 3.7 Administration of an Intermittent Infusion Via a Secondary Administration Set, revised 10/13/2025, indicated, To Be Performed By Licensed nurses according to state law and facility policy. A facility policy titled, Infusion Therapy - Intravenous (IV Fluids), revised 01/06/2026, indicated, The facility assures that each resident receives care and services for the provision of parenteral fluids consistent with professional standards of practice in order to provide: a. Safe administration of parental fluids by qualified, competent and trained staff in accordance with State laws/practice acts. An admission Record revealed the facility admitted Resident #125 on 04/22/2026. According to the admission Record, the resident had a medical history that included a diagnosis of infection and inflammatory reaction due to internal left hip prosthesis. Resident #125's Order Summary Report revealed an order dated 04/22/2026, for heparin lock flush solution 10 units per milliliter (mL), use 5 cubic centimeters intravenously every shift related to infection and inflammatory reaction due to internal left hip prothesis, flush PICC line after post-medication normal saline flush and an order dated 04/22/2026, for heparin lock flush solution 10 units per mL, use 5 mL intravenously every 12 hours related to infection and inflammatory reaction due to left hip prosthesis, flush unused PICC lumen with heparin after normal saline flush. Resident #125's Care Plan Report included a focus area initiated 04/27/2026, that indicated the resident had a peripherally inserted central catheter due to an infection. Interventions directed the licensed practical nurses (LPNs) and registered nurses (RNs) to assess the site as ordered by the prescriber and flush/lock as ordered. Resident #125's progress note written by the Medical Director (MD) and dated 04/27/2026, indicated the resident had bleeding from their PICC line due to operational error with the port not being fully clamped. Per the progress note, the MD directed the staff to continue to monitor the resident for any signs of infection and reeducate the staff. Contained within the facility investigation file was a handwritten statement from CNA #1 dated 04/30/2206, that specified, On either April 27 or April 28, 2026 my resident in room [Resident 125's room] [his/her] machine was going off and I told the nurse [RN #2] that [his/her] machine was going off and it said that [his/her] infusion was done and when I told her she said okay but never went to take care of it so. Per the handwritten statement, so yes I went down the hallway and turned [his/her] light off and I told [Resident #125] that I had let the nurse know that [he/she] was done with [his/her] infusion and to help the nurse out that's when I turned the machine off and flushed [his/her] picc line and place the cap back on and I let [RN #2] know and all she said was okay. Furthermore, the handwritten note indicated And all the supplies are in [his/her] room to flush [his/her] picc line. During an interview on 04/30/2026 at 10:37 AM, Registered Nurse (RN) #2 stated she witnessed CNA #1 disconnect Resident #125's PICC line. RN #2 stated she told CNA #1 that he could not handle the resident's PICC line and she would take over the care of the resident's PICC line. According to RN #2, CNA #1 did not state why he handled the resident's PICC line. During an interview on 04/30/2026 at 11:30 AM, Resident #125 stated one time CNA #1 used a syringe to flush their PICC. Resident #125 stated afterwards the PICC line was not clamped, there was a lot of blood, and the doctor came to assess their PICC line. During an interview on 04/30/2026 at 1:04 PM, RN #2 stated Resident #125 informed her that the interim DON stated the concern with the resident's PICC line was because it was not clamped properly. RN #2 stated Resident #125 informed her that CNA #1 had disconnected and flushed their PICC line. During an interview on 04/30/2026 at 1:16 PM, Licensed Practical Nurse Unit Care Coordinator (LPN UCC) #12 stated a certified nursing assistant (CNA) was not allowed to do anything with a resident's PICC line as the CNA was not licensed or trained. LPN UCC #12 stated she was told by RN #2 that there had been an issue with a CNA handling Resident #125's PICC line. During an interview on 04/30/2026 at 2:02 PM, the interim DON stated on 04/30/2026, she was told by Resident #125 that someone other than a nurse flushed their PICC line. The interim DON stated Resident #125 informed her that CNA #1 flushed their PICC line when it was beeping and the area started to bleed. Per the interim DON, she started an investigation regarding what the resident notified her of. The interim DON stated a CNA could not do anything with a resident's PICC line because the CNA was not trained. During an interview on 04/30/2026 at 2:30 PM, the MD stated a nurse told a nurse practitioner that there was a concern with Resident #125's PICC line so he went to examine the resident. The MD stated the PICC line looked fine, but there was a bit of blood on the resident's bed and gauze that was in the trash can. The MD stated when he looked closer at the PICC line, he noticed it was not clamped and the connect to the needle was not present. The MD stated he assumed whoever disconnected the PICC line, took the clear piece off and unscrewed the cap instead of disconnecting it. During an interview on 04/30/2026 at 3:48 PM, CNA #1 stated it was either 04/27/2026 or 04/28/2026, when he noticed Resident #125's PICC line was beeping and he turned it off. According to CNA #1, he sanitized his hands, put on gloves, sanitized the PICC line with a sanitizing pad, and flushed the resident's PICC line. CNA #1 stated he pressed pause on the machine twice and once the PICC line was sanitized he capped the PICC line. Per CNA #1, he then used a syringe and flushed the resident's PICC line with a 10 milliliter syringe of normal saline that he found in the resident's room. CNA #1 stated afterwards, he clamped the PICC line but was unsure how many times he twisted the syringe. CNA #1 stated he made sure there were no kinks or air in the tubing and there was no sign of blood when he flushed the PICC line. CNA #1 stated he was never trained in the facility how to handle a resident's PICC line and he only did so to help the nurses out. CNA #1 stated he did not think it was a problem for him to flush or take care of Resident #125's PICC line. During a follow-up interview on 05/01/2026 at 8:40 AM, the MD stated in her professional opinion if a non-qualified person were to disconnect and flush a resident's PICC line it would be hard to say without training what the adverse outcome would be. The MD stated if there was no green cap over the PICC line, there could be the possibility the resident could get an infection. During an interview on 05/01/2026 at 6:52 PM, the former Director of Nursing stated CNAs would never be trained on how to care for a resident's PICC line because it was not in their job description or scope of practice. During an interview on 05/02/2026 at 3:17 PM, the interim DON stated it did not meet the facility expectations to have a CNA disconnect or flush a resident's PICC line. The interim DON stated there was a risk for infection, risk of harm to resident, harm to the tubing site, liability to the facility, and liability to the CNA due to it being outside a CNA's scope of practice. During an interview on 05/02/2026 at 3:39 PM, the ED stated it did not meet expectations for a CNA to flush and/or disconnect a resident's PICC line or IV due to it being out of a CNA's scope of practice. The facility submitted a removal plan that was accepted by the state survey agency on 05/01/2026 at 7:29 PM. The removal plan indicated the following: The facility failed to ensure Resident #125 received treatment and care in accordance with professional standards of practice when certified nursing assistant (CNA) #1 flushed a resident's peripherally inserted central catheter (PICC) lumen used to deliver intravenous fluids on 04/27/2026. Facility staff, Registered Nurse (RN #2) was made aware on 04/23/2026 by Resident #125 that CNA #1 had flushed their PICC, and the facility failed to investigate. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 04/29/2026, Resident #125 was evaluated by the medical provider. No changes from the baseline were noted. On 04/30/2026, the Director of Nursing (DON) obtained a statement from Resident #125. On 04/30/2026, Resident #125 was evaluated by a licensed nurse. No changes from the baseline were noted. On 04/30/2026, the Executive Director (ED) and Regional [NAME] President (RVP) obtained a statement from Registered Nurse (RN) #2. At that time RN #2 was suspended pending investigation. On 04/30/2026, the Executive Director (ED) and Regional [NAME] President (RVP) obtained a statement from Certified Nursing Assistant (CNA) #1. At that time CNA #1 was suspended pending investigation. Following completion of the investigation, CNA #1 will be reported to nurse aide board related to practicing outside their scope of practice. On 04/30/2026, the Director of Nursing (DON) and Regional [NAME] President (RVP) obtained a statement from LPN Unit Care Coordinator #1. At that time LPN Unit Care Coordinator #1 was suspended pending investigation. On 04/30/2026 at 1:45 PM, the Executive Director (ED) notified the Medical Director of the incident involving Resident #125. On 04/30/2026, the Director of Nursing (DON) initiated an incident report on Resident #125 and the CNA practicing outside their scope of practice. The incident report includes notification to the medical provider, resident representative, and care plan updates as indicated/applicable. On 04/30/2026, the Director of Nursing (DON) obtained an order for new PICC line to be placed by NursePro (contract IV therapy company) The PICC line was able to be cleared of occlusion by the NursePro PICC Nurse, and a new PICC line was not needed. On 4/30/2026, the Executive Director (ED) and Director of Nursing (DON) completed a root cause analysis (RCA). The RCA revealed the following: A breakdown in staff understanding and enforcement of scope of practice and delegation expectations, including insufficient oversight by licensed nursing staff to ensure tasks were performed within appropriate roles. On 04/30/2026, the Director of Nursing (DON) completed an audit in Resident #125's room to ensure no flush supplies were available for use. The audit revealed that no flush supplies were available for use. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents with intravenous (IV) therapy have the potential to be affected. What measure will be put into place or systemic changes the facility will make to ensure that the deficient practice does not recur. The Director of Nursing (DON), Staff Development Coordinator (SDC), Regional Director of Rehab Services (RRD), Clinical Reimbursement Specialist (CRS), and/or licensed nurse-initiated quizzes with all licensed nurses (Registered Nurse [RN] and Licensed Practical Nurse [LPN]) on the nursing scope of practice and delegation of authority. Quizzes will be completed on 05/01/2026. Any licensed nurse who has not completed the quiz with a passing score by 05/01/2026 will not be allowed to provide direct resident care until education is completed. Any associate who does not complete training prior to 05/01/2026 will be removed from the schedule until training is completed, education will be provided by the Director of Nursing (DON), Staff Development Coordinator (SDC), and/or licensed nurse. Any associate on vacation and/or FMLA will complete training upon return prior to their next working shift; education will be provided by the Director of Nursing (DON), Staff Development Coordinator (SDC), and/or licensed nurse. Any licensed nurse who does not score a 100 on their quiz will be immediately re-educated, and another quiz will be completed until a passing score is achieved. The Executive Director (ED), Director of Nursing (DON), and/or Staff Development Coordinator (SDC) will provide quizzes to all associates upon hire, annually, and as needed. The Director of Nursing (DON), Staff Development Coordinator (SDC), Regional Director of Rehab Services (RRD), Clinical Reimbursement Specialist (CRS), and/or licensed nurse-initiated education with all licensed nurses (Registered Nurse [RN] and Licensed Practical Nurse [LPN]) on the facility policy and procedure, Infusion Therapy - Intravenous (IV Fluids). Education will be completed by 05/01/2026. Any associate who has not completed education by 05/01/2026 will not be allowed to provide direct resident care until education is completed. Any associate who does not complete training prior to 05/01/2026 will be removed from the schedule until training is completed; education will be provided by the Director of Nursing (DON), Staff Development Coordinator (SDC), and/or licensed nurse. Any associate on vacation and/or FMLA will complete training upon return prior to their next working shift; education will be provided by the Director of Nursing (DON), Staff Development Coordinator (SDC), and/or licensed nurse. The Executive Director (ED), Director of Nursing (DON), and/or Staff Development Coordinator (SDC) will provide education to all associates upon hire, annually, and as needed. The Director of Nursing (DON), Staff Development Coordinator (SDC), Regional Director of Rehab Services (RRD), Clinical Reimbursement Specialist (CRS), and/or licensed nurse-initiated quizzes with all Certified Nursing Assistants (CNAs) on their scope of practice. Quizzes will be completed on 05/01/2026. Any certified nursing assistant who has not completed the quiz with a passing score by 05/01/2026 will not be allowed to provide direct resident care until education is completed. Any associate who does not complete training prior to 05/01/2026 will be removed from the schedule until training is completed; education will be provided by the Director of Nursing (DON), Staff Development Coordinator (SDC), and/or licensed nurse. Any associate on vacation and/or FMLA will complete training upon return prior to their next working shift; education will be provided by the Director of Nursing (DON), Staff Development Coordinator (SDC), and/or licensed nurse. Any certified nursing assistant who does not score a 100 on their quiz will be immediately re-educated, and another quiz will be completed until a passing score is achieved. The Executive Director (ED), Director of Nursing (DON), and/or Staff Development Coordinator (SDC) will provide quizzes to all associates upon hire, annually, and as needed. The Director of Nursing (DON), Regional Director of Rehab Services (RRD), Clinical Reimbursement Specialist (CRS), and/or licensed nurse will have all Certified Nursing Assistant to sign a scope of practice attestation form which states the following: Certified Nursing Assistants provide supportive care including activities of daily living and basic nursing tasks under the supervision of a licensed nurse. They do not perform invasive procedures, sterile techniques, or tasks requiring clinical judgment, including care of IV access. Education will be completed by 05/01/2026. Any associate who has not completed education by 5/1/2026 will not be allowed to provide direct resident care until education is completed. Any associate who does not complete training prior to 5/1/2026 will be removed from the schedule until training is completed; education will be provided by the Director of Nursing (DON), Staff Development Coordinator (SDC), and/or licensed nurse. Any associate on vacation and/or FMLA will complete training upon return prior to their next working shift; education will be provided by the Director of Nursing (DON), Staff Development Coordinator (SDC), and/or licensed nurse. The Executive Director (ED), Director of Nursing (DON), and/or Staff Development Coordinator (SDC) will provide education to all associates upon hire, annually, and as needed. Starting 5/1/2026, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and/or licensed nurse will provide oversight by conducting audits to ensure all residents with IV access are being managed and flushed appropriately by a licensed nurse and not a certified nursing assistant (CNA). Audits will be conducted five (5) times per week for four (4) weeks; then three (3) times per week for four (4) weeks; then one (1) time a week for four (4) weeks. Results of the audits will be reported by the Director of Nursing (DON) [the Executive Director (ED) will be responsible for reporting in the absence of the Director of Nursing (DON)] to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months (starting with the facility's May meeting and ending in July) or until substantial compliance is met. On 4/30/2026, the facility held an emergency QAPI committee meeting, and the performance improvement plan was reviewed and approved by the facility's QAPI committee. On 4/30/2026, the Medical Director reviewed and agreed with the performance improvement plan. The QAPI Committee will review these results; and if deemed necessary by the committee, additional corrective action(s), measures, and/or systematic changes may be initiated. QAPI Committee Members include the following: the Executive Director, Medical Director, Director of Nursing, Assistant Director of Nursing, Infection Preventionist, Director of Rehab, Director of Social Services, Director of Activities, Director of Human Resources, Business Office Manager, Director of Environmental Services, Director of Maintenance, Director of Health Information Management, Clinical Dietary Manager, Consultant Pharmacist, and Community Representative. On 5/1/2026, the facility alleges compliance with the identified concern. All corrections were completed on 5/1/2026 The IJ was removed on 05/02/2026 at 6:08 PM after the survey team verified the facility's implementation of the removal plan as follows: Provider note revealed nurse practitioner evaluated the resident on 04/29/2026 and no concerns were identified. A licensed practical nurse performed a nursing assessment of Resident #125 on 04/30/2026 and documented the resident's PICC line was patent in both lumens. RN #2 and CNA #1 were suspended effective 04/30/2026 and documentation of the suspension was found in the employee's personnel file. An incident report was completed and documented within Resident #125's medical record. I The facility performed a root cause analysis on 04/30/2026. The facility reviewed intravenous therapy and CNA scope practice quizzes for 19 of 32 licensed nurses, with a plan to complete the remaining staff prior to the staff completing their next shift. Reviewed nurse in-service curriculum and staff sign off sheet for curriculum. Interviewed nurses that received education. Nineteen of 32 licensed nurse staff verified with plan to train the rest before their next shift. Reviewed CNA quizzes and education records on their scope of practice. Forty-one of 46 CNAs documented as completed by facility. Reviewed and confirmed completed quiz with score of 100%. Reviewed initial audits, dated 05/01/2026 and 05/02/2026, to ensure all residents with intravenous therapy (IV) access were being managed and flushed appropriately by a licensed nurse and not a CNA. No concerns identified. Interviewed the interim DON and ED on quality assurance performance improvement (QAPI) audits. The audits will be conducted five times per week for four weeks, then three times a week for four weeks, and then one time a week for four weeks. The results will be reported to the QAPI committee for review during the monthly QAPI meetings. Reviewed emergency QAPI meeting minutes and sign in sheet, dated 04/30/2026. Facility initiated program improvement plan on 04/30/2026. Reviewed follow up emergency QAPI meeting, dated 05/01/2026.

Based on observation, interview, and document review, the facility failed to follow the menu serving size for the turkey and dumpling entree for the lunch meal on 04/29/2026 for 76 of 83 residents who received food from the kitchen. Findings included: The facility Diet Type Report dated 05/01/2026, listed the diet order of 83 residents and of the 83 residents, one resident was ordered finger foods, one resident was ordered a vegetarian diet, one resident was ordered a full liquid diet, and four residents received nothing by mouth. The facility Diet SpreadSheet for the lunch meal indicated residents were to receive a #6 scoop of chicken and dumplings for the lunch meal on 04/29/2026. An undated facility document titled Scoop Chart indicated a #6 scoop held 5 ounces (oz) and a #12 scoop held 2.5 oz. During the lunch meal tray line observation on 04/29/2026 at11:31 AM, [NAME] #9 used a ladle to serve one portion of regular turkey and dumplings and a green-handled scoop to serve one portion of mechanically altered and pureed turkey and dumplings. During an interview on 04/29/2026 at 11:46 AM, [NAME] #9 stated she used a 4 oz ladle to serve the regular turkey and dumplings and a #12 scoop to serve the mechanically altered and pureed turkey and dumplings. During an interview on 04/30/2026 at 9:35 AM, the Registered Dietitian (RD) stated a #6 scoop held between 5 to 6 oz and a 4 oz ladle held 4 oz, which were not the same. The RD stated for the residents who received regular textured turkey and dumplings were underserved by at least 1 oz. The RD stated a #12 scoop was 1/3 cup, which equated to 2.67 oz and the residents on a mechanically altered and pureed diet were underserved their portion turkey and dumplings. According to the RD, serving too small of a portion could cause residents to lose weight. During an interview on 04/30/2026 at 9:56 AM, the Executive Director stated the expectation was for the kitchen staff to follow the portion sizes on the approved menu.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #81) of 25 sampled residents was assessed for their ability to self-administer their own medications. Findings included: A facility policy titled, Self-Administration of Medication, reviewed 09/15/2025, revealed, Procedure 1. If the resident desires to self-administer medication, the IDT [interdisciplinary team] will contact the resident's primary physician to make them aware of the resident request. 2. The IDT in consultation with the primary physician for the resident will conduct an assessment of the resident's cognitive, physical, and visual ability to carry out this responsibility. The policy specified, 4. The interdisciplinary assessment will be completed in the electronic medication record, and results review with the resident and/or responsible party. 5. After the IDT and primary physician review the assessment and determine the resident can safely self-administer, or self-administer and safely store medications at bedside, a physician's order will be obtained and the care plan for the resident will reflect the self-administration. An admission Record revealed the facility admitted Resident #81 on 03/21/2026. According to the admission Record, the resident had a medical history that included diagnoses of metabolic encephalopathy and dementia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/25/2026, revealed Resident #81 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #81's Care Plan Report with an admission date of 03/21/2026, revealed no evidence of a focus area that indicated the resident could self-administer their medications. During an observation on 04/29/2026 at 10:53 AM, Resident #81 was noted in their room and the resident had a shoe box that contained nine different over-the-counter vitamins and supplements, which were: PreserVision, an eye vitamin designed to reduce the risk of moderate to advanced age-related macular degeneration progression; Prevagen, an over-the-counter supplement intended to support brain function; Align, a probiotic used to support digestive and immune health; Nurtrafol, a hair growth supplement; vitamin D3, essential for calcium absorption, bone health, immune function, and muscle strength; a stool softener, used to help relieve constipation; Blink NurtiTears, a daily soft gel supplement designed to treat dry eye symptoms; melatonin, a supplement for insomnia; and Bye Bye Bloat, a supplement designed to quickly reduce digestive bloating, gas, and water retention caused by food, stress, or hormones. Resident #81's Order Summary Report with active orders as of 04/28/2026, revealed no evidence of physician orders for the multiple over-the-counter vitamins and supplements found in the resident's room. During an interview on 04/29/2026 at 11:02 AM, Licensed Practical Nurse Unit Care Coordinator (LPN UCC) #9 stated residents were allowed to self-administer their own medications they brought from home. LPN UCC #9 stated she was aware of the medications Resident #81 had in their room. During an interview on 04/27/2026 at 9:58 AM, Resident #81 stated they took supplements while at home and preferred to continue to take their own supplements throughout the day at the facility. During an interview on 04/29/2026 at 1:20 PM, the Licensed Practical Nurse (LPN) Admissions Nurse stated residents were allowed to only self-administer medications when they were screened and had passed an observation test. The LPN Admissions Nurse stated an order from the physician was required for the resident to self-administer their medications. During an interview on 04/30/2026 at 3:55 PM, Resident #81 stated they had not completed a test or had a self-assessment by the facility to determine if they could self-administer their medications. During an interview on 04/30/2026 at 4:09 PM, the interim Director of Nursing (DON) stated that when a resident desired to self-administer their medications, they were to be assessed to see if they were capable and an order from the physician would be obtained. The interim DON stated that once assessed, the resident would keep their medications in a locked drawer, the nurses would have a list of the medications on the electronic medication administration record of what the resident would be taking, and there would be a physician's order that specified what the resident could self-administer. The interim DON stated she was not aware of any residents who wanted to self-administer their medications. During an interview on 05/01/2026 at 6:04 PM, the Executive Director stated staff had been trained and were expected to follow the facility policy for residents who desired to self-administer their own medications.

Based on interview, record review, and facility policy review, the facility failed to ensure staff administered as needed pain medication when requested for 1 (Resident #123) of 3 observed for medication administration. Findings included: A facility policy titled, Pain Assessment and Management, revised 11/11/2025, revealed, Based on the comprehensive assessment of a resident, this facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. An admission Record revealed the facility admitted Resident #123 on 04/22/2026. According to the admission Record, the resident had a medical history that included diagnoses of lung cancer and breast cancer. Resident #123's Care Plan Report included a focus area initiated 04/22/2026, that indicated the resident expressed pain/discomfort. Interventions directed staff to administer the resident's pain medications as ordered (initiated 04/22/2026). Resident #123's Order Summary Report, with active orders as of 04/28/2026, revealed an order dated 04/22/2026, for oxycodone hydrochloride oral tablet 10 milligrams (mg), give one tablet by mouth every six hours as needed for pain. During medication administration observation on 04/28/2026 at 8:27 AM, Resident #123 informed Registered Nurse (RN) #2 that they had pain on a scale of nine out 10 and requested pain medication. RN #2 informed the resident that she would administer their pain medication later. During an interview on 04/28/2026 at 10:40 AM, Resident #123 stated they informed the nurse during medication administration of their pain and the nurse stated she would administer their pain medication later. Resident #123 stated the nurse had not returned to administer their requested pain medication. During an interview on 04/28/2026 at 10:59 AM, RN #2 stated she had not administered Resident #123's pain medication because of a glitch in the facility's computer system that needed to be corrected before she could administer the resident their pain medication. Resident #123's Medication Administration Record [MAR] for the timeframe 04/01/2026 - 04/30/2026, revealed RN #2 initialed the resident's MAR to indicate she administered the resident oxycodone hydrochloride oral tablet 10 mg on 04/28/2026 at 11:23 AM, two hours and 56 minutes after the resident requested the medication.

Based on facility policy review, medical record review, and interview, the facility failed to maintain accurate and complete medical records for 1 resident (Resident #43) of 24 residents reviewed for accuracy of medical records. The findings include: Review of the facility policy titled, Auditing and Monitoring of Medical Records, revised [DATE], showed .Auditing and monitoring of medical record documents is conducted to ensure medical records are complete and accurate and reflect current standards of documentation practices .Additional focused audits that may be done .may include, but are not limited to .Care plan .Audit for consistency between the MDS [minimum data set assessment] and the care plan .Monitor to ensure the care plan is current .Code Status . Audit for consistency between physician orders, advanced directives and any communication system for this that the facility might use . Resident #42 was admitted to the facility [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the current electronic physicians orders for Resident #43 showed status of FULL CODE with a revision date of [DATE]. Resident #43's Physician Orders for Scope of Treatment (POST) form dated [DATE], showed Do Not Resuscitate (DNR) with limited interventions. Resident #43's current electronic physicians orders showed .admit to hospice services effective [DATE] . with a revision date of [DATE]. Resident #43's comprehensive care plan created [DATE], revised [DATE], showed .Resident has Advanced Directive CPR [Cardiopulmonary Resuscitation]-Full Code with Full Treatment-no artificial nutrition . During an interview on [DATE] at 3:43 PM, the Assistant Nursing Coordinator confirmed the electronic medical record reflected a FULL CODE status and did not reflect Resident #43's wishes of Do Not Resuscitate (DNR). The ADON confirmed the medical record code status was inaccurate.

Based on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, record review, and interview the facility failed to complete a discharge Minimum Data Set (MDS) assessment timely for 1 resident (Resident #2) of 18 residents reviewed for MDS assessments. The findings include: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019, showed .Chapter 2: ASSESSMENTS FOR THE RESIDENT ASSESSMENT INSTRUMENT (RAI) .Discharge assessment .Must be completed .within 14 days after the discharge date . Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged from the facility on 7/12/2022. Record review revealed no documentation a discharge MDS assessment had been completed for Resident #2. During an interview on 10/12/2022 at 10:59 AM, the MDS Coordinator stated Resident #2 was discharged from the facility on 7/12/2022 and had not returned to the facility. Further interview confirmed the facility failed to complete a discharge MDS for the 7/12/2022 discharge from the facility.

Based on review of the Resident Assessment Instrument Manual 3.0 (RAI), medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #75) of 18 residents reviewed for MDS assessments. The findings include: Review of the RAI Manual 3.0 dated 10/2019 showed .the comprehensive assessment is considered complete on the date the RN [Registered Nurse] Coordinator indicates completion of the admission assessment .Assuming the resident does not have any significant changes in status or is not discharged from the facility the next assessment schedule is the Quarterly assessment . Resident #75 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's progress note dated 9/16/2022 for Resident #75 showed a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #75's quarterly MDS assessment dated [DATE], showed no documentation of the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 10/12/2022 at 10:58 AM, the MDS Coordinator confirmed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on facility policy review, record review, observation, and interview, the facility failed to implement an intervention to prevent falls for 1 resident (Resident #70) of 3 residents reviewed for falls. The findings include: Review of the facility policy titled, Fall Management, reviewed 9/29/2022, showed .The facility will assess the resident .and will identify appropriate interventions to minimize the risk of injury related to falls .Implement interventions .consistent with a resident's .care plan .in order to eliminate the risk .reduce the risk of an accident .a care plan will be developed and initiated .on any residents assessed to be at risk for falls . Resident #70 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Fracture of Unspecified Part of Neck of Left Femur, Gastrointestinal Hemorrhage, Unspecified [CONDITION(S)] of Liver, History of Falling, Muscle Weakness (Generalized), Unspecified Dementia, and [CONDITION(S)]. Review of a comprehensive care plan dated 7/28/2022, showed Resident #70 was .at risk for falls r/t [related to] .hx [history] of falls, unsteadiness on feet. The care plan was updated on 8/8/2022 Mats at bedside while in bed . Review of a 5-Day Minimum Data Set (MDS) assessment dated [DATE], showed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe impairment. Resident #70 required extensive assistance of two persons for bed mobility and toilet use, required the extensive assistance of one person for transfer, and required total dependence of one person for locomotion on unit and bathing. During observations on 10/10/2022 at 2:50 PM; 10/11/2022 at 9:01 AM, 2:29 PM, and at 4:29 PM showed Resident #70 lying on the bed with no fall mats noted at the bedside. During an observation and interview on 10/11/22 at 4:32 PM, Licensed Practical Nurse (LPN) #1 confirmed the fall mats for Resident #70 were not in place and LPN #1 confirmed the .fall mats are supposed to be . LPN #1 reviewed Resident #70's care plan and confirmed the fall mats at bedside were an intervention on Resident #70's care plan. During an interview and record review on 10/12/2022 at 11:01 AM, the MDS Coordinator confirmed Resident #70's fall mats were to be in place when Resident #70 was laying on the bed, and the care plan was not followed if the mats were not in place for the resident's safety.

Based on review of facility policy, medical record review, review of hospital records and interview the facility failed to accurately document and maintain complete records of Physician Orders for Scope of Treatment (POST) for one resident, (Resident #1) of 3 residents reviewed for medical record accuracy. Review of the Facility Policy Advance Directives and Care Planning, last revised [DATE], revealed, .If the resident leaves the facility temporarily .ER [emergency room ] visit .copy of the advance directive is sent with the resident .the advanced directive status is communicated to the receiving provider .Each time the resident is admitted to the facility .the facility should review the advance directive .the social services director or designee should document this .in the medical record .and assist as needed with updating the documents . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was cognitively intact with a brief interview of mental status score (BIMS) of ,d+[DATE] and was able to make needs known and was independent in decision making. Resident #1 had no problem behaviors, was dependent upon 1 or 2 persons for activities of daily living (ADLs). Review of the facility Admission Assessments, and admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1's resuscitation status as full code (Cardiopulmonary Resuscitation [CPR] and all life saving measures to be performed in event of [CONDITION(S)]) on admission. Medical record review of Resident #1's POST form dated [DATE] showed .Section A: Cardiopulmonary Resuscitation (CPR) .Do Not Attempt .(DNR [Do not Resuscitate]/NO CPR) .Allow Natural Death This box was marked with an X Further review showed Section B: Medical Interventions .Comfort Measures Only .Do not transfer to hospital for life sustaining treatment . this box was marked with an X. Continued observation showed above the X mark, the entry was labeled as wrong in illegible handwriting that was undated or unsigned, the box was struck through with a single line. Below this entry in section B of the document a second directive was marked with an X which read .Limited additional interventions ., it too was undated and unsigned as to who had altered the original document. Continued review showed signature lines at the bottom of the document in which the resident name was blank, the resident signature was blank, and the line labeled Agent/Surrogate did not bear the responsible party for Resident #1's signature. It read verbal: (name of responsible party for Resident #1) POA/daughter. The facility nurse who prepared the form signed and dated it [DATE]. Review of the Social Services Notes showed no evidence POST documents for Resident #1 were updated during admissions or readmissions to the nursing home between [DATE] and [DATE]. During this period, Resident #1 was re-hospitalized , discharged then readmitted to the nursing home 2 times on [DATE] and [DATE]. Review of the Medication Administration Records for [DATE] and [DATE] listed Resident #1's resuscitation status as Full Code Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .full code . Review of a Nurse Practitioner Note dated [DATE], showed .Code Status, Full Code . Review of the Nursing Home to Hospital Transfer Form dated [DATE], showed the form was prepared by a facility nurse (Licensed Practical Nurse #8) on [DATE], at 12:00 PM (time of which Resident #1 was sent to the hospital for an acute episode of gastrointestinal bleeding). Under the section Code Status Resident #1 was listed as .Full Code with Full Treatment . Review of hospital documents received from the nursing home on [DATE] showed the hospital received the POST form which designated Resident #1 to be DNR and Comfort Measures Only and was not be hospitalized . However, the hospital also received the Transfer Form, which stated Resident #1 was a full code. Review of Hospital Physician Notes dated [DATE] at 2:53 PM showed, .I have reviewed [Resident #1's] paperwork from the facility .she is DNR, comfort measures only Review of the Emergency Department Course Notes revealed .I spoke with [Resident #1's] daughter .I did discuss Code status .she is DNR .comfort measures .discussed this with the patient as well .who agrees with the DNR .discussed results and plan of admission with the patient .who verbalized understanding and agreement . Medical record review showed on [DATE] Resident #1 required acute hospitalization and was directly admitted from her Physician's office where Resident #1 had been transported from the nursing home with no documentation. As a result, Resident #1 arrived to the hospital emergency room with no current or updated documentation of her POST status that day. Review of hospital records showed Resident #1's POST status was clarified by the admitting Physician via contact with the resident's Responsible Party (RP) then as well. Interview with the Responsible Party (RP) for Resident #1 on [DATE] at 5:06 PM by telephone, revealed she was not informed nor had authorized changes to the POST form as documented in the facility medical records dated [DATE]. RP reported she had not been presented documents to sign later on during Resident #1's stays at the nursing home, when she did order changes to Resident #1's POST status. The RP reported Resident #1 was transferred to a hospital for treatment several times and the hospital required clarification of the POST form by her, as conflicting information had been forwarded to them in nursing home documents. The RP reported on admission to the facility on [DATE], Resident #1's status was to have been Do Not Resuscitate (DNR) with limited interventions permitted and she had not authorized Resident #1 to be placed on comfort measures only which prohibited hospitalization of Resident #1 as documented in her records there. Continued interview revealed the RP reported each time Resident #1 was hospitalized , hospital officials had to clarify Resident #1's status, because the nursing home continued to submit POST documents which as written, stated Resident #1 was not be hospitalized at all, or were unclear related to her resuscitation status. Interview with the Administrator and Director of Nursing (DON) on [DATE] at 11:55 AM by telephone, confirmed the facility had failed to maintain completed POST documents, and accurate, concise documentation of Resident #1's POST status in its medical records.

Based on medical record review of Physician Orders, The Treatment Administration Record (TAR), Nursing Progress Notes, Wound Observation Tool (wound notes) and interview, the facility failed to perform heel dressing changes once weekly in accordance with Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Medical record review showed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] for rehabilitation with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the Admission Minimum Data Set (MDS) showed Resident #1 was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) Score of 5/15. Resident #1 was unable to bear weight or transfer without the use of mechanical devices and was dependent upon one or more persons for activities of daily living (ADLs). On readmission to the nursing home on 9/29/21, Resident #1 was free of pressure ulcers. Medical record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .change weekly and PRN . (as needed) . Medical record review of the September 2021 TAR showed dressings applied to Resident #1's heels on 9/30/21. Review of the October 2021 TAR showed a dressing change scheduled for 10/6/21, (6 days after initial application of the dressings) was not completed as ordered. Review of Nursing Progress Notes dated 10/10/21 at 1:26 PM revealed .Wound[s] were brought to this nurses attention by family .Date on bandages was 9/29 and 9/30 .Drainage noted from left heel .Both heels are black, possible blood blisters .dressings were changed .feet elevated off bed . Review of Wound Notes and the Corresponding TAR entries dated 10/11/21 showed Resident #1 sustained a stage 2 pressure ulcer 6.0 centimeters in length, 7.0 centimeters in width with no measurable depth to the right heel and a stage 2 pressure ulcer to the left heel that measured 6 centimeters length, 6 centimeters width with no measurable depth. Continued review showed both [CONDITION(S)] were described as facility acquired. Continued review showed both [CONDITION(S)] described as .clear fluid filled blister that has opened .stage 2 PU (pressure ulcer) . Interview with the Director of Nursing (DON) on 2/10/22 at 3:36 PM by telephone, revealed the DON reported she had not been made aware the dressing change scheduled for 10/6/21, was not performed or documented in the electronic records. The DON confirmed Resident #1's dressings initially applied as preventative measures on 9/30/29, had not been changed for 10 consecutive days as a result. The DON confirmed the facility failed to follow Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on facility policy review, review of manufacturer's recommendations, review of staff schedules, observations, and interviews, the facility failed to ensure staff adhered to proper infection control practices while cleaning and disinfecting resident rooms to prevent the spread of COVID-19, with the potential to affect residents on 3 of 4 hallways; and failed to ensure staff wore appropriate PPE and disinfected hands before and after entering COVID-19 isolation precaution rooms, with the potential to affect 2 of 11 residents. The findings include: Review of the facility policy, Standard and Transmission Based Precautions Guide to Infection Control, revised date [DATE], showed .PPE (personal protective equipment) Recommended for Unknown, Suspected, or Confirmed COVID-19 .includes the following .Gloves .Put on clean, non-sterile gloves upon entry into the patient room .Remove and discard gloves before leaving the patient room .and immediately perform hand hygiene .Gowns .Put on a clean isolation gown upon entry into the patient room . Review of the manufacturer's recommendations for use of Virex Tb (Ready to use Disinfectant Cleaner), showed .For Use As A Cleaner/Disinfectant: Spray evenly over surface to wet all surfaces thoroughly. Let product remain on surface for 3 minutes. Wipe with clean cloth, sponge or paper towel . Review of the facility housekeepers' schedule dated ,[DATE]-[DATE] showed Housekeeper #1 worked on the 200 hall, 300 hall, and the red zone cleaning resident rooms. During an interview with Housekeeper #1 on [DATE] at 10:00 AM, he stated he used Virex Tb on all high touch surfaces in resident's rooms. He stated he sprayed the disinfectant on the surface and wiped it off. The housekeeper stated the Virex Tb did not have to remain on the surface for any length of time. Observation and interview on [DATE] at 3:45 PM, on the COVID-19 unit, showed Housekeeper #1 in an empty resident room. The Housekeeper sprayed the over bed table with Virex Tb and immediately wiped the disinfectant off the table. During an interview with Housekeeper #1, he stated the Virex Tb is sprayed on the high touch areas and wiped off immediately. He had no knowledge of the manufacturer's instructions to allow the Virex Tb to remain on the surface for 3 minutes. Observation and interview on [DATE] at 8:15 AM, showed Certified Nursing Assistant (CNA) #1 working in the yellow zone (isolation rooms designated for residents who are new admissions or have returned from the hospital or outside the facility). CNA #1 entered Resident #1's room without a gown or gloves and delivered a breakfast tray to the resident. The CNA exited the room without disinfecting the hands, walked down the hall and retrieved a carton of milk, and entered the same room carrying a gown in her hand. The CNA delivered the carton of milk and exited the room carrying the gown in her hand, without disinfecting the hands. The CNA donned the gown in the hallway, entered Resident #2's room, retrieved the resident's breakfast tray, removed the gown, and exited the resident's room without disinfecting the hands. During an interview with CNA #1, she stated all residents in the yellow zone were on droplet/contact isolation and a gown and gloves were to be worn before entering the rooms and hands are to be disinfected before staff entered and exited the residents' rooms. During an interview with the Infection Preventionist on [DATE] at 9:40 AM, she stated all the residents on the yellow zone were on droplet and contact isolation and it was her expectation that all staff donned a gown and gloves before entering any resident room, and disinfected their hands before entrance and exit of the rooms. The Infection Preventionist stated it was her expectation housekeeping staff would follow manufacturer's recommendations for disinfectants when cleaning resident's rooms to prevent the spread of COVID-19. During an interview with the Housekeeping Supervisor on [DATE] at 10:00 AM, she stated Housekeeper #1 was in an isolation room of a deceased resident on the COVID positive unit. She stated Housekeeper #1 had been educated on the use of the disinfectant and it was her expectation housekeepers would follow the manufacturer's instructions for disinfectant use. She stated staff used Virex Tb to disinfect resident rooms and in high contact areas. The Virex Tb should be sprayed on surfaces, then left for 3 minutes and wiped off. During an interview with the Housekeeping Supervisor on [DATE] at 11:30 AM, she stated Housekeeper #1 had worked on 200 hall, 300 hall, and red zone; 3 of 4 hallways during the last 2 weeks.

Based on review of facility policy, medical record review, and interview, the facility failed to ensure the correct medications were sent home on discharge with 1 resident (#8646) of 3 residents reviewed. The findings include: Review of facility policy, Transfers and Discharges Effective Date 5/6/19, revealed .Discharge Responsibilities of Nursing: 1) Explain discharge procedure and reason to resident. Give copy of the Notice of transfer or Discharge as required,; include resident representatives. 2) .If medications are to be included, write this order, e.g. discharge to home with daughter; may take all medications. The discharge order form is used to document the discharge order. 4) Medications, if discharged to a home . Medical record review revealed Resident #8646 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. The resident was discharged home at 10:20 AM on 1/9/19. Interview with Licensed Practical Nurse (LPN) #1 on 5/29/19 at 11:05 AM in the conference room revealed the LPN had discharged the resident home on 1/9/19 at 10:20 AM, gave discharge instructions to the resident's husband including a list of the correct medications to be given to the resident at home but sent another resident's (#8629) medications home with the husband in error. The LPN explained the incorrect resident's medications were in a drawer in front of Resident #8646's medications and the Nurse accidently took the wrong medications to send home with the resident's husband. Upon discovery of the error during a subsequent medication pass the husband was notified of the mistake and arrangements were made to exchange the resident's medications for the wrong resident's medications. The LPN made the exchange with the husband giving him the correct medications and receiving the incorrect medications to return to the facility. The incorrect medications were returned to the facility and discarded by the Nurse. Review of a pharmacy document dated 1/14/19 revealed Resident #8629 was reimbursed for the medication signed out to her due to the LPN's mistake. Telephone interview with the resident's husband on 5/29/19 at 11:30 AM revealed the husband had not given the resident any of the other resident's medication to Resident #8646. Continued interview revealed the husband had been informed of the mistake by the facility, and he met with the Nurse at an agreed location and exchanged the medications for the correct medications for Resident #8646. Interview with the Assistant Director of Nursing on 5/28/19 at 3:49 PM in the conference room confirmed the LPN sent the wrong medications home with Resident #8646's husband on 1/9/19.

Based on observation and interview the facility failed to ensure dietary staff disinfected their hands before and after glove removal for 1 of 4 staff members observed. The findings include: Observation in the kitchen on 7/16/18 at 11:15 AM, revealed Dietary Staff #1 had been plating food at the steam table with bare bands. Continued observation revealed the staff member left the steam table, retrieved a loaf of bread from the bread rack, took it to the sandwich station, donned gloves, retrieved a knife from a drawer, retrieved cheese from the cooler, and began to prepare a sandwich. Further observation revealed the Dietary Manager finished preparing the sandwich and the dietary staff member discarded the gloves and returned to plate food at the steam table without disinfecting the hands. Interview with the Food Service Manager on 7/18/18 at 8:35 AM, in the hallway, confirmed the dietary staff are to disinfect their hands before and after glove removal. Interview with the Staff Development Coordinator on 7/18/18 at 1:30 PM, in the conference room confirmed dietary staff are included in the facility orientation which included handwashing education. Further interview confirmed all staff members are to disinfect their hands before and after glove removal.

Based on medical record review and interview, the facility failed to develop an accurate Minimum Data Set (MDS) assessment for 1 Resident (#63) of 32 residents sampled. The findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 day MDS dated [DATE] revealed a Brief Interview for Mental Status score of 6 indicating severe cognitive impairment. Further review revealed weight of 96 and no significant weight loss was indicated. Medical record review of the comprehensive care plan dated 7/6/18 revealed to serve diet as ordered and to provide and serve supplements as ordered by the dietician or physician. Medical record review of the resident's weights revealed the weight on 6/23/18 of 96 pounds (lbs) and the weight on 7/3/18 was 91 lbs indicating a 5.21% weight loss. Medical record review of a nutrition/dietary note dated 7/5/18 revealed the resident's weight was down 5.2 % in one week. Further review revealed to continue weekly weights. Interview with the MDS Nurse on 7/18/18 at 9:02 AM, in the conference room, confirmed the resident had a weight on 7/3/18 of 91 lbs. Continued interview confirmed the 14 day MDS was dated 7/6/18 with weight indicated on MDS of 96 lbs and no weight loss was indicated. Further interview confirmed the weight should have been recorded as 91 lbs and a weight loss of 5% or more in the last month should have been indicated. Continued interview confirmed the facility failed to develop an accurate 14 day MDS assessment for Resident #63.

Based on medical record review, observation, and interview, the facility failed to keep the call light in reach for 1 Resident (#63) of 32 residents sampled. The findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 day Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 6 indicating severe cognitive impairment. Further review revealed the resident required extensive assist of 1 person for bed mobility, transfers, locomotion, dressing, toileting and personal hygiene. Medical record review of Resident #63's care plan revealed .ADL self-care performance deficit r/t (relate to) dementia, impaired mobility .Encourage the resident to use bell to call for assistance . further review revealed .At risk for falls r/t impaired mobility .Call light within reach . Observation of Resident #63 on 7/16/18 at 2:37 PM, in the resident's room, revealed the resident sitting up in a wheelchair at the bedside on the door side of the bed with the call light laying across the bed toward the window side of the bed out of the resident's reach. Observation of Resident #63 on 7/18/18 at 7:52 AM, in the resident's room, revealed the resident lying in the bed with the call light hanging over the right side of the bed below the side rail. Observation and interview with the Director of Nursing (DON) on 7/18/18 at 7:54 AM, in the resident's room, revealed the call light was hanging over the right side of the bed. The DON asked the resident if the call light could be reached. The resident was unable to reach the call light and stated it's hard. Continued interview confirmed this was the second observation of the call light not in the resident's reach. Further interview confirmed the facility failed to keep the call light in reach for Resident #63.

Based on review of the (YEAR) annual survey results and interview, the facility failed to maintain compliance with Care Plan implementation and revision process as evidenced by repeated deficient practice cited in the annual survey dated 7/18/18. The findings include: Review of the (YEAR) annual survey report revealed the facility had deficient practice identified at F-279 for failing to develop a comprehensive care plan, and F-280 for failing to revise the care plan. The plan of correction stated the facility was in substantial compliance with Medicare and Medicaid requirements. Medical record review of Resident #51's current care plan failed to reveal care for the resident, who required his nutrition via TPN (Total Parental Nutrition), and also was at risk for pain due to [DIAGNOSES REDACTED]. Medical record review of Resident #63's current care plan failed to reveal care for the resident who required continuous Oxygen. Medical record review of Resident #19's current care plan failed to reveal care for the resident who had elevated blood sugars. Interview on 7/18/18 at 1:35 PM with the Administrator, Regional Vice President, and at the end of the interview the Director of Nurses revealed the facility completed audits on care plans for 3 months after last year's annual survey, and did not find any problems. Continued interview confirmed no further audits to ensure the care plans were accurate had been conducted.

Based on medical record review and interview, the facility failed to monitor the behavior of 1 (#28) of 5 residents reviewed for unescessary medications. The findings include: Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Order Summary Report printed on 7/17/18 revealed he received [MEDICATION NAME] (antipsychotic) liquid concentrate 2mg/ml (milligrams/milliliters) Give 1 ml by mouth three times a day (TID) for anxiety. Review of the Medication Administration Record [REDACTED]. No behavior monitoring on the MAR indicated [REDACTED]. Medical record review of the (MONTH) 12, (YEAR), Pharmacist Review requested a [DIAGNOSES REDACTED]. Further review revealed the physician wrote an order on 6/11/18 to refer the resident to psychiatric services for Anxiety, Combative, Agitation, and refuses meds and care. Medical record review of the physician's transfer orders dated 6/8/18 revealed the resident was to receive [MEDICATION NAME] 1ml at 9:00 AM, 1:00 PM, and at 5:00 PM, and the [MEDICATION NAME] cream was discontinued. Medical record review of Resident #28's care plan dated 6/15/18 revealed monitor for side effects of antipsychotic medication, and target behavior (does not list target behavior) .Observe for occurrence of target behavior symptoms and document per facility protocol . Medical record review and interview with Registered Nurse (RN) #1 on 7/18/18 at 10:05 AM, at the 100 nurses desk revealed no behavior monitoring sheet was found in the book the nurse's chart every shift. Further interview with RN #1 confirmed Resident #28's behavior was not monitored. Interview on 7/18/18 at 12:50 PM, with the Director of Nurses (DON) in the conference room, revealed .he hasn't had any behviors so we don't chart on behavior. Continued interview revealed the resident had a dosage reduction of the Hadol since being admitted and .hasn't had any behaviors .the resident was just expressing his rights to refuse care .The facility does not routinely monitor residents receiving antipsychotic medications . Interview on 7/18/18 at 1:22 PM, with RN #2 at the 100 nurse's desk revealed the resident .will yell out at times . Interview with Certified Nurse Assistant (CNA) #1 on 7/18/18 at 1:24 PM at the 100 nurse's desk revealed .will stiffen up and straighten his legs, yells no when he doesn't want to do something .other CNAs have told me he is combative . Interview with CNA #2 on 7/18/18 at 1:26 PM, at at the 100 nurse's desk, revealed .he is agitated a lot, he spits, he puts his hands up like he will hit you and he yells. Regularly acts like this especially with spitting . Interview with the DON on 7/18/18 at 1:35 PM in the conference room confirmed spitting and yelling out were not appropriate behaviors.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide oxygen therapy per the physician's order for 1 Resident (#63) of 5 residents receiving oxygen of 32 residents sampled. The findings include: Review of the facility policy Oxygen Administration/Safety/Storage/Maintenance last revised 11/29/17 revealed .Oxygen will be administered by a licensed healthcare provider only when ordered by the physician. The physician must specify the number of liters, method of administration and length of time the oxygen is to be administered . Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician orders dated 6/22/18 revealed .Oxygen at 2 liters/minute continuously per nasal cannula . Medical record review of the 14 day Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 6 indicating severe cognitive impairment. Further review revealed oxygen use while a resident. Observation of Resident #63 on 7/16/18 at 9:40 AM, in the resident's room, revealed Resident #63 was lying in the bed not wearing oxygen. Observation of Resident #63 on 7/17/18 at 7:41 AM, in the resident's room, revealed the resident lying in bed with oxygen not in use. Further observation revealed the nasal cannula and tubing were noted to be curled up and hanging on the humidifier bottle on the wall. Observation of Resident #63 on 7/17/18 at 7:53 AM, in the resident's room, revealed a staff member was observed exiting the resident's room. Further observation revealed the oxygen tubing and nasal cannula continued to be curled up and hanging on the humidifier bottle on the wall and not in use by the resident. Interview and observation with the Director of Nursing (DON) on 7/17/18 at 7:55 AM, in the resident's room, confirmed the oxygen tubing was wrapped on the humidifier bottle on the wall and not in use by the resident. Further interview confirmed that the oxygen was ordered continuous and had been observed to not be in use 3 times. Continued interview confirmed the facility failed to provide oxygen therapy per the physician's order for Resident #63.

Based on medical record review and interview, the facility failed to revise a comprehensive care plan to include risk for pain for 1 resident (#51) of 32 residents reviewed. The findings include: Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physicians order dated 6/26/18 revealed .[MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) 7.5-325 mg (milligrams). Give 1 tablet by mouth every 6 hours as needed for pain . Interview with the Minimum Data Set (MDS) Coordinator on 7/17/18 at 4:30 PM in the conference room, confirmed the facility failed to revise the comprehensive care plan for Resident #51 to include risk of pain. Interview with the Unit Manager for 200 and 300 hallway on 7/18/18 at 10:00 AM, in the conference room, confirmed Resident #51 had a [DIAGNOSES REDACTED].

Based on review of the facility policy, medical record review, observation and interview the facility failed to develop a comprehensive care plan for 3 residents (#51, #63 and #19) of 32 residents reviewed. The findings include: Review of the facility policy, Resident Assessment Instrument & Care Plan revised 11/28/16 revealed .The Care Plan includes Measure objectives, timeframes to meet the patient's, cultural, nursing, mental and psychological needs including services being provided to meet those needs . Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Total Parental Nutrition (TPN) order dated 6/26/18 revealed .Rate .60 ml/hr (milliliters per hour) . Medical record review of an Admission/Readmission Progress note dated 6/26/18 revealed .Diagnosis .Severe Protein Calorie Malnutrition, Severe Odynophagia (painful swallowing), with History of [MEDICAL CONDITION] .on TPN at 60 ml per hour per continuous pump via LUE (left upper extremity) picc (peripherally inserted central catheter) line . Medical record review of the residents comprehensive care plan dated 6/26/18 revealed it did not include the resident had TPN infused continuously by PICC line for nutrition. Observation of the resident on 7/16/18 and 7/17/18 at various times in the resident's room revealed the resident resting in bed with TPN infusing through a PICC line at 60 ml/hr. Interview with the Minimum Data Set (MDS) Coordinator on 7/17/18 at 4:30 PM, in the conference room, confirmed the facility failed to ensure a comprehensive care plan included the patient was receiving TPN for malnutrition through a PICC line. Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders dated 6/22/18 revealed .Oxygen at 2 liters/minute continuously per nasal cannula . Medical record review of the 14 day MDS dated [DATE] revealed a Brief Interview for Mental Status score of 6 indicating severe cognitive impairment. Further review revealed the resident required oxygen. Medical record review of Resident #63's care plan dated 6/25/18 and revised 7/6/18 revealed no documentation indicating the resident received oxygen. Observation of Resident #63 on 7/16/18 at 2:31 PM, in the resident's room, revealed the resident lying in the bed with oxygen in use via nasal cannula. Interview with the MDS Coordinator on 7/17/18 at 4:28 PM, in the conference room, confirmed that the oxygen use was not on the care plan. Further interview confirmed the facility failed to care plan the use of oxygen for Resident #63. Medical record review revealed Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Order Summary Report printed on 7/17/18 revealed Resident #19 received [MEDICATION NAME] (long acting) insulin 6 units daily, and to have her blood sugars checked before each meal and at bedtime, with administration of Humalog insulin (short acting) according to a prescribed scale. Medical record review of the (MONTH) (YEAR), Medication Administration Record [REDACTED]. Medical record review of the care plan dated 6/20/18 revealed no problem, goal, or approaches to address Resident #19 having elevated blood sugars especially while she is receiving antibiotics for the [DIAGNOSES REDACTED]. Interview with Resident #19 on 7/18/18 at 11:30 AM, in the resident's room, revealed her blood sugars had been much higher since the antibiotic was started. Interview with the Director of Nursing on 7/18/18 at 1:10 PM, in the conference room confirmed the resident's elevated blood sugars were not addressed in her current care plan.

Based on medical record review, observation and interview, the facility failed to implement interventions to prevent an injury from a fall/fracture of the right elbow resulting in harm to resident #4 of seventeen residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician Recapitulation Orders dated February 17, 2011 revealed "...NWB RLE( non weight bearing Right Lower Extremity)..." Medical record review of a Fall Risk assessment dated [DATE], revealed the resident was high risk for falls. Medical record review of the Interim Care Plan dated February 17, 2011, revealed the facility had implemented a low bed with a pressure sensitive alarm to the bed. Medical record review of a Nurse's note date February 26, 2011, revealed "Pt (patient) found on knees upon entering room by staff. Bed alarm ringing...both knees sl (slightly) red, no open areas noted. No c/o (complaints) of pain..." Medical record review of the fall investigation dated February 26, 2011, revealed "...Resident demonstrated use of call light. Discontinue TED (anti-embolism hose) hose..." Medical record review of a Nurse's note dated February 27, 2011, at 5:20 a.m. revealed "Resident found on the floor by...bed ' I thought I was at home'...does c/o(complain of) rt (right) elbow pain. Moves arms freely ..." Medical record review of the physician's orders [REDACTED]. Fall pads to floor around bed." Medical record review of the x-ray report dated February 27, 2011, revealed "...Slightly distracted Olecranon (elbow) fracture..." Medical record review of the fall investigation dated February 27, 2011, revealed the facility implemented a scoop mattress and mats to the floor upon the resident's return to the facility. Medical record review of a Nurse's note dated March 9, 2011, revealed "pt (patient) NPO (nothing by mouth) (after) midnight...Due to surgery tomorrow." Medical record review of a Nurse's note dated March 11, 2011, revealed the resident "returned from (local hospital) after surgery..." Observation on March 30, 2011, at 10:45 a.m, revealed the resident in bed with pressure alarm low bed, scoop mattress with bolsters to the bed and mats on the floor at bedside. Interview with the Director of Nursing and the Corporate Nurse on March 29, 2011, at 1:30 p.m., in the conference room, confirmed on February 26, 2011, the resident fell from the bed with no injury and the facility removed the TED hose and provided education on use of the call light. Continued interview confirmed the facility failed to implement interventions to prevent an fall/injury after the fall on February 26, 2011, and on February 27, 2011, the resident sustained [REDACTED].