Every finding on record at Life Care Center of Morehead

Based on interview, record review, and review of the facility's policies, the facility failed to ensure its staff implemented written abuse policies and procedures to protect residents from the potential of physical and psychosocial harm to include threat allegations not being reported to administration or properly investigated per the facility's policies for 1 of 15 sampled residents, Resident (R) 1.On [DATE], Certified Nursing Assistant (CNA) 2 encountered R1's family member (F1) making threats against her and the facility. CNA2 failed to contact administration related to the threats to ensure protection per the facility's policy until a written statement was provided by CNA2 on [DATE].On approximately [DATE], F1 made statements to Licensed Practical Nurse (LPN) 1 about bringing a large silver and gray object to the facility that went Bang, Bang, Bang. LPN1 failed to contact administration related to the statements to ensure protection per the facility's policy until a written statement was provided by LPN1 on [DATE].The findings include:Review of the facility's policy titled, Abuse-Protection of Residents, dated [DATE], revealed the following methods to ensure the protection of residents during an investigation: removal of access by the alleged perpetrator to the alleged victim and assurance that ongoing safety and protection is provided for the alleged victim and, as appropriate, other residents, to include notification of the alleged violation to other agencies or law enforcement authorities.Review of the facility's policy titled, Security Alert, dated [DATE], revealed facility associates should use this policy in conjunction with the lessons of the See Something; Say Something; Do Something process for handling safety and security concerns. A Security Alert will be used for the following: 1. Any person(s) in the facility or facility parking lots, demonstrating suspicious behavior; 2. Armed intruder/active shooter; 3. Disgruntled former employee or family member; and 4. Domestic situations. Further review of the policy revealed the following additional guidance related to a Security Alert: 1. Any associates who witness any of the above activities must notify the nurse in charge or, if more immediate, the police (911); 2. The associate will give the nurse in charge the appropriate information such as the type of activity, location of the activity, and description of person(s) involved; and 3. The nurse in charge will contact the Executive Director immediately to relay the information. Additionally, if a direct threat of violence is made towards the facility, facility staff or residents, contact the police.Review of the facility's policy titled, Weapons on Facility Grounds, dated [DATE], revealed any resident or visitor found in violation of this policy may be subject to discharge or removal from the facility and may be reported to the police. Staff should never place themselves at risk under any circumstances and should avoid threat of physical harm. The Police Department shall be notified (911) at the first indication a serious/dangerous situation could develop. The seriousness of a situation involving a weapon of any kind should never be taken lightly. Strict adherence to this policy is required for the safety of all occupants and associates of the facility.Review of R1's Face Sheet found in the facility's Electronic Medical Record (EMR) revealed the facility admitted R1 on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD), malignant carcinoid tumor of the stomach, and type II diabetes with unspecified complications.Review of R1's significant change in status Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 12 out of 15. This score indicated R1 had moderate cognitive impairment.Review of R1's Care Plan initiated on [DATE] revealed R1 had a behavior problem in which she allowed F1 to be noncompliant with her care. F1 turned down oxygen, was hateful to R1, and removed and looked for pain patches on R1 but R1 allowed F1 to do so on her own discretion.Review R1's Nursing Progress Notes (NPN) found in the facility's EMR revealed on [DATE] at 2:57 PM, a nurse entered R1's room and F1 was present at her bedside. A lab result was explained to R1 and the Medical Director wanted R1 to wear a bilevel positive airway pressure (BIPAP) at that time, and the nurse explained the risks and benefits of BIPAP use. R1 agreed verbally to use the BIPAP and F1 advised it was contrary to what we agreed on and he stated, research is against it. Further review revealed the nurse explained that the Medical Director ordered the BIPAP and R1 was agreeable to use it. F1 advised again there were studies against it. The nurse proceeded to power on and apply BIPAP, F1 looked at R1 and said, if you are going to wear the BIPAP then I am leaving. R1 stated, I have to wear the BIPAP, it is why I've been so sleepy. F1 then exited the room and retrieved a wheelchair in the hallway, folded it and brought it into the room, and shoved it in the corner of the roommate's side of the room. F1 approached R1 again and stated, are you going to wear it? R 1 advised yes and F1 stated, then I'm leaving. The nurse proceeded to apply the mask and turn the device on, and R1 was receiving the BIPAP with oxygen per the Medical Director's order at that time.Further review of R1's NPN dated [DATE] at 12:47 PM revealed F1 was at her bedside and admitted to removing oxygen tubing from the BIPAP machine and tying pillows up with the tubing to allow R1 to rest in the pillows while sitting up on the side of the bed, although R 1 was weak and unable to do so safely at this time. Nurse went into R 1's room and removed tubing from the pillows and adjusted them properly for resident support. F1 was educated on the need for safety with R1 and then F1 stated, he had a chair (referring to the folding chair behind door) he planned to put on the bed and help R 1 get in it, so she doesn't lean back. The nurse educated F1 again on R1's safety and F1 responded with it's about what R1 wants and not what you think is best. The nurse educated F1 again on safety and instructed F1 if the chair is found on the bed it would be removed from R1's room to ensure R1's safety. F1 did not respond and only stared at nurse.Additional review of R1's NPN dated [DATE] at 4:28 PM revealed F1 had been at her bedside off and on throughout the shift. F1 made comments about ordering tests to check R1 to see if she had parasites or to confirm the cancer so he could research medications to give R 1. On [DATE] at 4:36 PM, further review revealed CNAs brought to the nurse a black pouch lying open on R1's over-the-bed table that contained over-the-counter Claritin D (four tablets in blister pack), expired Nitroglycerin tablets, an Epi-pen, and an Albuterol Inhaler with a spacer. The nurse educated F1 about not bringing in over the counter (OTC) or previously prescribed medications from home for R1. Although F1 voiced understanding, F1 continued to bring them in.During an interview on [DATE] at 9:36 AM with CNA2, when asked by State Survey Agency (SSA) Surveyor if she had encountered visitors of family members getting upset with staff or residents, she stated Yes. CNA2 stated R1's F1 was coming out of R1's room on [DATE] and R1 began crying, and when asked what was wrong, R1 had told F1 to leave and not come back. CNA2 stated she asked R1 what happened and R1 stated, F1 just ripped off my oxygen and said I was not going to be using oxygen, and I did not need oxygen, it was just making it worse. CNA2 further stated she asked R1 if F1 had ripped the oxygen off her and she stated Yes. CNA2 stated R1 told her to tell F1 not to come back until he had cooled off and R1 also asked not to take calls from F1. CNA2 stated she walked down the hallway and F1 was complaining to another nurse, she walked up to F1 and told him he was not coming back to the facility until R1 went to sleep and he cooled down because he had ripped R1's oxygen tubing off her ears and hit her in the chin. F1 stated That is your imagination. CNA2 stated to F1, I do not think R1 would lie about it. CNA2 continued to state F1 then started screaming and stated, You are giving medication too much, too fast, and they turn it off for money. CNA2 then stated, We are doing no such thing. She stated staff tried to call the Assistant Director of Nursing (ADON) to let him know what had happened because there was no management in the building at the time, only nurse managers. CNA2 stated F1 then replied, I'll be back and I'll be bringing something with me. CNA2 stated, What was that supposed to be? F1 then stated, He is going to help me. CNA2 stated she did not call law enforcement. When asked by the SSA Surveyor what the facility policy stated if staff are threatened, CNA2 stated, We are to contact the DON or Administrator. When asked by the SSA Surveyor if she should have contacted the police, CNA2 stated, I was never told we could call police. During an interview on [DATE] at 9:42 AM with LPN1, she stated she one time had entered R1's room when F1 was in the room. F1 stated to LPN1, R1 does not want her oxygen on. LPN1 stated, I have to follow orders from the doctor, or I could lose my job. LPN1 stated she readjusted the oxygen flow to three liters for R1. LPN1 further stated other CNAs told her that F1 had taken the oxygen tubing off R1's BIPAP machine and tied up five pillows so R1 could keep sitting up on the side of the bed. LPN1 stated she tried explaining to F1 the dangers of propping R1 up in bed when R1 was unable to support herself, then she helped put R1 back in bed. F1 then stated to her, he had taken a garbage can, a wash basin, and pillows to prop R1 up in bed. LPN1 further stated, another incident occurred at the end of [DATE] on approximately [DATE], when F1 was very angry and upset in wanting a second opinion for R1. LPN1 stated F1 eventually called down but then became angry at the Medical Director and the refusal of another provider for not prescribing antibiotics for R1. F1 then made the statement he had something for the Medical Director, and it was a big object, it was silver, and it goes Bang, Bang, Bang. LPN1 stated she did report the conversation to the Medical Director.During an additional interview on [DATE] at 4:28 PM with LPN1, she stated during the time of the incident with F1, she stated she was dealing with a dying patient and forgot to chart the incident and to notify administration about the confrontation with F1.During an interview on [DATE] at 4:10 PM with Director of Nursing (DON), she stated she was off the day CNA2 made the report, but the ADON did not report to her an incident involving F1. She stated no staff made any statements concerning F1's threat to the staff. The DON stated if an incident occurred, we would tell staff to divert the person away from the staff member or resident and contact law enforcement. She stated she was disappointed that LPN1 and CNA2 did not follow the policy because we have measures in place to protect staff and residents.During an interview on [DATE] at 11:58 AM with the Executive Director, he stated staff never came to him stating F1 had threatened them with a gun. He further stated if this had happened, he would have told staff to call 911 if F1 came back to the facility. The Executive Director stated he could not believe staff did not report F1's threats to him. He stated the ADON had encountered F1 but F1 never mentioned a firearm and staff never reported the threat of a firearm.During an additional interview on [DATE] at 4:59 PM with the Executive Director, he stated it was his expectation for LPN1 and CNA2 to have reported the incident to him. He stated he would have called F1 to validate his statement and he would have clarified CNA2's statement. He further stated it was his expectation that LPN1 should have documented the incident in addition to contacting him or the DON.

Based on observation, interview, record review, and review of facility policies, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, that were identified in the comprehensive assessment for 1 of 19 sampled residents, Resident (R) 1.The facility admitted R1 on 01/05/2026 with a documented diagnosis of post-traumatic stress disorder (PTSD); however, the facility failed to include trauma-informed care and interventions for that care on R1's care plan. The findings include:Review of the facility's policy titled, Comprehensive Care Plans and Conferences, reviewed 08/29/2025, revealed the comprehensive care plan is developed within seven days of the completion of the initial comprehensive assessment and reviewed and revised following each assessment, thereafter.Review of R1's admission Record revealed the facility admitted the resident on 01/05/2026 with diagnoses including fracture of left femur, PTSD, and acute respiratory failure.Review of R1's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 02/16/2026, revealed the resident had a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating the resident was cognitively intact. Further review revealed R1 was assessed for an active diagnosis of PTSD.Review of R1's Comprehensive Care Plan revealed PTSD and/or trauma-informed care were not addressed.Review of R1's hospital discharge paperwork, dated 01/05/2026, revealed documentation showing the resident had a diagnosis of PTSD.Review of R1's Order Summary Report revealed PTSD listed as an active diagnosis. Further review revealed no active or standing orders for psychiatric care.Review of R1's Trauma Informed Care Assessment, dated 01/12/2026, revealed the resident indicated he had experienced personal trauma related to a transportation accident. Further review revealed R1 specified he experienced the following over the past month: repeated and disturbing dreams of the stressful event; feeling very upset when reminded of the stressful event; having physical reactions when reminded of the event (heart pounding, sweating, trouble breathing); avoiding memories or feelings related to the stressful experience; trouble remembering important parts of the experience; blaming self or someone else; and having strong negative feelings such as fear, horror, guilt, anger, or shame.In an interview with R1 on 03/17/2026 at 12:09 PM, he stated he was at the facility for therapy because he fell and broke his leg, but his goal was to return home. When asked about his past trauma, R1 declined to discuss anything related to the event.In an interview with State Registered Nurse Aide (SRNA) 5 on 03/19/2026 at 9:38 AM, she stated she determined a resident's care when she received report and from the Kardex. She further stated each resident's abilities and interventions were listed on the Kardex. SRNA5 stated it was important to know a resident's needs, so they were given proper care. Additionally, SRNA5 stated it was hard to provide assistance if she did not know what a resident's needs were. In an interview with Licensed Practical Nurse (LPN) 3 on 03/19/2026 at 9:49 AM, she stated R1 did not share much information with staff related to his trauma. She stated she was not aware of any specific triggers related to the resident's trauma. LPN3 further stated she made herself available if R1 wanted to talk and she provided him with encouragement. LPN3 stated it was important PTSD was listed on R1's care plan because it was hard to meet his needs if she did not know what they were.In an interview with the Social Services Director (SSD) on 03/19/2026 at 10:01 AM, she stated R1 was admitted to the facility for rehab following a fall that resulted in a broken leg. The SSD stated she addressed PTSD with R1 when he was admitted and he told her he was involved in a very terrible accident, but declined any further discussion related to specific triggers or the accident itself. When asked how needs were met when triggers were not readily identified, the SSD stated she monitored behavior changes such as increased isolation, depression, or aggression. The SSD stated it was important that staff were aware of R1's PTSD diagnosis and any known triggers so he received resident-centered care and was not re-traumatized. She said it was important that PTSD was listed on R1's care plan so staff were aware of his diagnosis, and he could be monitored for changes.In an interview with the MDS Coordinator on 03/19/2026 at 10:23 AM, she stated when she gathered information for the initial MDS and for each review, she looked at diagnoses, reviewed discharge summaries, interviewed residents/family, and talked to nursing. The MDS Coordinator stated the purpose of a care plan was to let staff know what a resident needed for his/her care. When the MDS Coordinator was asked to review R1's care plan, she stated PTSD was not included and there were no interventions that addressed the resident's trauma. She further stated it was somehow missed but should have been on R1's care plan.In an interview with the Director of Nursing (DON) on 03/19/2026 at 12:42 PM, she stated it was her expectation residents with PTSD received trauma-informed care, and it should be included in their care plan. She further stated quality care could not be provided if staff were not aware when residents had PTSD. The DON stated that even if R1's specific triggers were not known, there should have been interventions in place so R1 could be monitored for changes in behavior.In an interview with the Executive Director (ED) on 03/19/2026 at 1:08 PM, he stated it was his expectation that any resident with trauma or a diagnosis of PTSD felt safe, secure, and comfortable in the facility. He stated he expected PTSD to be included in R1's care plan because that was how staff identified his needs.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure residents who were trauma survivors received trauma-informed care based on professional standards and residents' experiences to eliminate or lessen triggers that could cause re-traumatization for 1 of 1 resident sampled for trauma informed care, Resident (R) 1.The facility admitted R1 on 01/05/2026 with a documented diagnosis of post-traumatic stress disorder (PTSD); however, the facility failed to include trauma-informed care and interventions for that care on R1's care plan. The findings include:Review of the facility's policy titled, Trauma-Informed Care, revised 01/06/2026, revealed the facility ensures residents who are diagnosed with mental disorder and psychosocial adjustment difficulty, or who have a history of trauma and/or post-traumatic stress disorder, receive treatment and services in accordance with professional standards of practice, and has a comprehensive person-centered care plan that reflects the resident's goals to eliminate or mitigate triggers that may cause re-traumatization of the resident. Additional review revealed in situations where a trauma survivor is reluctant to share his or her story, the facility should still attempt to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident.Review of R1's admission Record revealed the facility admitted the resident on 01/05/2026 with diagnoses including fracture of left femur, PTSD, and acute respiratory failure.Review of R1's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 02/16/2026, revealed the resident had a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating the resident was cognitively intact. Further review revealed R1 was assessed for an active diagnosis of PTSD.Review of R1's Comprehensive Care Plan revealed PTSD and/or trauma-informed care were not addressed.Review of R1's hospital discharge paperwork, dated 01/05/2026, revealed documentation showing the resident had a diagnosis of PTSD.Review of R1's Order Summary Report revealed PTSD listed as an active diagnosis. Further review revealed no active or standing orders for psychiatric care.Review of R1's Trauma Informed Care Assessment, dated 01/12/2026, revealed the resident indicated he had experienced personal trauma related to a transportation accident. Further review revealed R1 specified he experienced the following over the past month: repeated and disturbing dreams of the stressful event; feeling very upset when reminded of the stressful event; having physical reactions when reminded of the event (heart pounding, sweating, trouble breathing); avoiding memories or feelings related to the stressful experience; trouble remembering important parts of the experience; blaming self or someone else; and having strong negative feelings such as fear, horror, guilt, anger, or shame.In an interview with R1 on 03/17/2026 at 12:09 PM, he stated he was at the facility for therapy because he fell and broke his leg, but his goal was to return home. When asked about his past trauma, R1 declined to discuss anything related to the event.In an interview with Licensed Practical Nurse (LPN) 3 on 03/19/2026 at 9:49 AM, she stated R1 did not share much information with staff related to his trauma. She stated she was not aware of any specific triggers related to the resident's trauma. LPN3 further stated she made herself available if R1 wanted to talk and she provided him with encouragement. LPN3 stated it was important that staff knew when residents had a history of trauma so they were able to meet their needs.In an interview with the Social Services Director (SSD) on 03/19/2026 at 10:01 AM, she stated R1 was admitted to the facility for rehab following a fall that resulted in a broken leg. The SSD stated she addressed PTSD with R1 when he was admitted and he told her he was involved in a very terrible accident, but declined any further discussion related to specific triggers or the accident itself. When asked how needs were met when triggers were not readily identified, the SSD stated she monitored behavior changes such as increased isolation, depression, or aggression. The SSD stated it was important staff were aware of R1's PTSD diagnosis and any known triggers so he received resident-centered care and was not re-traumatized.In an interview with the Director of Nursing (DON) on 03/19/2026 at 12:42 PM, she stated it was her expectation residents with PTSD received trauma-informed care. She stated residents with past trauma received a PTSD assessment at admission to help determine possible triggers. She further stated, in situations where triggers were not easily identified, she expected that staff anticipated a resident's needs, when possible, looked for changes in behavior, and provided support and encouragement.In an interview with the Executive Director (ED) on 03/19/2026 at 1:08 PM, he stated it was his expectation that any resident with trauma or a diagnosis of PTSD felt safe, secure, and comfortable in the facility. He stated every resident with a known history or diagnosis of PTSD received a trauma assessment, and if specific triggers were not identified at that time, he expected that all staff monitored the resident for changes or new behaviors.

Based on observation, interview, record review, review of the glucometer's (device used to calculate a finger-stick blood glucose level) manufacturer's instructions, review of disinfectant wipe instructions, review of the Centers for Disease Control and Prevention (CDC) document, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and to implement interventions to protect the residents. The deficient practice had the potential to affect 34 of 34 residents, to who received fingersticks for blood glucose testing, with observations to include (Resident (R)7, R45, R37, and R244 ). Additional observations of deficient practice revealed they affected 4 of 27 sampled residents (R13, R27, R70, and R72). Observations revealed Registered Nurse (RN)1, Licensed Practical Nurse (LPN)1, and LPN3 failed to properly clean and disinfect shared glucometers after obtaining blood glucose measurements. Review of the manufacturer's recommendations revealed the staff was to use specific wipes validated by the manufacturer. Further review revealed staff was to use two wipes, one for cleaning and one for disinfecting, leaving the surface wet for a specific amount of time for the wipe, which the staff failed to do. Review of the product information for Sani-Cloth Bleach wipes, which the facility used to clean and disinfect glucometers, revealed its Environmental Protection Agency (EPA) number was not listed by the manufacturer as approved for the glucometer. Further review revealed the incorrect wipe had a dwell time of four minutes. Review of the facility's list of residents with bloodborne illnesses revealed one resident, Resident (R) 45, with human immunodeficiency virus (HIV), and the resident received blood glucose checks using the facility's shared glucometers. Immediate Jeopardy (IJ) was identified on 05/22/2025 and was determined to exist on 05/21/2025, in the area of 42 CFR 483.80 Infection Control, F880, at a Scope and Severity (S/S) of an K. The facility's Executive Director was notified of the IJ on 05/22/2025. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 05/23/2025, alleging removal of the IJ on 05/23/2025. The State Survey Agency (SSA) determined the IJ was removed on 05/23/2025, prior to exit on 05/23/2025, with remaining non-compliance at an S/S of an E while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Infection Control, revision date 03/21/2024, revealed the facility was to provide a comprehensive infection control program involving all departments to prevent and control infections acquired or brought into the facility. Review of the facility's policy titled, Standard Precautions, revision date 07/05/2022, revealed standard precautions were used as the first line of defense against preventing transmission of microorganisms. The policy stated the procedure included to utilize personal protective equipment (PPE), and resident care items for multiple residents were disinfected between uses with the approved disinfectant. Review of the CDC's document Standard Precautions for All Patient Care, Infection Control Basics, Health Care Providers, dated 04/03/2024, revealed hand hygiene meant cleaning hands with water and soap (e.g., plain soap or with an antiseptic) or antiseptic hand rub (alcohol-based foam or gel hand sanitizer); immediately before touching a patient [resident]; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient [resident]; after touching a patient [resident] or patient's [resident's] surroundings; after contact with blood, body fluids, or contaminated surfaces; and immediately after glove removal. It also stated gloves were not a substitute for hand hygiene, and if the task required gloves, perform hand hygiene before donning (putting on) gloves and touching the patient [resident] or the patient's [resident's] surroundings. Further review of the CDC's document, dated 04/03/2024, revealed staff should always clean hands after removing gloves. Per the document, it stated to wear gloves when coming in contact with blood or other infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment. Additionally, the document stated to change gloves and clean hands if gloves became damaged or soiled with blood or body fluids after a task; if moving from work on a soiled body site to a clean body site on the same patient [resident]; if moving from care on one patient [resident] to another patient [resident]; if they looked dirty or had blood or body fluids on them after completing a task; and before exiting a patient's [resident's] room. Review of the facility's glucometer manufacturer's instructions for cleansing the machine to reduce the risk of transmission of blood-borne pathogens, revised 04/2021, revealed it was to be cleaned and disinfected after each use on each patient [resident] using standard precautions and the manufacturer's disinfection procedures. Per the policy, the procedure included to clean the glucometer with the approved wipe (Super Sani-Cloth, EPA number 9480-4, purple top) with a contact time of two minutes before its next use. The instructions stated to use two wipes, one for cleaning and one for disinfecting, wiping the surface of the meter three times vertically and three times horizontally. Review of Super Sani-Cloth (EPA number 9480-4), the approved wipe for the glucometer utilized by the facility, revealed the instructions for cleaning and disinfecting was to clean with one wipe and disinfect with the second wipe allowing the surface to remain wet for two (2) minutes and allowing to air dry. Review of the facility's list for residents with Blood Borne Illnesses, dated 05/19/2025, revealed one resident, R45, diagnosed with Human Immunodeficiency Virus (HIV) Disease. Review of the facility's Midnight Census Report, dated 05/19/2025, listed the census with 34 residents receiving fingersticks for blood glucose testing, including R45. 1 a. Review of R45's admission Record revealed the facility admitted R45 on 01/19/2019 with diagnoses to include diabetes, encephalopathy,high blood pressure, and Human Immunodeficiency Virus (HIV). Review of R45's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 05/20/2025 revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of two out of 15, which indicated the resident was severely cognitively impaired. Review of R45's Physician's Orders, revealed an active order set, dated 03/20/2024, for a fingerstick to be obtained one time a day to check for blood glucose level. b. Review of R7's admission Record revealed the facility initially admitted the resident on 02/22/2021 with diagnoses including diabetes, cerebral vascular accident, and pneumonia. Review of R7's annual MDS, with an ARD of 04/25/2025, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, indicating intact cognition. Further review revealed the resident received five insulin injections during the last seven days. c. Review of R58's admission Record revealed the facility initially admitted the resident on 05/26/2020 with diagnoses including stroke, dementia, and atrial fibrillation. Review of R58's quarterly MDS, with an ARD of 03/24/2025, revealed the facility assessed the resident to have a BIMS of 12 out of 15, indicating moderate cognitive impairment. Observation on 05/21/2025 at 10:00 AM on the [NAME] Hall revealed RN1 checked R7's glucose. RN1 removed the glucometer from Medication Cart 2. The glucometer was in the top drawer, it was not in a container or a bag, and there was another glucometer in the same spot touching the other glucometer. RN1 put on gloves without sanitizing her hands and performed the glucometer check on R7. She then went to R7's roommate's bed (R58) and placed the glucometer on his bedside table. She talked with R58, picked up the glucometer, and placed it on the top of the medication cart. She removed her gloves and did not sanitize her hands. She opened the bottom right drawer of the medication cart and wiped the glucometer from 10:07:01 AM to 10:07:010 AM, nine seconds. After wiping the glucometer, she placed the glucometer back on the top of the medication cart, without using a barrier. RN1 left the glucometer on the top of the cart and went to give medications. Observation of the Sani-Cloth Bleach Germicidal Disposable Wipes RN1 used for R7's glucometer disinfection revealed its EPA number was 9480-8 (unapproved, orange top), and it was to remain visibly wet with the disinfectant for four minutes. During interview with RN1 on 05/21/2025 at 10:26 AM, she stated the facility's policy instructed to wipe all sides of the glucometer. She stated she always did three swipes on each side with a Sani-cloth wipe. She stated she thought she should wipe the glucometer and let it dry. She stated she did not think there could be any contamination because she wiped all sides of the glucometer. She said it was just an oversight that she did not let the glucometer stay wet for four minutes. She stated she had two glucometers, and she switched them for use. Per the interview, the RN revealed she was not aware the glucometers needed to be wet for four minutes. d. Review of R244's admission Record revealed the facility admitted the resident on 05/16/2025 with diagnoses to include dysphagia, diabetes mellitus, adult failure to thrive, and dependence on renal dialysis. Review of R244's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 05/20/2025, revealed the resident had a Brief Interview for Mental Status [BIMS] score of 10 out of fifteen 15, which indicated the resident had moderate cognitive impairment. Further review revealed the resident received four insulin injections during the last seven days. Review of R244's Physician's Orders, dated 05/16/2025 revealed a verbal order was given for fingerstick blood sugars four times a day for diabetes mellitus. Observation on 05/21/2025 at 11:50 AM revealed Licensed Practical Nurse (LPN) 3, prior to performing a fingerstick on R244, removed the glucometer which was lying on top of the South Hall Medication Cart without a barrier underneath. LPN3 entered R244's room, placed the glucometer on the overbed table, and donned PPE. After cleansing R244's right middle finger with an alcohol pad, LPN3 lanced R244's finger and obtained blood for checking the glucose level. After administering medications and insulin, LPN3 removed PPE and put on different gloves, picked up the glucometer, and placed it on top of the medication cart without a barrier underneath. LPN3 wore the same gloves, opened the bottom drawer of the medication cart, and removed a container of Sani-Cloth Bleach wipes, which was not the acceptable wipe. She removed one cloth and wiped the front and back of the glucometer for approximately four to five seconds with the one cloth and placed the glucometer on top of the medication cart without a barrier underneath. During interview with LPN3 at the time of the observation, on 05/21/2025 at 11:52 AM, she stated she did not have another resident to check for a glucometer check at that time. When asked about the dwell time for the disinfectant wipe for the glucometer, she stated, I don't know, probably two to three minutes. LPN3 further stated she did not know if the glucometer was clean when she used it, but she guessed it was. She stated it was important to clean and disinfect equipment properly to prevent spreading germs from resident to resident. e. Review of R37's admission Record revealed the facility initially admitted the resident on 10/21/2016 with diagnoses of diabetes, anemia, and coronary artery disease. Review of R37's annual MDS, with an ARD of 04/24/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating intact cognition. Further review revealed the resident received seven insulin injections during the last seven days. Observation on 05/21/2025 at 3:42 PM revealed LPN1 prepared to check R37's glucose. She opened the top drawer of Medication Cart 2 on the North Hall. She took one of two glucometers that were not in containers and lying next to each other. She did not sanitize her hands, and she put on gloves. She performed the glucose check on R37 and placed the glucometer without a barrier underneath on the top of the medication cart. She removed her gloves and did not sanitize her hands. She took out her keys and opened the bottom right drawer of the medication cart. She took out the Sani-Cloth Bleach Germicidal Disposable Wipes container. She removed a wipe and wiped the glucometer from 3:44:40 to 3:44:50 (10 seconds). She then put the glucometer in a cup and set it on top of the medication cart, started the timer for five minutes, and left. During interview with LPN1 at the time of the observation, on 05/21/2025 at 3:50 PM, she stated she was taught to wipe the glucometer three times each way and then let it dry for five minutes with the orange top sani-wipes. She stated she did not know to use the purple top sani-wipes. Further, she stated she had received training from the staff development coordinator in cleaning the glucometer a few months ago. During interview with the Infection Preventionist on 05/21/2025 at 3:20 PM, she stated each medication cart had two glucometers, and the process was for staff to wipe down the glucometer, using the proper wipe, set to the side, and use the other glucometer while the first was drying. Observation revealed two medication carts on the South Hall, and each had two glucometers which were lying in the top drawer of each medication cart side-by-side. When asked if there was a concern if staff did not follow the proper cleaning procedure, she stated it would cause cross contamination, and she would be concerned for the spread of bloodborne pathogens. During interview with the Director of Nursing (DON) on 05/22/2025 at 4:00 PM, she stated her expectation was for staff to follow guidelines to properly clean glucometers with the orange top wipes. She stated her concern would be if they did not follow the process, infection could be spread throughout the residents. Review of the facility's policy titled, Enhanced Barrier Precautions, revision date 04/22/2025, revealed staff providing high-contact care activities for residents in EBP isolation included dressing, bathing/showering, transferring, providing hygiene, linen or brief change, medical care device use, wound care, and assisting with toileting. It stated, during these high-contact care activities, staff was to wear PPE and follow EBP signage. Review of the facility's EBP signage (procedure to be used), posted on residents' doors in EBP, revealed everyone was to clean hands before entering and leaving the room. The signage revealed providers and staff must also wear gloves and a gown for high-contact resident care activities. Review of the facility's list of residents on EBP, dated 05/19/2025, revealed there were 24 residents listed, including R13, R27, R70, and R72. 2. a. Review of R27's admission Record revealed the facility initially admitted the resident on 06/08/2024 with diagnoses including respiratory failure, protein-calorie malnutrition, and diabetes. Review of R27's significant change in status assessment MDS, with an ARD of 03/25/2025, revealed the facility assessed the resident to have a BIMS score of four out of 15, indicating the resident had severe cognitive impairment. Further review revealed the resident had one stage 2 pressure ulcer and one stage 3 pressure ulcer. Observation on 05/19/2025 at 4:08 PM revealed Certified Nurse Aide (CNA)2 placed herself partially in Resident (R)27's bed and hugged the resident while she was in the bed without wearing a gown or gloves. Additional observation revealed R27's room door had signage placed for Enhanced Barrier Precautions (EBP) with Personal Protective Equipment (PPE) hanging on the back of the door. Further observation revealed R27 had an indwelling urinary catheter to bedside drainage. During interview with CNA2 on 05/20/2025 at approximately 12:00 PM, she stated she had received training on infection control and isolation procedures. When asked when staff should put on PPE if a resident was in EBP isolation, she stated anytime there was direct resident care or touching a resident to prevent germs from spreading. During continued interview with the Infection Preventionist (IP) on 05/21/2025 at 3:20 PM, she stated R27 was in EBP for a urinary catheter and wounds. b. Review of R13's admission Record revealed the facility admitted the resident on 01/28/2025 with diagnoses to include zoster encephalitis, malignant neoplasm of the brain, and infection with multidrug resistant organisms (MDRO). Review of R13's quarterly MDS, with an ARD of 03/24/2025, revealed the facility assessed the resident to have a BIMS score of 12 out of 15, which indicated the resident had moderate cognitive impairment. Observation on 05/19/2025 at 5:20 PM revealed RN1 went into R13's room to give an injection. R13 was in EBP due to infection with Multi Drug Resistant Organisms (MDRO). RN1 was only wearing gloves. She opened the left side of the brief and gave the injection. RN1 then left the room and went to the medication cart still wearing the same gloves. She took the keys out of her pocket and opened the drawer and removed an alcohol pad. RN1 returned to R13's room and went to the right side of the bed. She opened the right side of the resident's brief and gave the injection in the right hip, exited the room with her contaminated gloves on, and obtained ice without taking her gloves off. She removed her gloves and put them in the trash can, moving the can with ungloved hands. She did not sanitize or wash her hands. During immediate interview with RN1 after the observation, on 05/19/2025 at 5:30 PM, she stated she could not remember when she was trained in infection control. She stated she had received so much training she could not remember if she had infection control training. She stated she should have sanitized her hands before putting on her gloves and after removing the gloves, she just forgot. c. Review of R72's admission Record revealed facility admitted the resident on 03/01/2025 with diagnoses to include diabetes, stroke, and heart disease. Review of R72's quarterly MDS, with an ARD of 04/10/2025, revealed the facility assessed the resident to have a BIMS score of nine out of 15, which indicated the resident had moderate cognitive impairment. Review of R72's Progress Note, dated 05/12/2025 and untimed, revealed the resident had a stage 3 pressure wound to her lower sacrum. During interview with R72 on 05/19/2025 at 3:50 PM, she stated she had a sore on her butt, which was getting better, and the nurses were putting something on it to take care of it. Observation on 05/21/2025 at 8:05 AM revealed CNA5 entered R72's room without wearing a gown or gloves after the resident requested help to reposition. Additional observation revealed R72's door had signage for EBP. During immediate interview with CNA5 after exiting R72's room at 8:10 AM, she stated she had helped the resident to reposition and had not donned Personal Protective Equipment (PPE), but she should have to prevent the spread of germs. d. Review of R70's admission Record revealed the facility admitted the resident on 12/02/2022 with diagnoses which included unspecified protein-calorie malnutrition, unspecified dementia, and acute ischemic heart disease. Review of R70's significant change in status assessment MDS, with an ARD of 03/20/2025, revealed the facility assessed the resident to have a BIMS score of five out of 15, which indicated severe cognitive impairment. Review of R70's Wound Assessment, dated 04/17/2025 revealed the resident had an acute Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer acquired on 02/10/2025 and has received a status of Not Healed. Initial wound encounter measurements were 1cm [centimeter] length x 1.5cm width with no measurable depth, with an area of 1.5 sq cm [square centimeter]. There was a Moderate amount of purulent drainage noted. Observation on 05/22/2025 at 1:15 PM revealed there was EBP signage on R70's door. Continued observation of R70's dressing change by LPN7 revealed LPN7 did not follow EBP. The LPN did not wear a gown during this high-contact activity, and the wound cleaner container was hung on the scrub pocket with the spray tip touching the scrubs. During interview with LPN7 on 05/20/2025 at 8:50 AM, she stated it was important to wear proper PPE each and every time direct care was provided to a resident in EBP to prevent the spread of infection and germs. During interview with RN2 on 05/19/2025 at 5:25 PM, she stated if a resident was on EBP, staff should put on PPE prior to touching the resident for prevention of spreading germs. During continued interview with the Infection Preventionist (IP) on 05/21/2025 at 3:20 PM, she stated anytime there was high-contact care given that involved touching a resident, PPE should be put on correctly. She stated hand hygiene audits were performed randomly with yearly training. She stated staff was trained to use soap and water after providing care to a resident with diagnoses of C-difficile or Noravirus (gastrointestioanl infection characterized by diarrhea, vomiting, and stomach pain) but was allowed to use hand sanitizer other times. Review of the facility's policy titled, Cleaning and Disinfection of Non-Critical Patient [Resident] Care Equipment, revision date 08/22/2022, revealed non-critical reusable patient [resident] care equipment was cleaned daily and before and after reuse with an approved disinfectant based on manufacturer guidelines or Environmental Protection Agency (EPA)-registered hospital disinfectant. 3. Observation on 05/19/2025 at 4:10 PM, 05/20/2025 at 11:20 AM, and 05/22/2025 at 12:18 PM, revealed the Hoyer lift (mechanical lift used to transfer residents from one surface to another) on the South 2 Hall had drops of a brown-colored substance on the base of the lift. During interview with CNA5 on 05/21/2025 at 8:10 AM, she stated the entire Hoyer lift should be cleaned after each use. During continued interview with the DON on 05/22/2025 at 4:00 PM, when asked how often the Hoyer lifts should be cleaned, she stated after each use, including the base of the lift. During interview with the Executive Director on 05/22/2025 at 4:20 PM, he stated his tasks included oversight of the building and assuring the needs and safety of the residents and staff were met. The Executive Director revealed he expected staff to follow the infection control policies and procedures for the prevention of spreading infection throughout the facility. The facility provided an acceptable IJ Removal Plan on 05/23/2025 verbatim: 1. How corrective action will be accomplished for those residents found to have been affected by the deficient practice? On 5/22/25, the Director of Nursing (DON) removed the Orange topped Sani-Cloth Bleach wipes from the North Unit medication carts #1 and #2 and replaced with the Purple topped Sani-Cloth Germicidal Disposable wipes which Environmental Protection Agency (EPA) number is listed by the manufacturer as approved for the glucometer. On 5/22/25, the Director of Nursing (DON) removed the Orange topped Sani-Cloth Bleach wipes from the South Unit medication carts #1 and #2 and replaced with the Purple topped Sani-Cloth Germicidal Disposable wipes which Environmental Protection Agency (EPA) number is listed by the manufacturer as approved for the glucometer. On 5/22/25, the Director of Nursing (DON) removed the Orange topped Sani-Cloth Bleach wipes from the [NAME] Unit medication carts #1 and #2 and replaced with the Purple topped Sani-Cloth Germicidal Disposable wipes which Environmental Protection Agency (EPA) number is listed by the manufacturer as approved for the glucometer. On 5/22/25, the Director of Nursing (DON) provided Resident (R) 45 with his own personal glucometer device to be kept in his room to ensure his glucometer device is to be used for his own personal use and not shared with other residents. The Executive Director, Director of Nursing and Interdisciplinary Team completed a Root Cause Analysis (RCA) on 5/23/2025. 2. How facility will identify other residents having the potentlal [sic] to be affected by the same deficient cract1ce [sic]? All residents receiving finger stick blood glucose checks have the potential to be affected. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? On 5/22/2025, the Regional Director of Clinical Services provided education to the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator and Infection Preventionist Nurse on the following: o Blood Glucose Monitoring Policy o Assur Prism multi® Blood Glucose Monitoring System Reference Manual o Omnicare Glucometer Cleaning Poster o [NAME] Blood glucose monitoring, long-term care procedure o [NAME] Blood glucose monitoring, long-term care skills checklist o Glucometer Cleaning and Disinfecting-Quick Reference Guide o [NAME] Glucometer Assure Quality Control Checks and Cleaning Procedures o [NAME] Skills Checklist-Cleaning and Disinfecting the Meter Starting on 5/22/2025, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), Infection Prevention Nurse and/or Regional Director of Clinical Services will provide education to fill licensed nurses (Registered Nurses and Licensed Nurses) on the following: o Blood Glucose Monitoring Policy o Assur Prism multi® Blood Glucose Monitoring System Reference Manual o Omnicare Glucometer Cleaning Poster o [NAME] Blood glucose monitoring, long-term care procedure o [NAME] Blood glucose monitoring, long-term care skills checklist o Glucometer Cleaning and Disinfecting-Quick Reference Guide o [NAME] Glucometer Assure Quality Control Checks and Cleaning Procedures o [NAME] Skills Checklist-Cleaning and Disinfecting the Meter Any associate who has not completed training by 5/23/2025 will not be allowed to provide direct resident care until training is completed. The Director of Nursing (DON), Staff Development Coordinator (SOC), Infection Prevention Nurse and/or Regional Nurse will provide education to all new associates upon hire during orientation. [The facility's name] does not utilize agency staffing. As of 5/23/25, the facility has educated 23 out of 26 licensed nurses. On 5/23/25, the Director of Nursing (DON) placed a copy of the Omnicare Glucometer Cleaning poster and the Quick Reference Guide for glucometer cleaning on each medication cart as a guide to ensure the facility follows standard precautions during the performance of routine testing of blood glucose and ensure proper cleaning and disinfecting of the shared glucometer monitors that are used for more than one resident. The Medical Director reviewed and agreed with this plan of removal on 5/22/2025 with a copy provided to him on 5/23/25. AD Hoc QAPI meeting was held on 5/23/2025 regarding this plan of removal. Attendees were Executive Director, Medical Director, Director of Nursing, Staff Development Director, Infection Preventionist, Activity Director, Social Service Director, Health Information Manager, MOS Coordinator, Director of Rehabilitation, and Dietary Manager. A second AD Hoc OAPI [sic] meeting will be conducted on 5/23/25 to review audit tools that were completed to identify any deficient practice and provide re-education as indicated. 4. How the facilitv [sic] clans [sic] to monitor its oerformance [sic] to make sure that solutions are sustained. The Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SOC), Infection Prevention Nurse and or Regional Nurse will conduct [NAME] Skills Checklist-Cleaning and Disinfecting the Meter for one nurse per unit per shift (dayshift & nightshift), seven (7) days a week until IJ removal and then five (5) times a week for four (4) weeks, then three (3) times a week for four (4) weeks, then one (1) time a week for four (4) weeks. The Director of Nursing and/or Regional Director of Clinical Services will Audit (Audit #4 A Skills Checklist- Cleaning and Disinfecting the Meter) the skills checklists to ensure the facility follows proper cleaning and disinfecting of the shared glucometer monitors that are used for more than one resident. If any non compliance is identified, a licensed nurse will provide re-education. The Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SOC), Infection Prevention Nurse and or Regional Nurse will conduct a visual observation and complete [NAME] Blood glucose monitoring, long-term care skills checklist for one nurse per unit, seven (7) days a week until IJ removal, then five (5) times a week for four (4) weeks, then three (3) times a week for four (4) weeks, then one (1) time a week for four (4) weeks. The Director of Nursing and/or Regional Director of Clinical Services will Audit (Audit #4 B Skills Checklist- Blood Glucose Monitoring) the skills checklists to ensure the facility follows standard precautions during the performance of routine testing of blood glucose. If any non-compliance is identified, a licensed nurse will provide re-education.

Based on observation, interview, and review of the facility's policies, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to affect 87 of 90 residents who consumed food from the kitchen and snacks from the North and South Units. The findings include: Review of the facility's policy titled, Safe Food Handling, revised 04/20/2025, revealed thawing some foods at room temperature might not be acceptable because it might be within the danger zone for rapid bacterial proliferation. Further review revealed the recommended methods to safely thaw frozen foods included thawing in the refrigerator in a drip proof container and in a manner that prevented cross contamination, thawing the item in a microwave oven, or thawing as part of a continuous cooking process. Continued review revealed frozen food must be thawed under refrigeration or in the cooking process. Additional review revealed snacks and other food items sent from the food service department were handled safely related to temperature, labeling, and storage. Review of the facility's policy titled, Nourishment and Snacks, revised 05/08/2025, revealed nourishment and snacks would be prepared and stored using food safety guidelines. Further review revealed resident nourishments and snacks could be prepared in advance and stored in the nourishment room refrigerator/freezer outside of the food service department to be served by nursing staff. Continued review revealed the nourishment/snack refrigerators should be clean and free of non-resident food items, and items stored in the units should adhere to safe food handling and food safety, specifically labeling and dating. Observation of the kitchen on 05/19/2025 at 2:45 PM revealed five rolls of frozen ground beef thawing at room temperature in a bin resting on a rolling cart . Further observation revealed a commercially prepared container of sliced meat in the reach-in refrigerator that was unlabeled and undated. Continued observation revealed a 12-ounce can of soda that was unlabeled and undated. Observation on 05/21/2025 at 6:15 PM revealed snacks in a bin, already placed on top of the North Unit nurse's station counter, ahead of the 8:00 PM snack distribution time, including meat sandwiches and milk, which were not in the refrigerator. Observation of the North Unit nourishment refrigerator on 05/22/2025 at 4:26 PM revealed one box from a fast food restaurant with no label for the intended resident or date. The observation further revealed a lunch box containing two energy drinks and without a label or date. Observation of the South Unit nourishment refrigerator on 05/22/2025 at 5:03 PM revealed a shopping bag containing fruit and crackers belonging to Certified Nurse Aide (CNA) 15, who retrieved it and stated there was a staff refrigerator in their break room where staff was expected to place their own food items. Observation also revealed a shopping bag containing apples and a carton of chocolate milk, unlabeled and undated. During interview with Cook/Dietary Aide (DA) 1 on 05/19/2025 at 2:45 PM, she stated she believed the commercially prepared meat in the reach-in refrigerator was leftover from a prior activity. She further stated she thought the soda might belong to a staff member, and prepared snacks were taken to the units at about 2:30 PM and about 7:00 PM each day. She stated the ground beef was thawing and would go into the walk-in refrigerator later in the afternoon to finish thawing to be used the following day. During interview with Cook/DA2 on 05/21/2025 at 8:16 AM, she stated when thawing meats, they removed the meats from the walk-in freezer, placed a label with the pull date and use by date on the packaging, placed the meat in a pan and allowed it to begin thawing, and then later placed the pan in the bottom shelf of the walk-in refrigerator. During interview with Licensed Practical Nurse (LPN) 6 on 05/21/2025 at 6:15 PM, she stated nighttime snacks were often delivered directly to the nurse's station, not to the nourishment refrigerator, around shift change. During telephone interview with Registered Nurse (RN) 5 on 05/21/2025 at 8:02 PM, she stated the nighttime snacks arrived about the time night shift arrived around 6:00 PM or 6:30 PM. She stated snacks were placed on the nurse's station counter and not in the refrigerator. She stated the aides started night shift by feeding those residents who might still need assistance, collect trays, round, and then pass snacks with their ice pass. During interview with LPN2 on 05/22/2025 at 1:39 PM, she stated the kitchen delivered a box of snacks to the nurse's station while shift change staff was in report. She stated sometimes she put the box in the refrigerator later, after shift report, or the aides would distribute after they passed the resident's ice. During interview with the Registered Dietician (RD) on 05/22/2025 at 2:18 PM, she stated best practice was to put frozen meats from the freezer to the refrigerator at least 24 hours in advance of preparing the meal. Further, she stated it was best practice to avoid putting meat on the counter to thaw at room temperature. During interview with the admission Coordinator on 05/22/2025 at 4:26 PM, she stated the reason it was important to label and date stored items in the Nourishment Room was so residents did not get food that was spoiled. She stated food should be labeled if it was something brought in for a specific resident. During interview with the Certified Dietary Manager (CDM) on 05/23/2025 at 1:37 PM, she stated to thaw meat, the expectation and policy was to take the meat straight from the freezer, place it in a pan, and label and date the item. She further stated all meat and poultry would go to the bottom shelf of the walk-in refrigerator. She stated the sliced ham in the refrigerator was left from a prior activity and kept for resident snacks. She stated it should have been labeled and dated. She stated the nourishment refrigerators on the units should only hold resident items, and those should be labeled and dated. She stated staff snacks or lunches should not be in the nourishment refrigerators. She stated she had educated dietary staff to remove unlabeled items from the refrigerators. The CDM stated the kitchen staff delivered snacks at around 10:00 AM, 3:00 PM, and 8:00 PM. She stated staff should not have delivered at 6:00 PM because that was too early for nighttime snacks. She stated they typically delivered to the nurse's stations. During interview with the Director of Nursing on 05/23/2025 at 2:44 PM, she stated staff drinks or snacks should be stored in the break room, and putting those in a nourishment refrigerator for residents was not acceptable. During interview with the Executive Director on 05/22/2025 at 4:32 PM, after he observed the lunch bag found in a nourishment refrigerator, he stated he had not identified the owner of the lunch bag. He further stated it was important to label and date items in the refrigerator so that the right resident received them and so they did not distribute food that might be spoiled. During another interview with the Executive Director on 05/23/2025 at 3:11 PM, he stated his expectation was that all the food was stored correctly, and he relied on the CDM and the RD to assure staff followed the prescribed policies. He further stated if they had problems, they notified him. He stated if snacks were not passed in a timely fashion, they should be stored in the refrigerator. He stated all items in the nourishment refrigerator must be labeled and dated, and it was not acceptable for staff to keep personal items in a nourishment refrigerator.

Based on interview, record review, and review of the facility's policy, the facility failed to provide the necessary activity of daily living, bathing, to maintain good personal hygiene for 1 of 27 sampled residents, Resident (R) 51. The findings include: Review of the facility's policy titled, Activities of Daily Living, last reviewed 09/10/2024, revealed the resident would receive assistance as needed to complete activities of daily living (ADL), and any change in the ability to perform ADLs would be reported to the nurse. Further review revealed ADLs included hygiene activities such as bathing, dressing, grooming and oral care. Review of R51's admission Record revealed the facility admitted her on 04/15/2025 with diagnoses including displaced trimalleolar fracture of right lower leg, difficulty in walking, and dysphagia. Review of R51's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/18/2025, revealed her Brief Interview for Mental Status [BIMS] score was 13 of 15, indicating her cognitive status was intact. The admission MDS also indicated the resident was dependent for showering and bathing. Review of R51's Point of Care charting since admission revealed she received bed baths on 04/24/2025, 05/06/2025, 05/09/2025, and 05/22/2025. In an interview on 05/20/2025 at 10:47 AM, R51 stated staff was always rushing through her care because there were not enough of them. She further stated she mostly received partial bed baths instead of full showers or full bed baths because the aides did not have enough time for a full shower. In additional interview with R51 on 05/22/2025 at 2:53 PM, she stated she had only been given one full bath and hair wash since admission, and that happened at 3:00 AM. She further stated she had received partial baths perhaps five times. She stated on those occasions, she was given a washcloth to wash her face, and the aide washed her arm pits, applied deodorant, and put a little lotion on her legs. She stated she felt embarrassed and that everybody was looking at her because she was not clean. In an interview on 05/21/2025 at 5:09 PM, Certified Nurse Aide (CNA) 6 and CNA7 stated they often worked with just the two of them as aides for [NAME] Hall, which had 34 residents. They stated those residents had a lot of care needs. Per interview, they stated 18 of the 34 residents were a two-person assist, so CNA6 and CNA7 worked as a team to provide care to these residents. They stated when there were only two aides for that hall, residents typically did not get full showers, only partial bed baths, and other aspects of their care were rushed. During interview with the Director of Nursing (DON) on 05/23/2025 at 2:44 PM, she stated aides would come to her if they could not give a shower, and she directed them to ask night shift to shower/bath the resident, but sometimes that did not get charted. She stated a bed bath included washing head to toe and nails trimmed, and the residents should be offered a wash-up with face, armpits, and skin folds every day. During interview with the Executive Director on 05/23/2025 at 3:27 PM, he stated his expectation was that staff got their tasks done, and if having issues, to let leaders know so they could help. He stated a resident should get their shower on their day, and they should get a bath and linen changed on their day.

Based on observation, interview, record review, review of the manufacturer's guidelines, review of a journal article, and review of the facility's policy, the facility failed to provide the services to prevent possible complications of enteral feeding including but not limited to diarrhea, vomiting, and dehydration for 1 of 2 residents sampled for tube feeding care, Resident (R) 244. The findings include: Review of the facility's policy titled, Enteral Nutrition Therapy (Continuous), revision date 09/10/2024, revealed the facility would provide continuous enteral nutrition therapy in accordance with Physician's Orders and professional standards of practice. The policy stated the [enteral feeding pump] proximal spike sets should be replaced once every 24 hours unless otherwise ordered. Per the policy, a resident who was fed by enteral means should receive appropriate treatment and services to prevent complications of enteral feedings including but not limited to aspiration (inhaling food or drink into airway), diarrhea, vomiting, dehydration, and metabolic abnormalities (ability of the body to convert food and drink into energy). Review of the formula company's recommendation, dated 12/14/2024, revealed precautions included: unless a shorter hang time was specified by the set manufacturer, hang product up to 48 hours, otherwise hang for no more than 24 hours. Review of R244's admission Record revealed the facility admitted the resident on 05/16/2025 with diagnoses to include dysphagia, diabetes, adult failure to thrive, and dependence on renal dialysis. Review of R244's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 05/20/2025, revealed the resident had a Brief Interview for Mental Status [BIMS] score of 10 out of fifteen 15, which indicated the resident had moderate cognitive impairment. Review of R244's Physician's Orders, dated 05/19/2025, revealed an active order for Nepro with Carb Steady (enteral formula) at 50 milliliters (ml) an hour with water flushes of 125 ml every four hours of purified water. Review of R244's Care Plan, dated 05/19/2025, revealed the resident required tube feeding related to a swallowing problem and not eating well. Further review revealed no interventions listed for how often to change the tube feeding closed set. Review of R244's Medication Administration Record (MAR) revealed, beginning the night shift on 05/16/2025 and through the day shift on 05/22/2025, it was initialed as tube feed being administered. Observation on 05/19/2025 at 4:56 PM revealed R244 had a tube feeding solution of Nepro 1.8 cal and water flush hanging on the pole with the tube feed pump and line primed, and both were dated for 05/16/2025. Further observation revealed neither the feeding solution or the water was hooked to the resident or infusing. During interview with Registered Nurse (RN) 2 on 05/19/2025 at 5:25 PM, she stated the tube feeding solution should be discarded after 24 hours. She stated if a resident was administered a solution that had been hanging for longer, the resident could possibly get sick. When asked if she was taking care of R244 today, she stated yes, but was not sure why the solution and water flush were dated for 05/16/2025. During interview with Licensed Practical Nurse (LPN) 3 on 05/19/2025 at 6:39 PM, she stated she had been the admitting nurse for R244 on 05/16/2025. When asked what the process was for continuation of orders, she stated the nurse got in touch with the provider to verify the orders, and she called the provider. When asked what the provider had ordered for R244's tube feedings, she stated he said to continue them. She stated that meant the feeding was to continue, but she was unsure of the rate. She stated she thought she remembered changing the solution over the weekend but could not recall if it was dated. She stated she thought the feeding solution was sent from the hospital but could not say for sure when asked why the solution and water flush were dated for 05/16/2025. The State Survey Agency (SSA) Surveyor attempted to reach the night shift nurse for 05/16/2025 by telephone on 05/19/2025 at 7:04 PM. However, there was no answer, and a voice message was left without response. During interview with LPN5 on 05/20/2025 at 8:50 AM, she stated the tubing feeding solution and the tubing should be changed every 24 hours. She stated it was important because there was a chance the solution could go bad, and the resident could possibly get food poisoning. During interview with RN8 on 05/22/2025 at 10:35 AM, she stated tube feedings should be discarded after 24 hours to prevent bacterial growth in the tubing and feeding solution. She stated if she found a feeding solution outdated and hanging, she would discard immediately and fill out an incident report. During interview with the Infection Preventionist Nurse on 05/23/2025 at 12:13 PM, she stated tube feeding solutions should be discarded after 24 hours. She stated it was important because if the feeding solution and set were left over the 24 hour limit, there was a chance of bacterial growth and that could increase the resident's risk of infection. She stated if staff found a feeding solution and set hanging and it was past the 24 hour limit, they should discard it, assess the resident, and immediately notify the provider. She stated an incident report (IR) should be made, but she was not aware of R244's outdated solution. During an interview with the Director of Nursing (DON) on 05/22/2025 at 3:25 PM, she stated if feeding solutions were hanging longer than 24 hours, the solution could clabber and make a resident sick. She stated the tubing and solution were supposed to be changed every 24 hours. She stated she had not been made aware R244's feeding solution was outdated and still hanging in the resident's room. During an interview with the Executive Director on 05/22/2025 at 4:20 PM, he stated his tasks were to offer oversight for the building to assure safety of the residents. Further, the Executive Director stated it was his expectation that staff would follow the facility's policies and procedures.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide effective pain management for 2 of 5 residents investigated for pain management, Resident (R) 5 and R59. The findings include: Review of the facility's policy, Nursing Documentation, dated [DATE], revealed the facility implemented interventions to prevent or manage each individual resident's pain, beginning at admission. Review of the facility's policy, Administration of Medications, dated [DATE], revealed the facility would ensure medications were administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. 1. Review of the Closed Record revealed the facility admitted R59 on [DATE] at approximately 5:30 PM from the hospital to recover from a fall at home that resulted in a right hip fracture. Further review of the Closed Record revealed diagnoses to include peripheral vascular disease and diabetes. Review of the admission Minimum Data Set Assessment with an ARD date of [DATE] revealed the facility assessed R59 as having a Brief Interview of Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Review of the physician orders dated [DATE] revealed an order for Oxycodone 30 mg to be given every 6 hours as needed for pain. Review of progress note effective date [DATE] at 1:15 AM written by Licensed Practical Nurse (LPN) 6 revealed R59 was complaining of pain in the right hip. LPN6 wrote R59 was aware they were waiting on the pain medication to be delivered from the pharmacy. Further review revealed LPN6 administered acetaminophen 650 mg at 1:15 AM. Review of progress note effective date [DATE] at 02:08 AM written by LPN6 revealed R59 requested pain medication. LPN6 informed R59 that she would notify pharmacy and have the medication sent stat. LPN6's next sentence stated she notified the pharmacy of urgent need for medications to be delivered and the pharmacy stated they would have the medications sent by 6:00 AM or 6:30 AM. LPN 6 documented at 3:08 AM spoke with Director of Nursing (DON), informed her of what was going on. Review of progress note effective date [DATE] at 3:50 AM written by LPN6 revealed R59 was yelling out requesting pain medications. R59 was informed that the medications still had not arrived. LPN6 offered to send R59 to the emergency room (ER) for pain evaluation. R59 requested to be sent to the ER. During interview with LPN6 on [DATE] at 7:55 AM, she stated the facility admitted R59 and she could not get his pain medication because there was not another nurse in the facility with a code to access the facility's emergency medication system, so she sent him to the emergency room (ER). She further stated the Oxyconde 30 mg was available in the emergency medication system but there was not another nurse in the facility that had the code to obtain the medication and it took two nurses to enter the codes to get in the secured system. During a post-survey interview with the contracted pharmacy, on [DATE] at 2:55 PM, the pharmacist stated Oxycodone was available in the emergency medication system. During interview with the Director of Nursing (DON) on [DATE] at 10:32 AM, she stated the emergency medication system required two nurses to enter a code in order to remove medications from the system and she said the process for giving the nurses codes to access the emergency medication system was to contact the pharmacy by way of electronic mail (e-mail). She stated the pharmacy issued the codes, and any new nurse or any nurse who had an expired code was given a new code. She stated she tried to look at the list of nurses' codes and their expiration date monthly, but she was not always able to review it. She stated the importance of the codes was so nurses could access medications that were not in the medication cart. She stated, to her knowledge, there had always been two nurses in the facility who had codes to the emergency medication system. She stated, if there were not two nurses in the facility who had a code, the nurses should contact her, and she would come to the facility. 2. Review of R5's admission Record revealed the facility admitted the resident on [DATE] with diagnoses to include acquired absence of left great toe, chronic kidney disease, and type two diabetes with polyneuropathy (disorder of the peripheral nerves). Review of R5's CCP, dated [DATE], revealed the facility assessed the resident as at risk for pain in her wrist and leg related to diabetes complications. Further review revealed the facility included interventions such as administering controlled medications as ordered and providing nonpharmacologic treatments for pain. Further review of the CCP, dated [DATE], revealed the facility assessed the resident as at risk for needing more medications to achieve adequate pain relief and included interventions such as administering analgesic (pain relief) medicine as ordered and reviewing when the medication regimen was not followed as ordered. Review of R5's significant change MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of 14 out of 15, indicating the resident was cognitively intact. Further review revealed the facility noted R5 received scheduled and as needed pain medications. Review of R5's Medication Administration Record (MAR), dated 01/2025, revealed the physician ordered 300 mg of gabapentin (a medication for nerve pain) to be administered three times per day for leg pain. Further review revealed the facility failed to administer 14 doses of gabapentin from [DATE] to [DATE], and R5 did not receive any additional pain medication during this time. Review of R5's Progress Notes, dated [DATE] at 1:54 PM, revealed Registered Nurse (RN) 5 documented sending a request for a refill for R5's gabapentin because it was running low. Per review, RN5 called the physician and the pharmacy, and the pharmacy told her the prescription was not sent in. She did not remember specifically if she followed-up after the calls because this had happened so many times. Review of R5's Progress Note dated [DATE] at 7:32 AM, revealed RN5 documented R5 was out of gabapentin, even though the prescription was requested on [DATE]. In an interview on [DATE] at 3:48 PM, R5 stated she recalled the facility running out of her gabapentin in 01/2025. She stated staff told her the pharmacy had not refilled her medicine, and it took days to get it fixed. R5 stated she was in pain, and she felt a shooting sensation down her leg. Per the interview, R5 did not want to complain to the nurses because she knew they were trying, but her pain was increased while she was not receiving her gabapentin. Additionally, R5 stated no staff member had suggested heat, ice, or different positions to relieve her pain. In an interview on [DATE] at 6:37 PM, RN5 stated she recalled R5 running out of gabapentin on more than one occasion, including in 01/2025. She further stated she had notified the pharmacy a week prior, when she noticed the resident's medication supply was low. Per the interview, R5's dose of gabapentin was not available in the emergency medication system. RN5 stated she did not recall R5 complaining of additional pain during that time, but the resident had received other pain medications, which helped prevent the resident's pain from getting out of control. Additionally, she stated it was important to manage the resident's pain because no one wanted to be in pain. During a post-survey interview with the contracted pharmacy, on [DATE] at 2:55 PM, the pharmacist stated gabapentin was available in the emeregency medication system. In an interview on [DATE] at 10:25 AM, the DON stated the facility's process for obtaining medication refills included faxing a refill reminder sticker to the pharmacy, submitting a request on the electronic health record, and having cycle fills of routine medications that were refilled automatically. She stated the facility had issues with getting routine medications and narcotics from the pharmacy in a timely manner. Per interview, the pharmacy the facility was currently using was new to them and they had problems with miscommunication with them. Additionally, the DON stated the facility did not have a 24-hour pharmacy in town to use as a back-up if the main pharmacy failed to deliver a medication. In an interview on [DATE] at 3:46 PM, the Executive Director (ED) stated he expected the facility to have medications available for residents as much as possible. He further stated if something happened that resulted in the medication not being available, he expected staff to call the physician and the pharmacy and get either a rush delivery or a code to obtain the medication out of the emergency medication system. He stated staff should also let the DON and himself know about the situation. The ED stated he expected residents to receive their pain medication as ordered so that their pain did not rise to uncontrollable and intolerable levels. Per the interview, the ED was not aware of R5 missing 14 doses of gabapentin in late 01/2025 and could not explain how the process failed.

Based on interview, record review, and review of the facility's policy, the facility failed to provide pre-and post-dialysis communication documentation for 1 of 6 dialysis residents, Resident (R) 42. The findings include: Review of the facility's policy titled, Area of Focus: Dialysis, revision date 11/19/2024, revealed instructions for day of dialysis included to check medications especially blood pressure and cardiac medications and to initiate the Pre/Post Dialysis Communication Form to be sent to the dialysis clinic with the resident, ensure transportation was scheduled, and send snack/lunch with the resident. Further review revealed the treatment, upon the resident's return to the facility, included to obtain vital signs and monitor vascular access site. Per the policy, staff was to complete the Pre/Post Dialysis Communication Form, transcribe any orders sent from the dialysis clinic, and maintain the dialysis transfer form in the resident's medical chart. Review of R42's Face Sheet revealed the facility admitted the resident on 02/27/2025 with diagnoses to include diabetes, chronic kidney disease stage five (5), and dependence on renal dialysis. Review of R42's quarterly Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 04/02/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact. Review of R42's Physician's Orders dated 11/07/2024, revealed an active order for the resident to receive dialysis every Monday, Wednesday, and Friday related to chronic renal failure. Review of R42's Care Plan, initiated on 11/11/2024, revealed a focus included hemodialysis related to renal failure. Goals included the resident would have no signs and symptoms of complications from dialysis. However, interventions did not include initiation, completion, and documentation of the Pre/Post Dialysis Communication Form. Review of the facility's blank document Pre/Post Dialysis Communication Form revealed sections titled Pre-Dialysis and Post-Dialysis, including if a meal was given to the resident to take to the dialysis center, were to be completed by the Skilled Nursing Facility (SNF). Further review included a section for the dialysis center to complete prior to the resident's return to the facility. Review of R42's hemodialysis treatment records received from the dialysis center revealed R42 received eight hemodialysis in-center treatments from 05/02/2025 through 05/19/2025. Review of R42's hard copy medical chart revealed the Pre/Post Dialysis Communication Form was not located for the 05/02/2025 through 05/19/2025 dialysis treatments. Review of R42's electronic medical record (EMR) revealed no Pre/Post Dialysis Communication Form was located or assessments charted as performed for the 05/02/2025 through 05/19/2025 dialysis treatments. During interview with R42 on 05/19/2025 at 5:50 PM, he stated he had just returned from dialysis and was doing well. When asked if he took any papers with him to the center earlier today or brought any back, he stated he really could not remember. During interview with Registered Nurse (RN) 8 on 05/22/2025 at 10:35 AM, she stated dialysis residents were supposed to be assessed pre- and post-dialysis treatment, findings placed on the communication form, the form given to the resident to take to the dialysis center, and the form completed by the dialysis center and returned to the facility with the resident. However, she stated there were times this process was not followed. When asked if the information was charted elsewhere, RN8 stated staff was supposed to chart the pre- and post-dialysis assessments in the progress notes. She stated the form, when and if returned from the dialysis center, was placed on a clip board at the nurse's station, but the dialysis center seldom sent it back to the facility. When RN8 was asked what process was followed if the form was not returned, she stated staff called the dialysis center and requested the form be faxed. She stated completion of the form was important to know the pre- and post-baseline of the resident to detect any change in condition. Review of the clip board documents during interview revealed no dialysis forms. During continued interview with RN8, she stated medical records staff picked up the forms that were placed on the clip board. During interview with Medical Records (MR) staff on 05/22/2025 at 10:55 AM, she stated she did pick up the dialysis forms and scanned them into the EMR, but they were not always on the clip board. During interview with Licensed Practical Nurse (LPN) 2 on 05/22/2025 at 1:47 PM, she stated she thought vital signs and a weight were to be taken on a resident prior to them going to dialysis, and a weight was supposed to be obtained upon return, but she did not send that many residents to dialysis. When asked why it would be important for pre- and post-dialysis assessments to be completed and charted, she stated to know the baseline so the resident could get the best care. During interview with the Director of Nursing (DON) on 05/22/2025 at 3:25 PM, she stated the dialysis forms should be completed and returned to the facility so staff could monitor the resident pre- and post-dialysis for any changes. During interview with the Executive Director on 05/23/2025 at 4:46 PM, he stated staff completing the Pre/Post Dialysis Communication Form was important because it determined the status of the resident pre- and post-dialysis to assure the safety of the resident.

1. Review of R50's admission Record revealed the facility admitted R50 on 07/08/2024 with diagnoses including [NAME]-[NAME] syndrome (a rare, autoimmune disorder in which the immune system attacked the neuromuscular junctions), type 2 diabetes, and carcinoma-in-situ of the lung. Review of R50's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating her cognitive status was intact. Review of R50's Physician Orders, initiated on 12/13/2022, revealed an order for Pyridostigmine Bromide ER(used to improve muscle strength in patients with certain muscle diseases), 180 milligrams (mg) daily by mouth. Further review revealed it was ordered to manage the effects of [NAME]-[NAME] syndrome. Review of R50's Medication Administration Record [MAR] for April 2025 revealed she missed the dose of Pyridostigmine Bromide ER on [DATE]. Review of R50's Administration Note, dated 04/03/2025, revealed pharmacy cancelled the order for Pyridostigmine Bromide ER the previous night after Licensed Practical Nurse (LPN)1 had reordered it. Further review of the note revealed LPN1 had requested the medication be sent that day. Review of R50's MAR for May 2025 revealed she missed the doses of Pyridostigmine Bromide ER on [DATE] and 05/19/2025. Review of R50's Administration Note, dated 05/18/2025, revealed the medication was out of stock in the cart and had been reordered from pharmacy. Review of R50's Administration Note, dated 05/19/2025, revealed the medication was on order. Review of the facility's Pharmacy Calls/Notifications log revealed a call on 04/02/2025 at 9:36 AM regarding R50's missing Pyridostigmine Bromide, and the result was that the medication required Prior Authorization (PA) from the insurance company. Further review revealed a call on 05/19/2025 at 10:00 AM, with indicated response that the missing medication would be sent that evening. Continued review revealed a call on 05/20/2025 at 9:15 AM regarding the Pyridostigmine Bromide, with indicated response that it would be sent on the first run that date. Observation on 05/20/2025 at 1:58 PM, revealed R50 in bed and looking weak with a flat affect. During interview with R50 on 05/20/2025 at 1:58 PM, she stated she was very concerned about a needed medication she had not received for three days. She stated she understood the problem, and it had something to do with insurance and that it had happened before. She stated the medication was for an autoimmune condition that left her weak and unable to stand without it. Observation on 05/23/2025 at 11:46 AM revealed R50 with a much brighter affect and feeling better after the Pyridostigmine Bromide ER had been restarted. During interview with R50 on 05/23/2025 at 11:46 AM, she stated she felt much better today. She stated the medicine was for [NAME] syndrome, and it affected her muscles and made her not be able to stand up. She stated with the medicine her muscles worked better, and without the medicine, she was so weak she could not get up and get around. She stated she typically could get up and move with a walker but could not if she was without her medicine. She stated she had a harder time talking when she was without the medicine. She stated she felt much better today. During interview with LPN1 on 05/21/2025 at 5:22 PM, she stated the problem was the medication required a Prior Authorization (PA). She stated the facility received nine of 30 ordered pills the previous afternoon, 05/20/2025. She stated when she returned from vacation on 05/19/2025, R50 was out of the medication, so she called the pharmacy and requested a stat (immediate) delivery, but they did not send it. She also stated a PA was supposed to go to the doctor's office for them to send to the pharmacy for refilling the medication. She stated when she spoke to the pharmacy, they would tell her they needed a PA and sent the request to the physician and to the facility. In the meantime, she stated, staff had requested from the Administrator or Director of Nursing (DON) to pay for the short-term refill pending the authorization being approved. LPN1 stated they normally ordered refills directly through the electronic heath record (EHR). But for this medication, she stated the pharmacy notified the provider but would call the facility if the PA was not received. She stated sometimes pharmacy sent that to the facility as well, and those would be taken to the DON. During interview with LPN6 on 05/22/2025 at 8:24 AM, she stated if a medication was not stocked in the cart, she ordered it right then through point-click-care (PCC), a software the facility used. However, she stated when she ordered at night, then it still might not be in when she returned to work, and she had to call again. She stated the facility had a telephone log for pharmacy calls so anybody who followed the nurse who ordered a given medication could see it on the computer, and it should have been on the log. During interview with LPN2 on 05/22/2025 at 1:21 PM, she stated when R50's Pyridostigmine Bromide ER was received, the manifest indicated the pharmacy sent nine pills, and owed 21. She stated she ordered medicines directly through PCC, and also took the sticker off the medication box and added that to a list of stickers on a paper form, and then faxed it to the pharmacy. She stated she usually ordered refills three to four days out from being out of the medication. LPN2 stated, if knowing from the past that a medication was difficult to get, she would order earlier. She stated if a medication required a PA, she might not be aware of that as those were managed on day shift, but if alerted for such, the day nurse called the doctor for that. She stated when putting in orders, the only alert from the screen were possible interactions. She stated there was not an alert if the medication required a PA, and that information would come from a pharmacist. LPN2 also stated she knew at least two other nurses who used the added step of faxing the stickers. During additional interview with LPN1 on 05/22/2025 at 5:26 PM, she stated the facility had received the remainder of ordered pills for R50. She stated PAs were previously not a problem, and a PA was in effect for a year. However, she stated after 01/01/2025, that had changed, and now a PA was required every month. She stated the pharmacy had reported they had sent the PA to the physician, but the facility had not received a response. She also stated she started having more problems with this in April 2025, and the facility had paid for the medicine since then. During interview with the Staff Development Coordinator (SDC) on 05/22/2025 at 2:39 PM, she stated the facility provided education on medication management if there was a complaint. For example, she stated if there was a complaint that came up at the morning staff meeting, the DON asked for education for that issue, then she would develop a review with the policy for the staff. She stated staff nurses kept up with medication management. She stated she did not do specific education on reordering, that came with assistance from their preceptor. During interview with the contracted Pharmacist on 05/22/2025 at 10:08 AM, he stated Pyridostigmine Bromide orders required a PA. He also stated there was an attempt to refill on 05/18/2025, and the non-covered authorization form was completed. He stated this form was necessary because insurance would not pay, so either the facility could pay or work to get an alternate medication. He stated the medication was not covered, but he did not know why and could not say if this was a permanent issue. He stated all he could say was a PA was required as evidenced by a PA documented as requested on 05/13/2025. He stated the methods to pursue included using an interface from another pharmacy for review of issues. He stated he had been working on the communication process. He stated the pharmacy's Clinical Intervention Center generated the PA, which then went to the physician or facility per the facility's preference. He stated for this facility, he could not say the process but agreed to reach out to the Clinical Intervention Center and request they call. During additional interview with the Pharmacist on 05/23/2025 at 9:01 AM, he stated for this facility, PA notifications went to an interface from another pharmacy, and also generated a fax to the facility. He further stated the PA could go to the provider if a facility chose. For this facility, he stated, a PA went to a fax number in the facility but was changed to a different fax number last week per request of the DON. The Pharmacist stated R50's medication was ordered on 05/13/2025, kicked to the Clinical Intervention Center due to the PA and nonpayment without it. In turn, he stated it generated a notice of the needed PA to OCC, which the facility could have access to, and generated a fax to the selected number. He stated the facility could see OCC with their own login, so a nurse or manager would have to do that manually on that website. He stated the website could have alerts sent via email, but the alerts could not be seen in PCC. During interview with the DON on 05/23/2025 at 10:19 AM, she stated when she talked to the pharmacist last week, she learned when a medication required a PA, if the pharmacy would notify the facility, the facility would pay for a short supply pending the PA approval. She stated the current strategy was for the pharmacy to notify the facility of a PA by fax. In the past, she stated the pharmacy had a staff member who included PA notices on paper on the midnight delivery, so the facility would have it in hand the following morning. She stated the paper PA notices stopped maybe six months ago, but she was not sure of the exact timeframe. She stated she had an in-person meeting with the Pharmacist, when they went over the interface from another pharmacy together, but the links did not take them to relevant information or the system crashed. Since then, she stated the pharmacy had been sending the notices by fax. She also stated the facility had only a few residents who were taking medications which required a PA, such as something insurance would not cover, so the facility paid for those. She further stated the pharmacy sent the PA, and the DON completed the form. She stated, then Medical Records staff took the PA to the provider or they obtained the signature when the provider was in the building. Then, she stated the facility sent the PA back to the pharmacy. During additional interview with the DON on 05/23/2025 at 2:44 PM, she stated she called the pharmacy when she was no longer receiving PA notices on paper. She stated the pharmacy told her those staff members were no longer there, and they did not offer an explanation or how they were to transmit those. After that, she stated a notice would show up on a random basis, and she assumed there was nobody on a medication that required a PA. She stated she and another nurse manager were the only ones who had access to the interface from another pharmacy, but the floor nurses did not and would not have received the notices. During interview with the Executive Director on 05/23/2025 at 3:11 PM, he stated if there were problems with getting residents' medications, he expected staff to alert the provider and work with pharmacy. He stated, if the issue was still not resolved, he expected staff to contact him or the DON, and they could contact the Regional Pharmacist directly. He stated he expected if those actions did not resolve the problem, then the facility could source the medication from a retail pharmacy.2. Review of R5's admission Record revealed the facility admitted the resident on 01/25/2023 with diagnoses at time of survey including acquired absence of left great toe, chronic kidney disease, and type two diabetes with polyneuropathy (disorder of the peripheral nerves). Review of R5's significant change MDS, with an ARD of 04/16/2025, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, indicating the resident was cognitively intact. Further review revealed the facility noted R5 received scheduled and as needed pain medications. Review of R5's MAR, dated 01/2025, revealed the physician ordered 300 mg of gabapentin (a medication for nerve pain) to be administered three times per day for leg pain. Further review revealed the facility failed to administer 14 doses of gabapentin from 01/12/2025 to 01/30/2025. Review of R5's Progress Note, dated 01/10/2025, revealed Registered Nurse (RN) 5 documented sending a request for a refill for R5's gabapentin because it was running low. Per review, RN5 called the physician and the pharmacy, and the pharmacy told her the prescription was not sent in. Review of R5's Progress Note, dated 01/17/2025, revealed RN5 documented R5 was out of gabapentin, even though the prescription was requested on 01/10/2025. In an interview on 05/23/2025 at 3:48 PM, R5 stated she recalled the facility running out of her gabapentin in 01/2025. She stated staff told her the pharmacy had not refilled her medicine, and it took days to get it fixed. R5 stated she was in pain and felt a shooting sensation down her leg. Per interview, R5 did not want to complain to the nurses because she knew they were trying, but her pain was increased while she was not receiving her gabapentin. In an interview on 05/23/2025 at 6:37 PM, RN5 stated she recalled R5 running out of gabapentin on more than one occasion, including in 01/2025. She further stated she had notified the pharmacy a week prior, when she noticed the medication supply was low. Per interview, R5's dose of gabapentin was not available in the facility's emergency medication system. In continued interview, RN5 stated on multiple occasions, she had notified the physician of the need for a refill prescription and would call the pharmacy to follow up on a refill. She stated the pharmacy would tell her they did not have it, even though the physician told her they sent it in. Additionally, RN5 stated a delivery requested as STAT (as quickly as possible; high priority) would often not arrive for 10 hours from the pharmacy. During a post survey interview with the contracted pharmacy, on 06/10/2025 at 2:55 PM, the pharmisist stated that gabapentin was available in the emergency medication system at the facility. In an interview on 05/22/2025 at 10:25 AM, the Director of Nursing (DON) stated the facility's process for obtaining medication refills included faxing a refill reminder sticker to the pharmacy, submitting a request on the electronic health record, and having cycle fills of routine medications that were refilled automatically. She further stated staff could request a rush delivery from the pharmacy or pull the medication from the emergency medication system with an access code from pharmacy. In continued interview, the DON stated the facility had issues with getting routine medications and narcotics from the pharmacy in a timely manner. Per interview, the pharmacy the facility was currently using was new to them, and they had problems with miscommunication with them. Additionally, the DON stated the facility did not have a 24-hour pharmacy in town to use as a back-up if the main pharmacy failed to deliver a medication. In an interview on 05/23/2025 at 3:46 PM, the Executive Director stated he expected the facility to have medications available for residents as much as possible. He further stated if something happened that resulted in the medication not being available, he expected staff to call the physician and the pharmacy and get either a rush delivery or a code to obtain the medication out of the emergency medication system. In continued interview, he stated the facility noted the communication barriers with pharmacy on 05/12/2025 around admission and readmission, as well as not receiving refills. Per interview, he stated he was not aware of R5 missing 14 doses of gabapentin in late 01/2025. Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement. The facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 5 residents investigated for pharmacy services, Resident (R) 5 and R50. The findings include: Review of the facility's policy, Reordering, Changing, and Discontinuing Medication Orders, revision date 7/01/2024, revealed facilities are encouraged to reorder medications electronically or by fax whenever possible staff may use electronic orders. Facility staff [the pharmacy's software program, secure web portal for pharmacy management, communication, and reporting] log in [the pharmacy's software program] to access medication, order status, payment and more. [The pharmacy's software program] should be restricted by assigned user identification and password and should be controlled by the Director of Nursing or designee. Further review revealed facilities were encouraged to reorder medications electronically or by fax whenever possible, and the reorders would be written and submitted on the pharmacy's Refill Order Form and would be faxed to the pharmacy, if permitted by applicable law. Continued review revealed authorized facility staff would use the software to electronically reorder resident medications, and staff should review the transmitted reorders for status and potential issues and pharmacy response. Review of the facility's policy titled, Nursing Documentation, reviewed 09/05/2024, revealed the facility implemented interventions to prevent or manage each individual resident's pain, beginning at admission. Review of the facility's policy titled, Administration of Medications, reviewed 09/16/2024, revealed the facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals stored in the facility were not expired; were labeled and stored in accordance with currently accepted professional principles; and, included the appropriate accessory and cautionary instructions and the expiration date, when applicable, for three (3) of six (6) observed medication carts. The findings include: Review of the facility's policy titled, LTC Facility's Pharmacy Services and Procedure Manual, dated October 2016, revealed that once any medication or biological package was opened, the facility would follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Further review revealed facility staff would record the date opened on the medication container when the medication had a shortened expiration date once opened. Furthermore, the facility should ensure that medications and biologicals were stored at their appropriate temperatures according to the United States Pharmacopoeia guidelines. Continued review revealed the facility should ensure that medications and biologicals that have an expired date on the label and/or had been retained longer than the manufacturer or supplier guidelines were stored separate from other medications until destroyed or returned to the pharmacy or supplier. Furthermore, the policy stated the facility should: (1) store all medications and biologicals requiring special containers for stability in accordance with manufacturer/supplier specifications; and (2) destroy or return all discontinued and outdated/expired medications or biologicals in accordance with the Pharmacy return/destruction guidelines; and (3) ensure that all medications and biologicals for expired, discharged , or hospitalized residents were stored separately, away from use, until destroyed or returned to the Pharmacy. 1. Observation of the North Wing Medication Cart #2, on 03/19/2021 at 9:40 AM, revealed: one (1) opened bottle of eye drops with no opened date on the label, not in its original packaging, and without resident identification; one (1) opened bottle of [MEDICATION(S)] (corticosteroid for nasal inhalation) with no opened date on packaging or container and no accessory and cautionary instructions; one (1) bottle of Lantanoprost (eye drops used to treat Glaucoma) 0.005% improperly stored in the medication cart and not in the refrigerator as required; and one (1) bottle of ProSource, a nutritional supplement, (manufacturer's expiration date (MED) of 2/2022) with an opened date of 12/03/2020. Facility guidelines stated to discard the bottle three (3) months after opening. Further observation revealed one (1) bottle of [MEDICATION(S)] (vasodilator used to treat angina) with an expiration date of 09/2020; and one (1) Breo Inhaler (used to treat some lung diseases), removed from its foil pouch with no opened date on the container or package and with no accessory and cautionary instructions. Facility guidelines stated to discard six (6) weeks after opening or at 0, whichever came first. Interview with Licensed Practical Nurse (LPN) #3, on 03/19/2021 at 9:50 AM, revealed she had worked at the facility for ten (10) years and had been assigned to the North Wing. LPN #3 stated the bottle of [MEDICATION(S)], with an expired date of 09/2020, should have been returned to the Pharmacy. LPN #3 further stated nursing staff was responsible for ensuring medications were labeled according to the facility's process, which was to record the date opened on the medication package when the medication had been opened. Furthermore, LPN #3 stated if an item was found to be expired, labeled, and or stored improperly, nursing staff was responsible to discard the medication according to policy. Continued interview with LPN #3 revealed all medication and food supplements should be stored according to the manufacture's guidelines. In addition, she stated refrigerated items needed to be retrieved from the refrigerator, prior to administration, and then placed back in the refrigerator for proper storage. 2. Observation of the South Wing Medication Cart #1, on 03/19/2021 at 9:15 AM, revealed one (1) box of [MEDICATION(S)] [MEDICATION(S)] (used to treat [CONDITION(S)] (COPD) per nebulizer) ampules stored in an opened foil pouch and in the bottom of the package with no opened date on the foil pouch, and one (1) box of [MEDICATION(S)] [MEDICATION(S)] ampules stored in an opened foil pouch with an opened date of 01/17/2021. Guideline instructions stated to discard ampules fourteen (14) days after opening the foil pouch, and unused ampules must be stored in the closed foil pouch to protect from light. Additional observation revealed one (1) large clear bag holding individual [MEDICATION(S)] (bronchodilator used to treat some lung diseases) packages stored in the medication cart, but package instructions stated to store in a refrigerator. Further observation revealed one (1) opened bottle of ProSource (MED of 2/2022) with no opened date on the bottle; and the resident that used it was discharged from the facility on 12/08/2020. Additional observation revealed two (2) bottles of liquid allergy medication (MED of 2/2022) opened with no opened date; one (1) unopened bottle of liquid allergy medication with the manufactured and expiration dates torn off the bottom of the packaging; and four (4) vials of [MEDICATION(S)] (an antipsychotic) five (5) milligrams (mg)/vial located in the top drawer of the medication. This medication was discontinued on 02/04/2021. Observation of the South Wing Medication Cart #2, on 03/19/2021 at 10:55 AM, revealed one (1) Breo inhaler not in the foil pouch and with no opened date on the container. Additional observation revealed two (2) unopened boxes of [MEDICATION(S)] (a bronchodilator used to treat COPD) Inhalation Solution, with no dates on either boxes. Medication Guidelines for [MEDICATION(S)] Inhalation Solution stated to refrigerate or store pouches at room temperature for no longer than six (6) weeks. Further observation revealed two (2) unopened [MEDICATION(S)] pens. The instructions stated to refrigerate the pens until opened. Additional observation revealed [MEDICATION(S)] (a corticosteroid used to treat asthma) 0.25 mg/2 milliliter ampules (MED of 10/2021) in an opened, not closed, foil pouch with an opened date of 03/01/2021. Their instructions stated to discard ampules two (2) weeks after opening foil pouch, and any unused ampules should be stored in a closed foil pouch to protect from light. Further observation revealed one (1) unopened [MEDICATION(S)] insulin pen with instructions to refrigerate until opened. Interview with LPN #2, on 03/19/2021 at 12:05 PM, revealed she had worked at the facility for two (2) years, and had been assigned to the South Wing. LPN #2 stated the [MEDICATION(S)], stored in the medication cart, should have been refrigerated. She stated the four (4) vials of [MEDICATION(S)] 5 mg/vial, located in the top drawer of Medication Cart #1 and discontinued on 02/04/2021, should have been returned to the Pharmacy. Further, she stated the two (2) unopened [MEDICATION(S)] pens and the one (1) unopened [MEDICATION(S)] insulin pen should have been refrigerated until opened and kept in the original packaging. In addition, LPN #2 stated insulin pens should be stored in a sanitary manner, inside the original plastic bag packaging to prevent cross-contamination. Per interview, LPN #2 stated the one (1) bottle of ProSource (MED of 2/2022) for the resident that was discharged on [DATE], should have been discarded at the time of discharge. Continued interview with LPN #2, on 03/19/2021 at 12:05 PM, revealed nursing staff was responsible for ensuring medications were labeled according to facility policy, which was to record the date opened on the medication package. In addition, she stated if an expired or improperly stored or labeled item was discovered, nursing staff was responsible to discard the medication according to policy. Furthermore, LPN #2 stated that all medication and food supplements should be stored according to the manufacturer's guidelines. Per interview, refrigerated items needed to be retrieved from the refrigerator prior to administration and then placed back in the refrigerator for proper storage. LPN #2 further stated following medication guidelines and facility policy was important to ensure the safety of all residents. Interview with the Director of Nursing (DON), on 03/19/2021 at 1:10 PM, revealed she had been employed at the facility for four (4) years. The DON stated, when medications arrived in the facility from the Pharmacy, they were delivered to the appropriate wing where nursing staff was expected to verify receipt of each medication by using a check-off sheet. She stated nurses were responsible for stocking the medication carts and the appropriate storage of medications. Per interview, all medications were to be left in their original packaging and dated when open. Additionally, she stated solutions were to have an opened date and an expiration date; and insulin pens were to be stored inside the individual original plastic bag packaging to prevent cross-contamination. The DON stated if an item was found to be labeled or stored improperly or expired, she expected nursing staff to discard the medication. She further stated nursing staff was expected to follow facility medication storage and labeling guidelines. According to the DON, each medication cart was equipped with several Medication Guidelines, located at the back of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further interview revealed nursing staff was responsible for ensuring medications were labeled according to facility policy, which was to record the date opened on the medication container. Additional interview with the DON, on 3/19/2021 at 2:40 PM, revealed routine audits of medication carts were conducted by the DON, the LPN trainer, and the RN Weekend Supervisor. The DON stated there was no documentation for these audits. Further interview with the DON revealed it was her expectation that all medication and food supplements were stored according to the manufacturer's guidelines. The DON stated following the facility's policies and manufacturer's guidelines was important to ensure the safety of all residents. Interview with the Administrator, on 03/19/2021 at 2:50 PM, revealed it was his expectation for medications to be stored and labeled appropriately per the directives from manufacturer's guidelines and the facility's policies. He further stated the residents' safety relied on staff following these important guidelines and policies.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to prepare, store, and serve food under sanitary conditions. Observations, on 03/16/2021 and 03/17/2021, revealed food not labeled and dated, cleaning cloths not in sanitizer buckets, and an incomplete dish machine temperature log. The findings include: Review of the facility's policy titled, Food Safety, dated 11/28/2017, revealed food was stored and maintained in a clean, safe, and sanitary manner following federal, state, and local guidelines to minimize contamination and bacterial growth. Per policy, food was labeled and dated with the received date, and leftovers were dated properly and discarded within seventy-two (72) hours unless otherwise indicated. Per policy, opened dry storage foods were removed from the original packaging before being placed in an ingredient bin or storage container. Per policy, opened packages of food were resealed tightly to prevent contamination of the food item, and the use by date would be used. Review of the facility's policy titled, Safe Use of Chemicals, dated 01/11/2019, revealed sanitizer buckets were used for dishtowels. Review of the facility's form Dish Machine Temperature Log, March revealed the documentation for temperature and sanitizer were not recorded from 03/13/2021 to 03/15/2021. Review of the facility's menu titled Dinner, Monday, March 15, 2021, a daily dinner menu, for 03/15/2021, which was updated each day with the new date and new menu offerings, revealed the chocolate cream pie was on the menu for 03/15/2021. Observation of the kitchen, during the initial tour, on 03/16/2021 at 11:23 AM, revealed a soiled dish machine temperature log not completed, from 03/13/2021 through 03/15/2021. Documentation of temperatures was incomplete for each meal listed under the wash and rinse cycles, including recording the strength of the sanitizer. In addition, observation of two (2) wrapped chocolate cream pies in the refrigerator near the tray line revealed neither was labeled or dated. Additional observations of the kitchen, on 03/17/2021 at 9:30 AM, revealed cleaning cloths lying on the counters throughout the production area not kept in the sanitizer bucket and soiled linens in the bucket in the mop closet area. Further observations revealed three (3) ingredient bins with dried powder on the tops not labeled or dated. Of the three (3), two (2) were round and opaque with lids, and one (1) was clear, square, and had a blue lid with the appearance of a white powder like substance on it. Further observation revealed one (1) wrapped chocolate cream pie remained in the refrigerator near the tray line not labeled or dated. Interview with the Diet Aide/Cook #1, on 03/19/2021 at 1:01 PM, revealed the dish washer temperatures should be recorded on the temperature log because the dish machine might not reach proper temperatures to sanitize the dishware. Per interview, cleaning cloths should be placed in the sanitizer bucket when not in use. In addition, Cook #1 stated all food should be labeled and dated with opened and end dates. Then, per interview, foods at the end date and/or foods not labeled or dated were thrown out. Cook #1 stated dry ingredient bins should be labeled and dated for identification of ingredients and with the date of expiration. Interview with Cook #2, on 03/19/2021 at 1:09 PM, revealed cleaning cloths were kept in the sanitizer bucket to prevent cross-contamination of kitchen areas. Cook #2 stated foods that were labeled and dated were kept on a tray in the refrigerator by the serving line. Per interview, the pie on the shelf of the refrigerator that was not labeled or dated should have been discarded, and the dry ingredient bins should have been labeled and dated for three (3) months. Interview with Dietary Aide #2, on 03/19/2021 at 1:17 PM, revealed it was important to record dish washer temperatures to ensure proper sanitizing of dishware. Per interview, cleaning cloths were kept in the sanitizer bucket to sanitize the cloth not in use. The Aide stated desserts used the night before needed to be labeled and dated with the day opened and the day of expiration, which was within three (3) days. In addition, Dietary Aide #2 stated the dry ingredient containers should be labeled and dated to prevent a mix-up of the ingredients used in residents' foods. Interview with the Dietary Manager, on 03/19/2021 at 1:23 PM, revealed the dish washer temperatures were not recorded and should have been because it was important to document the dish machine temperatures to know that dishware had been sanitized. Per interview, it was important to place the cleaning cloths in the sanitizer bucket in order to not spread germs and bacteria around the kitchen and prevent cross-contamination. The Manager stated foods not labeled or dated were thrown out because they could cause bacterial spread to other foods causing cross-contamination. In addition, the Manager stated any desserts placed in the refrigerator on a tray should be labeled or dated; therefore, the pies that were not labeled or dated should have been thrown out. Interview with the Administrator, on 03/19/2021 at 2:50 PM, revealed he expected dietary staff to complete the temperature dish washer log, put cleaning cloths in the sanitizer bucket, and label and date all food.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) state guidelines for COVID-19. Observations, on 03/17/2021 at 9:45 AM, revealed State Registered Nurse Aide (SRNA) #1, on the North Wing Unit, failed to properly change Personal Protective Equipment (PPE), dispose of PPE, and perform hand hygiene. Additional observations, on 03/17/2021 at 2:40 PM, revealed SRNA #2, on the South Wing Unit, failed to change PPE and properly perform hand hygiene after providing care for a resident. The findings include: Review of the facility's policy titled, Standard and Transmission Based Precautions, Chapter Four, revealed the purpose of the policy was to ensure the facility took appropriate precautions to decrease the risk of transmission of infection. Further review of Subheading Universal Source Control Measures (Use of Face Masks and Face Coverings); undated, revealed staff was instructed that if they touched or adjusted their facemask, they should perform hand hygiene immediately. In addition, the policy stated staff would receive job-specific training on PPE and must demonstrate competency with selection and proper use of putting on and removing PPE without self-contamination. Review of the Subheading Hand Hygiene, dated 05/07/2020 and revised 12/04/2020, revealed the facility educated staff on hand hygiene, and the education included using alcohol based hand rub (ABHR) before and after all resident contact; before putting on and after removing gloves; prior to removing face mask/shields; after touching face mask/shields; and before putting on and after removing PPE. Review of the Subheading Coronavirus (COVID-19) (SARS-CoV-2), revised 02/11/2021, revealed the facility would follow the core principles of COVID-19 Infection Prevention as defined by CMS and the CDC. Review of the CDC Infection Control Guidelines, updated 08/19/2020, revealed removal of PPE, specifically the gown, was to be performed prior to exiting the resident's room, followed by hand hygiene. 1. Observation of SRNA #1, on 03/17/2021 at 9:40 AM, on the North Wing 200 Hall, revealed she exited a resident's room without doffing (removing) and disposing of her gown or using ABHR. Per observation, SRNA #1 went down the hallway, where she doffed her gown, rolled the gown up, and placed it on the hallway floor. Then, SRNA #1 obtained a new gown from the PPE container located on the floor, outside the residents' rooms. Per observation, without using ABHR, SRNA #1 donned (put on) a new gown, picked up the contaminated gown, and disposed of it in another resident's trash receptacle. SRNA #1 continually touched her facemask with an ungloved hand without using ABHR. These actions by SRNA #1 were all in violation of the facility's policy. SRNA #1 was about to enter another resident's room in the contaminated PPE and without sanitizing her hands properly, when the State Survey Agency Surveyor intervened. Interview with SRNA #1, on 03/17/2021 at 9:45 AM, revealed she had been employed at the facility for one (1) month. She stated she had received education and training upon hire, and continued to receive Infection Control and Prevention (ICP) education and training on how to doff and don PPE properly. SRNA #1 stated the correct procedure was to doff PPE while still inside the resident's room, put it in a red biohazard lined trash receptacle, and then use ABHR prior to leaving the room. Further interview revealed the purpose of proper hand hygiene and proper doffing of PPE was to decrease the risk of transmission of infection. 2. Observation of SRNA #2, on 03/17/2021 at 2:40 PM, on the South Wing 300 Hall, revealed she entered Resident #66's room. Per observation, SRNA #2 touched surfaces and leaned up against the bed. SRNA #2 then came out of Resident #66's room without doffing PPE or using ABHR before exiting the room and entering Resident #32's room. Interview with SRNA #2, on 03/17/2021 at 2:40 PM, revealed she had received education on ICP practices and training on how to doff and don PPE properly. According to SRNA #2, all residents were on Transmission Based Precautions (TBP) due to a Covid-19 outbreak within the facility. Continued interview revealed the facility's policy stated gloves and gowns must be changed prior to exiting a resident's room; and, ABHR must be used before and after resident care and before and after donning and doffing PPE. Additionally, SRNA #2 stated when no resident care was given, staff did not need to change gowns between residents. However, the facility's policy stated removal of PPE, specifically the gown, was to be performed prior to exiting the resident's room, followed by hand hygiene. SRNA #2 stated, I didn't use sanitizer when I came out of the room, but I should have. Further interview revealed the purpose of proper hand hygiene and doffing of PPE was to decrease the risk of transmission of infection. Interview with LPN #2, on 03/19/2021 at 12:05 PM, revealed she had worked at the facility for two (2) years and had been assigned to South Wing. Additionally, she had received ICP training on the use of PPE and hand hygiene. Continued interview revealed LPN #2 monitored staff to ensure they followed proper ICP practices. She stated if she observed a failure in technique, she would educate on the spot. LPN #2 stated correctly wearing and disposing of PPE and proper hand hygiene was important to prevent the spread of infection. Interview with the Infection Preventionist (IP), a Registered Nurse (RN), on 03/19/2021 at 1:20 PM, revealed the facility was on TBP due to positive Covid-19 testing in the facility. Therefore, she stated staff and visitors were required to wear PPE at all times, which included: (1) N-95 mask; (2) face shield; (3) gown; and (4) gloves, if providing direct care. The IP stated it was his expectation that staff followed the facility's policy and procedure regarding Infection Control and Prevention (ICP); and staff should change PPE before and after providing care to a resident. He stated he expected staff to use proper technique for donning and doffing PPE. Furthermore, staff was to follow facility policy and the education they had received regarding hand hygiene and PPE. Continued interview revealed all staff was provided with an individual bottle of ABHR, and all rooms were equipped with ABHR dispensers. However, some had not been refilled due to the lack of supply. The IP stated all staff had been trained in Infection Control policy and procedures, and he performed ongoing audits of staff for adherence to guidelines. Additionally, the IP stated if a failure in ICP was observed, he would provide immediate feedback and education. Further interview revealed the purpose of proper hand hygiene and doffing of PPE was to decrease the risk of transmission of infection; and he expected Infection Control guidelines to be maintained at all times to decrease the potential spread of infection. The IP stated the SRNA's did not follow correct procedures per the facility's policies and training by not doffing their gowns and performing hand hygiene before exiting the residents' rooms. Interview with the Director of Nursing (DON), on 03/19/2021 at 1:10 PM, revealed she had been employed at the facility for four (4) years. The DON stated staff was given training on infection control upon hire and routinely due to the Covid-19 outbreak within the facility, and the IP audited staff for ICP compliance. Further interview revealed the purpose of proper hand hygiene and doffing of PPE was to decrease the risk of transmission of infection. Continued interview revealed the DON monitored staff to ensure they followed proper ICP practices. She stated if she observed a failure in technique, she would educate the person immediately. The DON stated it was her expectation that all staff followed the facility's policies and procedures related to ICP, and the SRNA's should have done so. Interview with the Administrator, on 03/19/2021 at 2:50 PM, revealed he expected Infection Control guidelines to be maintained at all times to decrease the potential spread of infection.

Based on observation, interview, record review, review of Abbott Nutrition manufacturer's instructions, and review of the facility's policy, it was determined the facility failed to ensure residents received appropriate treatment and services to prevent complications of enteral feeding for a subset of one (1) of one (1) sampled residents with an enteral feeding, Resident #21. Total number of sampled residents was eighteen (18). The findings include: Review of the facility's policy titled, Enteral Nutritional Therapy (Tube Feeding), undated, revealed, when providing enteral nutritional therapy, (tube feeding), the licensed nurse was to make sure the enteral formula container was labeled with the patient's identifiers; formula name, strength, date and time of formula preparation; date and time the formula was hung; rate of administration; initials of the person who prepared, hung and checked the enteral formula against the order; and expiration date and time. Also, per policy, the enteral administration set would be labeled with the date and time it was first hung. In addition, the policy stated to change the closed system and the enteral administration set according to the manufacturer's instructions. Review of the Abbott Nutrition manufacturer's instructions, dated 02/04/2013, revealed, for [MEDICATION(S)] 1.2 Cal for use with Abbott Safety Screw Connector set (closed system), the product could hang for up to forty-eight (48) hours when clean technique and only one screw cap feeding set was used. Per the instructions, if these conditions were not met, the product could hang for no longer than twenty-four (24) hours. Review of Resident #21's medical record revealed the facility admitted the resident on 05/18/2015, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's Quarterly Minimum Data Set (MDS) Assessment, dated 01/06/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), which indicated severe cognitive impairment. Observation of Resident #21, on 03/17/2021 at 10:26 AM, revealed, beside his/her bed, a tube feeding closed system with a spiked bottle, which was not labeled with a name, room number, date, time, rate, and type of feeding. In addition, the intravenous (IV) fluid bag was not labeled. Interview with Licensed Practical Nurse (LPN) #3, on 03/17/2021 at 10:28 AM, revealed the tube feeding should be hung with name, date, time, formula, and rate. She further stated the tube feeding hung yesterday, for Resident #21, was labeled, and she had not seen that the current tube feeding was not labeled with the required information. LPN #3 stated the evening shift mostly changed the tube feeding, and evening shift staff did not complete the information on the label. Interview with LPN #1, on 03/18/2021 at 9:20 AM, revealed tube feedings needed to be labeled with the time, date, name, formula, rate and initials. LPN #1 also stated a tube feeding should be changed immediately if it was not labeled with the needed information. Interview with Registered Nurse (RN) #2, on 03/18/2021 at 9:30 AM, revealed she worked the evening shift and checked the tube feeding order with the tube feedings in supply. RN #2 stated tube feedings should be labeled with the date, initials, resident name, formula, and rate. She stated she had hung the tube feeding bottle for Resident #21 with the appropriate information on the label, the evening of 03/16/2021. However, the observation of this tube feeding bottle, on 03/17/2021 at 10:26 AM, revealed it was not labeled. Interview with Director of Nursing (DON), on 03/19/2021 at 2:45 PM, revealed it was important to label the tube feeding with the identifiers of name, date, rate, time, formula, and initials and to ensure the resident was receiving the tube feeding according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Administrator, on 03/19/2021 at 2:53 PM, revealed his expectation was for staff to label and date tube feedings according to the facility's policy.

Based on observation, interview, record review, review of the facility's investigation, and review of the facility's policies, it was determined the facility failed to ensure residents were protected from accidents and hazards for one (1) of six (6) sampled residents (Resident #1). On 07/09/2020 around 3:45 AM, State Registered Nurse Aide (SRNA) #1 notified Licensed Practical Nurse (LPN) #1 that Resident #1 was found in the Breezeway with a blue substance in his/her mouth. The resident did not seem, at first, to be in any acute distress, but then began to have dry heave and became agitated. The identified source of the substance was a bottle of toilet bowl cleaner that was left in the breezeway. Resident #1 was transported by ambulance to the local hospital Emergency Department (Hospital #1), and later, by ambulance, to another hospital (Hospital #2), located approximately fifty-nine (59) miles and one (1) hour away, to be seen for a [MEDICATION NAME] Surgical consultation. Resident #1 was admitted to Hospital #2 for eight (8) days and was diagnosed with [REDACTED]. The facility's failure to ensure residents did not have access to hazardous chemicals to prevent ingestion has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified, on 10/16/2020, and was determined to exist on 07/09/2020, at 42 CFR §483.25 Quality of Care (F689). Substandard Quality of Care was identified at 42 CFR §483.25 Quality of Care. The facility was notified of the Immediate Jeopardy on 10/13/2020. An acceptable Allegation of Compliance was received, on 10/16/2020, which alleged removal of the Immediate Jeopardy on 07/16/2020. The State Survey Agency verified the facility implemented corrective actions and was in compliance, on 07/16/2020, as alleged, prior to the State Survey Agency's investigation. Therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled, Event Management System, effective date 05/23/2019, stated all residents upon admission were provided an environment that was free from accident hazards over which the facility had control. Review of the facility's policy titled, Resident Rights, dated 06/08/2020, revealed each resident had the right to have a safe environment including, but not limited to, receiving treatment and supports for daily living safely. Review of Resident #1's medical record revealed the facility initially admitted the resident, on 02/25/2020, and readmitted him/her, on 04/23/2020, with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 06/01/2020, revealed the facility assessed the resident's cognition as severely impaired, with a Brief Interview for Mental Status (BIMS) score of ninety nine (99), which indicated the resident was not interviewable. Review of Resident #1's Comprehensive Care Plan (CCP), dated 06/11/2020, revealed Resident #1 was dependent on staff for meeting intellectual and physical needs in relation to cognitive deficits. In addition, the CCP revealed a focus of elopement risk, related to wandering. Interventions included fifteen (15) minute checks and providing a safe wandering environment. Interview and/or observation of Resident #1 was not possible, as the resident no longer resided at the facility. Review of the facility's investigation and Quality Assurance and Performance Improvement (QAPI) findings, for the incident that occurred on 07/09/2020, revealed Resident #1 was found to have consumed Crew Super Blue Mild Acid Bowl Cleaner (toilet bowl cleaner) which was left in the breezeway (a hallway which connected the North and South Units and had a locked door into the South Unit, so North Unit residents could go into the breezeway as a normal occurrence). Further review revealed Resident #1's room was in close proximity to the breezeway. According to the investigation, after staff identified the resident had consumed the toilet bowl cleaner, he/she was transported to the local hospital (Hospital #1). Resident #1 was later transferred to another hospital (Hospital #2) to be seen for a [MEDICATION NAME] (CT) Surgical consultation. Resident #1 was diagnosed with [REDACTED]. Review of Resident #1's medical records, from Hospital #1, revealed the resident was seen in the emergency room (ER), on 07/09/2020, with the first vital signs taken at 4:24 AM; vital signs were within normal range. The resident was PO challenged (giving water for the resident to drink orally) but was unable to take oral fluids without coughing and gagging. Continued review revealed transfer to another facility was needed for the resident to have a CT Surgical consultation. The ER record stated Resident #1's medical condition was serious at the time of transfer by ambulance to Hospital #2. Review of Resident #1's medical records, from Hospital #2, revealed the resident was admitted to the hospital, on 07/09/2020, after consumption of drain cleaner. Further review revealed, in consultation with the Poison Control Center, Physicians attempted a PO challenge in which Resident #1 could not complete due to agitation and trouble swallowing. Further review revealed a the hospital conducted a computerized tomography (CT) scan of the Thorax, Upper Endoscopy, [MEDICATION NAME] Swallow Study, and multiple laboratory studies which determined Resident #1 had Esophagitis, Gastritis, and Aspiration Pneumonia from the consumption of the toilet bowl cleaner. During the hospitalization , Resident #1 had a Percutaneous Endoscopic Gastrostomy performed with a tube inserted for feeding due to Dysphagia. Continued review revealed Resident #1 was discharged , on 07/17/2020, to the Skilled Nursing Facility (not the facility he/she had lived) in fair condition. Review of the Material Safety Data Sheet (MSDS) for Crew Super Blue Mild Acid Bowl Cleaner (toilet bowl cleaner), provided by Johnson and Johnson, revealed the product contained the hazardous ingredient of Oxalic Acid. It further revealed ingestion of Oxalic Acid could cause irritation to the mouth, throat and stomach. Further review revealed the product was recommended to be kept out of reach of children. Attempts to interview Licensed Practical Nurse (LPN) #1, who responded to the incident, were unsuccessful. Review of Licensed Practical Nurse #1's written statement, dated 07/09/2020, revealed she responded to a request from SRNA #1 to help with Resident #1, whom they suspected had consumed a blue substance which was identified as Crew Super Blue Mild Acid Bowl Cleaner. Further review of the statement revealed Resident #1 was in the breezeway, located close to his/her room, where the cleaner was located. LPN #1 documented Resident #1 was assessed, the primary care Physician and family were notified, and then the resident was sent to the local medical facility (hospital) for further evaluation. Interview with SRNA #1, on 10/13/2020 at 1:00 PM, revealed on 07/09/2020 around 3:45 AM, she found Resident #1 in the breezeway area with a blue substance around his/her mouth and along the wall. She stated she immediately yelled for LPN #1 to come and assist. She stated upon further investigation, she found the bottle of Crew Super Blue Mild Acid Bowl Cleaner on the floor in the breezeway with the lid open. SRNA #1 stated there were bottles of cleaner left in the hallway, but she had not seen them prior to this incident. Further interview revealed Resident #1 did not appear to be in any form of acute distress, but did begin to dry heave and became agitated. SRNA #1 stated she investigated the contents of the bottle to see how much was possibly consumed by Resident # 1, and noticed the bottle was mostly full, but some of the contents were on the floor and wall where Resident #1 was found. SRNA #1 stated she then began a sweep of the unit to ensure other residents were safe and no other hazards were present. Continued Interview with SRNA #1 revealed Resident #1 was on fifteen (15) minute checks due to his/her cognitive deficits and behaviors and had just been observed at the nursing station five (5) minutes prior to the incident. Interview with the Maintenance Director, on 10/13/2020 at 1:30 PM, revealed on 07/08/2020, a shipment was received from a carrier around mid-afternoon. The Director stated the order was received at the back door and brought to a central location in the facility for a Central Supply Technician to take to the appropriate places. Further interview revealed, on 07/08/2020, the supply of Crew Super Blue Mild Acid Bowl Cleaner was received in a damaged shipping box, and a thorough check of the contents revealed no leaks or damaged bottles, so the order was accepted. He stated all contents of the delivery were placed in the breezeway between the North and South Units, against the wall. Per interview, the bottles of Crew Super Blue Mild Acid Bowl Cleaner were placed one (1) by one (1) against the wall, and he notified Central Supply for pick-up and distribution of the supplies. Further interview revealed all hazardous chemicals in the facility were to be placed in a secure and appropriate place; and, in this instance, he assumed the Central Supply Technician was in route to put the supplies away. Interview with the Central Supply Technician/Resident Transportation, on 10/13/2020 at 2:00 PM, revealed all orders prior to this incident were placed in the breezeway by Maintenance staff. She stated, on 07/08/2020, she had multiple transportation appointments with residents and was not able to complete distribution of the supplies. Further interview revealed the Crew Super Blue Mild Acid Cleaner was not in plain sight, when the stock was being picked to take to the storage areas, nor was it communicated to her that the bottles were out of the box. She stated she missed the unboxed toilet bowl cleaner. The Technician stated all forms of hazardous chemicals were to be kept behind lock doors and should never be left unattended. Interview with the Housekeeping Supervisor, on 10/13/2020 at 2:30 PM, revealed she was she did not work on 07/08/2020, but when an order arrived at the facility, housekeeping would go to check for any housekeeping supplies, and take them to the housekeeping department where they would be under lock and secured from residents. Further interview revealed all hazardous chemicals should be placed in secure locations away from residents and should never be unattended. Interview with the MDS Coordinator, on 10/13/2020 at 2:30 PM, revealed her office was located in the breezeway where the supplies were left unattended on 07/08/2020. She stated she did not see any exposed bottles of potentially hazardous chemicals that day, and the facility kept all chemicals locked in a secure location. The MDS Coordinator stated they were not to be left unattended in residential living quarters. Interview with the Director of Nursing (DON), on 10/15/2020 at 3:27 PM, revealed she had received a call regarding the incident from nursing staff and immediately came to the facility to begin the incident review process. She stated, upon arrival, the Super Crew Blue Mild Acid Bowl Cleaner had been removed from the area and placed in a secure location, and the facility was swept for other potential hazards. The DON stated Resident #1 was sent to the local medical facility. Further interview revealed, under no circumstance, was it appropriate to leave hazardous chemicals unattended and near cognitively impaired residents. The DON stated all residents had the right to live in a safe environment, and she expected all staff to ensure residents' environments were kept safe from potential hazards. Per interview, she stated now the facility had put in safeguards to prevent further accidents. Interview with the Executive Director, on 10/15/2020 at 3:48 PM, revealed he had been employed at the facility for ten (10) years. He stated he was notified, on 07/09/2020, of the incident involving Resident #1 and his/her consumption of the Crew Super Blue Mild Acid Bowl Cleaner. He stated the DON told him when she arrived at the facility, the toilet bowl cleaner had already been removed, and the Physician and Family Representative had been informed of the incident. Further interview revealed the Executive Director and DON had completed an immediate sweep of the facility, assessing residents and ensuring other potential hazards were not accessible. He stated this sweep had identified no other concerns. Further interview revealed he expected no hazardous chemicals to be left unattended and never to be left in the vicinity of cognitively impaired residents. Continued interview with the Executive Director revealed he immediately educated the Central Supply Technician and Maintenance Director, on 07/09/2020, about never leaving hazardous chemicals unsecured where residents had access to them. In addition, he stated all staff were in-serviced on hazardous chemical storage, accidents and hazards, and Dementia care. The Executive Director stated he expected staff to maintain a safe environment for all residents, especially those who were cognitively impaired. **The facility implemented the following actions to correct the Immediate Jeopardy and deficient practice: 1. The toilet bowl cleaner was immediately removed from the breezeway by clinical staff, on 07/09/2020 around 3:50 AM. 2. The LPN assigned to Resident #1 assessed the resident; completed an Incident Report; notified the Ambulance Service, Physician, and family; and sent the resident to the emergency room of Hospital #1 for evaluation, on 07/09/2020 at 3:50 AM. 3. Resident #1's CCP was updated to reflect his/her current status, on 07/09/2020. 4. On 07/09/2020, facility rounding was completed with no additional delivery boxes or unsecured hazardous materials discovered. Resident rooms were searched for other forms of accident hazards by the Executive Director and Director of Nursing. 5. Education was provided by the Executive Director to the Maintenance Director and Central Supply Technician, on 07/09/2020, about the new delivery process where all supplies were to be placed in a proper location or in the storage area that had a locked door not accessible by residents. 6. Education topics were provided to all departments, by the Executive Director and Director of Nursing, which included hazardous chemical containment, safety/poison control center, neglect, change of condition, incident management/accidents, care plans, physician orders, care of Dementia patients/behaviors, the new process for the facility's deliveries, vendor notification of the new delivery process. This education was completed for all staff members by 07/13/2020. 7. The facility conducted a Hazardous Chemicals Safety Audit, beginning 07/09/2020, to be done daily every shift for four (4) weeks, then weekly for four (4) weeks, and then once per month rounding on each shift to ensure all hazardous chemicals were properly stored. 8. The facility conducted audits based on staff interviews and physical checks for hazardous chemicals, beginning 07/13/2020, to be done daily every shift for four (4) weeks, then weekly for four (4) weeks, and then once per month. The audit consisted of (1) staff being interviewed each shift to ascertain if there were any unsecured hazardous chemicals. 9. The facility conducted Delivery Audits, beginning 07/13/2020, to be done daily for four (4) weeks, then weekly for four (4) weeks, then once per month. The Executive Director or Maintenance would audit deliveries to ensure hazardous chemicals, when delivered, were immediately stored in a secure location. 10. Results of audits would be reviewed monthly by the Interdisciplinary Team. The IDT core members were the Director of Nursing, Staff Development Coordinator, MDS Coordinator, and Social Services Director. The results would also be reviewed monthly by members of the QAPI Committee. QAPI Committee members were the Medical Director, the Executive Director, the Director of Nursing, the Staff Development Coordinator, the MDS Coordinator, the Social Services Director, the Activity Director, the Dietary Manager, the Health Information Manager, the Maintenance Director, the Housekeeping Supervisor, the Laundry Supervisor, the Therapy Representative, and other Ad Hoc members. If noncompliance was identified, re-education would be provided with progressive discipline as directed. Also, the IDT would meet and re-implement initial audit timing to daily each shift for four (4) weeks, then weekly for four (4) weeks and then once per month for (1) month. In addition, the QAPI meeting conducted, on 07/15/2020, found the facility's safety protocol provided an abatement for potential accident hazards and with the on-going program in place, proper management was in place to prevent further accident hazards. **The State Survey Agency validated the facility's plan of action was carried out by: 1. Interview with SRNA #1 and the DON, on 10/13/2020 at 1:00 PM, revealed she and other staff immediately removed the Crew Super Blue Mild Acid Bowl Cleaner (toilet bowl cleaner) from the Breezeway and placed it in a secure location away from all residents. 2. Review of the Nursing Progress Notes, dated 07/09/2020 at 3:45 AM, revealed nursing documentation of the incident. Further review of the Nursing Progress Notes revealed LPN #1 immediately responded to Resident #1. LPN #1 assessed the resident; completed an Incident Report; notified the Ambulance Service, Physician, and family; and sent the resident to the Hospital #1's emergency room for evaluation, on 07/09/2020 at 3:50 AM. 3. Review of Resident #1's CCP revealed the resident had updates provided to care areas related to wandering and cognitive impairment to specify the need for a safe wandering environment. 4. Review of Room Rounds and Checks documentation revealed all rooms were rounded on by members of the IDT team, and no hazards or potential hazards were discovered. Further review revealed specific areas, housekeeping, medicine, and treatment carts were secured and checked by the Executive Director. Interview with the Executive Director, Director of Nursing, Social Service Director, LPN Trainer, and MDS Coordinator, on 10/15/2020, confirmed such action was taken, on 07/09/2020, and no issues were identified. 5. Interview with the Maintenance Director and the Central Supply Technician, on 10/13/2020 at 1:30 PM and at 1:45 PM, revealed both were educated by the Executive Director on hazardous chemicals and proper storage of such, on 07/09/2020. Review of Educational Sign-in Sheets, dated 07/09/2020, revealed the Maintenance Director's and the Central Supply Technician's signatures on the sheets, in verification of both receiving education about hazardous chemicals and the storage process. 6. Review of Education Sign-in Sheets for topics hazardous chemical containment, safety/poison control center, neglect, change of condition, incident management/accidents, care plans, Physician orders, care of Dementia patients/behaviors, and the new process for facility deliveries revealed all staff attendance with signature verification conducted by the Executive Director and Director of Nursing (DON). Interviews, on 10/16/2020, with SRNA #2 at 11:45 AM, SRNA #3 at 11:48 AM, LPN #2 at 12:37 PM, LPN #3 at 12:44 PM, and the Social Services Director at 1:00 PM, revealed they were required to complete education or could not work the floor, and all education was mandated to be completed by 07/13/2020. Interview with the Executive Director, on 10/13/2020 at 3:48 PM, and again, on 10/16/2020 at 1:30 PM, revealed all staff were educated on hazardous chemical containment, safety/poison control center, neglect, change of condition, incident management/accidents, care plans, Physician orders, care of Dementia patients/behaviors, and the new process for facility deliveries by the DON and the Executive Director. All education had to be completed by staff prior to being allowed to work, and those who could not attend inservices, had alternate forms of education delivered to them. 7. Review of the Hazardous Chemicals Safety Audit Calendar revealed, starting on 07/09/2020, areas of the facility including residential rooms, treatment areas, housekeeping areas, maintenance areas, and other non-clinical areas received daily checks from members of the IDT team. Further review revealed audits were still being completed by the Executive Director. Interview with the Executive Director and Director of Nursing, on 10/13/2020 at 3:30 PM; and, on 10/16/2020 at 1:30 PM, revealed dedicated staff members conducted thorough sweeps of all areas of the facility looking for potential hazardous materials that would be considered out of place or improperly stored. Further interview revealed no materials were found, and the facility's assessments were still on-going. 8. Review of Staff Interview Audits, from 07/13/2020 to 10/01/2020, revealed staff interviewed had not identified any unsecured hazardous chemicals in the facility. Review of Physical Checks for Hazardous Chemicals, from 07/10/2020 to 09/10/2020, revealed there had not been any unsecured hazardous chemicals found in the facility. 9. Review of the Delivery Audit Calendar, on 10/16/2020 at 9:45 AM, revealed beginning on 07/13/2020, the facility began the process of ensuring deliveries were assessed for quality assurance and for safe storage. Further review revealed the Executive Director was responsible for signing off on the correct receiving and storage processing of deliveries. Interview with the Maintenance Director, on 10/16/2020 at 9:30 AM, revealed all orders now have to be signed off by the Executive Director who assured all supplies were placed in proper locations which was behind locked doors or, an appropriate storage location. Interview with the Executive Director, on 10/16/2020 at 1:15 PM, revealed each delivery, beginning on 07/13/2020, was examined for quality and for correct distribution through the facility. He stated if items were not immediately put away, all stock was to be kept behind locked doors. Further interview revealed this process was on-going and would be the new standard going forward. Observations, on 10/13/2020, 10/14/2020, and 10/16/2020, revealed stock was kept in secure areas and behind keypad locked doors, and hazardous chemicals were secured in appropriate departments. 10. Review of the QAPI Meeting minutes, dated 08/19/2020, and 09/09/2020, revealed the ongoing audits for hazardous chemicals and storage were continuing, with no issues identified for noncompliance for both months. Interview with the Executive Director, on 10/16/2020 at 1:30 PM, revealed the QAPI team met, on 07/15/2020, to review initial results of the performance improvement plan related to the incident with Resident #1. He stated QAPI members determined corrective actions had been effective, and the facility was in compliance with regulations.

Based on interview, record review and review of the facility's Policy, it was determined the facility failed to ensure residents were free from abuse for two (2) of five (5) sampled residents (Resident #2 and Resident #3). On 08/04/19, while on the porch of the facility, Resident #1 threw amber in the direction of Resident #2 and called the resident a [***] . Resident #1 was agitated, went inside the facility and made physical contact with Resident #3's right upper arm. Resident #1 and Resident #3 had previous resident-to-resident encounters on 07/31/19 and 05/08/19. On 07/31/19, Resident #3 grabbed Resident #1's coffee and both grabbed at each other's wrist. On 05/08/19, Resident #1 and Resident #3 had a resident-to-resident altercation and the facility provided education to staff on 05/13/19 and 05/17/19 to keep Resident #3 away from Resident #1. The Findings include: Review of the facility's Policy titled Protection of Residents: Reducing the Threat of Abuse and Neglect, dated revised 01/21/19 and dated reviewed 04/15/19, revealed to minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse. Per the Position Statement and Guidelines section of the policy, each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone and it is the policy and practice of this facility that all residents will be protected from all types of abuse. Further review of the policy revealed a prevention section of the policy, documenting it is the policy of this facility to prevent and prohibit all types of abuse. Continued review revealed the facility must identify, assess, care plan for appropriate interventions and monitor residents with needs and behaviors, which might lead to conflict or neglect, such as verbally aggressive behavior or physically aggressive behavior. Continued review of the policy revealed the Investigation and Protection procedure, which documented following identification of alleged abuse, the resident(s) receive prompt medical attention as necessary and the resident(s) are protected during the course of the investigation to prevent recurrence. Staff will respond immediately to protect the alleged victim(s)/others and integrity of the investigation. Continued review of the policy revealed when an incident or suspected incident of resident abuse is reported, the administrator/designee will investigate the occurrence and protection will be provided to the alleged victim and other resident(s) from the alleged perpetrator. The policy documented if the accused abuser is another resident, the residents must be separated while investigating the incident and interventions must be implemented to assure safety of all residents. Review of the facility's Resident Rights Policy, dated revised 11/09/16, revealed the resident has a right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The resident has a right to be treated with respect and dignity. 1) Review of the facility investigation of an incident titled Brief Description of Incident, dated 08/04/19, revealed at approximately 1:00 PM on 08/04/19, Resident #4 reported that he/she and Resident #2 were sitting on front porch and Resident #1 came outside and sat next to them. Continued review revealed Resident #1 was fine at first and was talking normal, then Resident #1 stated to Resident #2 that he/she had a wind up clock and Resident #2 stated no it was electric and Resident #1 stood up and said [***] and Resident #1 had a cup of ambeer and threw it with some of the juice from the cup hitting Resident #2. Continued review of the facility investigation revealed Resident #4 reported Resident #2 was trying to calm Resident #1 and patted the resident's hand and Resident #1 stated he was going to tell staff that Resident #2 hit him/her. Per the report, Resident #1 came in the building and informed staff that Resident #2 hit him/her on the arm with an open hand. Further review of the facility investigation revealed Resident #1 was upset and went to his/her room and began rummaging through his/her personal belongings and some of the resident's belongings ended up in the hallway. Resident #3 was wheeling up the hallway and began to pick up the items and Resident #1 saw this and went up to Resident #3 and made contact with Resident #3's right upper arm. The investigation indicated staff were present and the residents were separated immediately. Continued review of the facility investigation revealed the comment page, dated 08/09/19, which documented Resident #1 had a Brief Interview Mental Status (BIMS) score of fourteen (14) out of fifteen (15), Resident #2 a BIMS of six (6) out of fifteen (15), and Resident #3 a BIMS of zero, zero (00) out of fifteen (15). The investigation indicated the police were notified with no recommendations. Resident #1 was sent to the hospital on [DATE] for evaluation for increased anxiety and agitation and upon the resident's return to the facility was placed on one to one. The psychiatrist saw resident #1 on 08/05/19. The psychiatrist recommended for an in-patient stay at the mental health unit with the physician and guardian in agreement. Resident #1 was on one to one until he/she left the faciity on [DATE]. (Resident #1 returned to the facility on [DATE]). A Bariatric chair, that Resident #1 sits in, in the dining area was relocated so Resident #1 will not be sitting in the entrance to the dining room from the north hall way. Per the documentation, with the completion of the investigation it was determined that Resident #1 did call Resident #2 a [***] and throw ambeer in Resident #2's direction and it was also determined that Resident #1 did make contact with Resident #3; however, the facility was unable to determine the reasoning for the contact. Per continued review, Resident #4, who was sitting on the front porch when Resident #1 became upset, reported Resident #1 had been talking about a brother coming to see him and taking him for a ride but the brother never showed up. Continued review of the facility investigation of the incident on 08/04/19 revealed staff statements. Review of the statement documented by Licensed Practical Nurse (LPN) #3 revealed she was sitting at the nurses station on South wing and Resident #1 came to the desk and stated Resident #2 hit him/her. LPN #3 documented going to talk to Resident #2 about this, Resident #2 denied it, and Resident #4 was also present on the porch and advised he/she had witnessed the incident. Continued review of the statement revealed Resident #4, an alert and oriented x 3 resident, reported that Resident #1 was talking to Resident #2 and Resident #2 answered Resident #1 about a clock then Resident #1 threw tobacco spit on Resident #2 and called the resident a [***] , and then entered the facility from the porch. Further review of the statement documented by LPN #3 revealed she went to the North Wing Nurse, to notify LPN #4 what had been reported by Resident #4. Review of the facility investigation revealed a documented statement per SRNA #1, which revealed on 08/04/19 at approximately 1:15 PM, Resident #1 was walking up and down the hall already agitated and had been throwing stuff, cursing staff and threatening to blow the building up and pack clothes and go home. The statement documented Resident #1 walked past Resident #3 who was sitting in the hallway doing nothing and stopped and started punching Resident #3 (not sure how many times but more than once) and they proceeded to separate the two residents. SRNA #1's statement indicated Resident #3's arm was bleeding but did not know that is what caused it. Review of the facility investigation/staff statement documented by Housekeeper #1 revealed on 08/04/19, while she was walking toward North hall, Resident #1 had words with Resident #3 and then hit Resident #3. The documentation indicated Resident #1 was already upset raising his/her voice. Review of the Weekly Skin Integrity Data Collection for Resident #3, dated 08/04/19, revealed the right elbow had an old skin tear that had reopened, dressing intact and no new bruises noted. 2) Review of the facility investigation of incident, dated 07/31/19, Brief Description of Incident, revealed at approximately 5:00 AM on 07/31/19, staff witnessed Resident #3 sitting next to Resident #1 in the dining room and Resident #3 went to grab Resident #1's coffee cup and Resident #1 quickly grabbed it and then Resident #3 made contact with resident #1's left wrist with an open hand. Per the documentation, with the completion of the investigation it was determined that Resident #3 did make contact with Resident #1's hand or wrist but the facility was unable to determine if Resident #3 was hitting or trying to get Resident #1's coffee cup. It was also determined in the investigation that Resident #1 made contact with Resident #3's wrist as well and that the facility was unable to determine if Resident #1 was hitting or just trying to keep Resident #3 from getting his/her coffee cup. Review of the Weekly Skin Integrity Data Collection for Resident #3, dated 07/31/19, revealed a new bruise to the left wrist and the document noted the resident's son and physician were notified. Record review of the Weekly Skin Integrity Data Collection for Resident #1, dated 07/31/19, revealed bruising noted to left wrist. 3) Review of the facility investigation of an incident, dated 05/08/19, Brief Description of Incident, revealed at approximately 7:30 AM on 05/08/19, staff witnessed Resident #3 wheel up next to Resident #1 in the dining room and a moment later Resident #3 made contact with Resident #1 in the left upper arm. The residents were immediately separated and no injuries noted. Continued review of the facility investigation revealed the comment page, dated 05/13/19, which documented Resident #1 had a BIMS of twelve (12) out of fifteen (12) and Resident #3 a BIMS of zero, zero (00) out of fifteen (15). Skin assessments of Resident #1 and Resident #3 were completed with no injuries noted to either resident related to the incident. Staff education regarding resident-to-resident altercation began on 05/08/19 and was ongoing. Education provided was regarding resident to resident altercation and to attempt to keep Resident #1 and Resident #3 away from each other due to Resident #3 thinking Resident #1 is his/her son. Per the investigation, the facility was able to determine that Resident #3 did make contact with Resident #1's upper left arm. The facility was unable to determine the reasoning for the contact; however, Resident #3 thinks Resident #1 is his/her son and they do resemble each other and both of their first names are the same. Per continued review, this was the reason the facility was educating staff to keep Resident #3 and Resident #1 away from each other as much as possible and encourage Resident #3's son to visit as often as possible. The investigation documented Resident #3 becomes upset when Resident #1 does not speak to him/her; thinking his/her own son will not speak to him/her. Resident #1 does not like it when Resident #3 thinks Resident #1 is his/her son. Review of the document Life Care Centers of America, Inc. In-service Programs, Chapter 5 Class Attendance Record, date conducted 05/13/19 to 05/17/19 revealed the subject of the in-service was Abuse, Neglect, Resident to Resident Altercation/Keep Resident #3 away from Resident #1. Record review revealed the facility admitted Resident #1 on 05/24/16. Further review of Resident#1's medial record revealed diagnoses, which included Unspecified Dementia with Behavioral Disturbance; [MEDICAL CONDITION] Disorder, Depressive Type; Emotional Lability and Moderate Intellectual Disabilities. Review of the most recent Minimum Data Set (MDS) assessment, a quarterly assessment dated [DATE], revealed Resident #1 was assessed by the facility to have a BIMS score of fourteen (14) out of fifteen (15), indicating cognitively intact. Review of Resident #1's Comprehensive Care Plan revealed a plan of care with onset date 06/22/17, the Resident has a history of manipulative behaviors and crying related to depression and [MEDICAL CONDITION] with a goal that the resident will display behaviors/symptoms less than daily and a target date of 10/2/19. Interventions included to redirect as necessary, monitor for manipulative behaviors and administer medications as ordered. Continued review of Resident #1's plan of care revealed a focus area of Resident has history of manipulative behaviors and agitation related to MR (mental [MEDICAL CONDITION]), initiated 05/16/19, with the goal that the resident will not experience behaviors that are harmful to self and others through the next review date with target date 08/09/19. Some interventions documented were to assist the resident to develop more appropriate methods of coping and interacting. Offer resident chewing tobacco. Encourage the resident to express feelings appropriately. If reasonable, discuss the resident's behavior and explain/reinforce why behavior is inappropriate and or unacceptable to the resident. Redirect by talking about the resident's family (nieces and nephews) and resident's dog. In addition, Resident #1 had a plan of care that the resident has poor decision-making skills related to the [DIAGNOSES REDACTED]. Some of the interventions included cueing, reorient and supervise as needed. Review of Resident #1's medical record/progress note, dated 08/04/19 at 1:39 PM documented by LPN #4, revealed the resident came to the nurses desk upset and said another resident hit him/her and that Resident #1 sat down on the walker in front of nurses station and was still upset and started yelling and cursing at staff and that the nurse (LPN #4) asked Resident #1 not to do that and go to his/her room to calm down and the resident stormed off and was yelling as he/she went down the hallway. Per the progress note, LPN #4 documented shortly after that, she was behind the nurses desk doing paperwork and heard staff say that Resident #1 and Resident #3 were fighting and she came around the corner and saw Resident #1 and Resident #3 in front of one another and she jumped between them and separated them and asked Resident #1 to go to his/her room and calm down and Resident #1 proceeded to yell and throw stuff. Per the progress note, Resident #1's sister was called to see if she could get the resident to calm down and he/she got more upset with her and then LPN #4 spoke to her and received permission to send Resident #1 to the emergency room for evaluation. Per a Progress Note, dated 08/04/19 at 4:39 PM, Resident #1 returned to the facility from the emergency room via ambulance and the resident was to be one to one, until the next day due to recent altered mental status. Observation, on 08/21/19 at 10:36 AM, revealed Resident #1 was in the Dining Room wearing a hat, sitting in the front area of the dining room near the window, with a walker near the resident. Interview with Resident #1, on 08/21/19 at 12:12 PM, revealed Resident #1 said he/she had been to the hospital lately due to he/she had a breakdown, a [MEDICAL CONDITION] breakdown, then said nervous breakdown. Resident #1 indicated when on the porch, Resident #2 hit him/her on the arm and Resident #1 denied calling Resident #2 a bad name and said that Resident #2 called him/her a bad name. Further interview with Resident #1 revealed the resident indicated he/she was going to throw the tobacco spit in the trash but Resident #2 would not let him/her through and he/she threw the tobacco spit at the ground. Resident #1 said he/she came inside and told nurse LPN #3. Continued interview with Resident #1 revealed he/she went to his/her room and indicated Resident #3 got Resident #1's flashlights off the floor and hit him/her two times on each upper arm. Resident #1 stated the flashlights must have fallen out of his/her walker in his/her room and indicated Resident #3 came in his/her room and took the flashlights and he/she grabbed them back. Resident #1 denied hitting Resident #3, saying he/she did not hit Resident #3 one bit and he/she thinks I am his/her son and I am not. Resident #1 indicated he/she has told Resident #3 but the resident does not listen. Resident #1 said he/she has talked to the police about it and next time Resident #3 hits me he/she goes to jail. Resident #1 indicated the police took him/her to the hospital, and then he/she came back here. He/she stated he/she was at the hospital for forty (40) days and was happy to come back home and while at the hospital he/she couldn't have tobacco or anything. Resident #1 was tearful when speaking about his/her brother and when speaking about his/her roommate and said the roommate was leaving soon. Continued interview with Resident #1 revealed he/she feels safe at the facility. Record review revealed the facility admitted Resident #2, on 03/12/19. Further review of the clinical record revealed Resident #2's [DIAGNOSES REDACTED]. Review of the most recent MDS assessment for Resident #2, a Quarterly assessment dated [DATE], revealed the resident was assessed to have a BIMS score of six (6) out of fifteen (15). Further review of the MDS revealed there were no behaviors, no mood indicators, and no [MEDICAL CONDITION] per the assessment for Resident #2. Review of the Care Plan for Resident #2 revealed a plan of care dated 04/01/19 that the resident has history of self-isolating at times relating to [DIAGNOSES REDACTED]. Interventions included to monitor for signs or symptoms of increased depression and report to the Charge nurse, introduce resident to others with similar interest and encourage the resident to discuss concerns/issues with social services. Observation of Resident #2, on 08/21/19 at 10:15 AM, revealed Resident #2 was sitting in his/her room in a wheelchair with the right foot in a footrest, and left hemi tray that was folded over to the side, with the television on. Interview with Resident #2, on 08/21/19 at 10:15 AM, revealed the resident recalled the incident with the tobacco juice. Resident #2 said stained and motioned to his/her shirt. Resident #2 was unable to recall the other resident's name. Resident #2 could recall that this resident said something mean to him/her but could not recall what was said. Continued interview with Resident #2 revealed he/she did not touch the other resident (Resident #1) and that he/she was just talking to his/her friend and then motioned to his/her shirt/clothes again. Per interview, the person had never done anything to Resident #2 and has not done anything since this incident. Resident #2 did not know if the other resident was upset over something. Resident #2 indicated staff helped him/her get cleaned up and Resident #2 denied being afraid of the other resident (Resident #1). Record review revealed the facility admitted Resident #3, on 12/10/18. Further review of Resident #3's medical record revealed diagnoses, which included [MEDICAL CONDITION] with late onset; Dementia in other Diseases Classified Elsewhere with Behavioral Disturbance; Cognitive Communication Deficit; Wandering in Diseases Classified Elsewhere and Muscle Weakness (Generalized). Review of the most recent MDS assessment, which was a Quarterly Assessment, dated 05/27/19, revealed Resident #3 was assessed to have a BIMS score of zero, zero (00) out of fifteen (15). Further review of the MDS revealed Resident #3 was assessed as having Mood indicators score of three (3) of twenty-seven (27) with trouble concentrating twelve (12) to fourteen (14) days. Per the assessment, Resident #3 was assessed as having verbal behavioral symptoms directed toward others on one (1) to three (3) days, and wandering behavior that occurred daily. Review of Resident #3's Comprehensive Care Plan revealed a plan of care that the resident has depression related to [MEDICAL CONDITION] dated initiated 05/20/19 with a goal documented the resident will exhibit indicators of depression, anxiety or sad mood less than daily by review date with a target date of 09/30/19. Interventions included to report to the physician as needed for risk for harming others; increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons; the resident needs time to talk, encourage the resident to express feelings. Review of Resident #3's medical record/progress notes, dated 08/04/19, revealed the resident was in a wheelchair propelling self in the hallway when another resident punched the resident in the right arm causing a skin tear to the right elbow area. There was no documented evidence of a progress note/Nurse's Note related to the resident-to-resident altercation between Resident #3 and Resident #1 on 07/31/19. Review of the NRSG: Skin Integrity Data Collection, dated 08/04/19, revealed an old skin tear reopened, with the dressing intact. Review of an Incident Follow-Up and Recommendation Form, for Resident #3 for incident date 08/04/19, dated 08/05/19, revealed the resident was involved in resident to resident altercation with Resident #1 and Resident #1 made contact to Resident #3's right upper arm and the resident incurred a skin tear at right posterior elbow and staff report that Resident #3 had skin tear to same area that had recently resolved and this caused the skin tear to reopen. Further review of the documentation revealed, on 08/09/19, there were no signs or symptoms of infection at the area and monitor would continue. Observation of Resident #3, on 08/22/19 at 10:47 AM, revealed the resident was in a wheelchair in front of the Nurse's Station on the 300 hall wearing tennis shoes, a watch to the left wrist, and a wander alarm bracelet to the right wrist. Staff transported the resident to his/her room. Interview with resident #3, on 08/22/19 at 10:47 AM, revealed the resident was asked if anyone ever hurt him/her or hit him/her at the facility and the resident shrugged and said he/she did not think so. Continued interview with Resident #3 revealed the resident stated, We have to find out how it works and then held up his/her hand in a fist and stated he/she could take care of himself/herself. Record review revealed the facility admitted Resident #4 on 06/04/19. Review of the most recent MDS assessment, an Admission assessment, dated 06/21/19, revealed Resident #4 was assessed to have a BIMS score of fifteen (15) out of fifteen (15), indicating cognitively intact. Continued review of the MDS Assessment revealed Resident #4 was not assessed as having behaviors or mood indicators. Observation of Resident #4, on 08/21/19 at 11:55 AM, revealed the resident was in a wheelchair and appeared clean and appropriately dressed. Interview with Resident #4, on 08/21/19 at 11:55 AM, revealed he/she and Resident #2 were on the porch talking and Resident #1 came out and sat down. Resident #4 explained that Resident #2's family had taken the resident yard selling and the resident had bought an item to store belongings in that looked like a clock but it was not. Continued interview revealed Resident #1 said you got a wind up clock and Resident #2 said no, and Resident #1 said yes you did and stood up and said [***] and threw tobacco spit towards Resident #2 and it got all over Resident #2 and the porch. Per interview, Resident #1 slapped Resident #2's hand, but he did not think it was hard, and Resident #1 said he/she was going to go inside and tell the nurse that Resident #2 hit him/her. Resident #4 stated Resident #2 never touched Resident #1. Continued interview with Resident #4 revealed Resident #1 went inside and the nurse came out and asked Resident #2 if he/she hit Resident #1 and she said no and he thinks they took Resident #2 inside to get her cleaned up after that. Per interview, Resident #4 said he/she feels safe at the facility. Resident #4 stated Resident #1 has a seven (7) year old mind and he/she was not sure what caused the resident's behavior that day, and stated maybe medications, and said Resident #1 tells him all the time that his/her brother is going to get him/her and take him home, but he doesn't, and stated maybe Resident #1 built that up in his/her mind. Interview with State Registered Nursing Assistant (SRNA) #1, on 08/21/19 at 1:00 PM, revealed she has received training regarding abuse prohibition. Continued interview with SRNA #1 revealed she did not witness the incident on the porch but on 08/04/19, Resident #1 came from the porch, storming down the hallway, cursing staff and threatening to blow up the building and when asked what happened, Resident #1 said Resident #2 hit him. Continued interview revealed LPN #4 could not calm the resident and he/she was in his/her room packing clothes, came out of room, and got a walker. Per interview, Resident #1 had previously thrown a rolling walker and when resident #1 obtained the walker and began walking down the hall, some contents had fallen out of the basket of the walker, a flashlight she thought. Further interview with SRNA #1 revealed Resident #3 was in a wheelchair in the hall and she guessed Resident #1 thought Resident #3 bothered the flashlight and Resident #1 hit Resident #3 three or four times. SRNA #1 reported it was hard to see where Resident #3 was hit because Resident #1 was standing in front of Resident #3 but she could tell it was multiple times. Further interview revealed Resident #3's arm was bleeding after the incident. SRNA #1 stated she did not see Resident #3 hit Resident #1. Continued interview with SRNA #1 revealed the police came and Resident #1 denied everything. SRNA #1 further explained that Resident #3 thinks Resident #1 is his/her son and they have the same name and look similar, so Resident #3 would try to talk to Resident #1 but Resident #1 did not like it. Interview with Housekeeper #1, on 08/21/19 at 5:00 PM, revealed on 08/04/19 Resident #1 was at the Nurse's Station on the corner prior to the resident-to-resident altercation. Housekeeper #1 stated she could hear Resident #1 yelling with a raised voice and could see Resident #1 as he/she started walking towards his/her room. Housekeeper #1 further explained that Resident #3 was in the hall in his/her wheelchair and close to Resident #1's room but not directly in front of it. Continued interview with Housekeeper #1 revealed she heard Resident #1 say something to Resident #3 and stated she did not hear Resident #3 say anything to Resident #1 to provoke him/her and then Resident #1 hit Resident #3. Housekeeper #1 reported she could not tell where Resident #1 hit Resident #3 but could tell that contact was made and that Resident #3's elbow was bleeding. She stated she did not know if it was bleeding from that contact or what. Interview with SRNA #4, on 08/22/19 at 12:03 PM, revealed she worked on 08/04/19 but did not witness anything other than she heard Resident #1 screaming down the hall. SRNA #4 indicated she was aware Resident #1 and Resident #3 had a previous altercation in the dining room but was not aware of the details. Continued interview revealed SRNA #4 has received training regarding abuse and she considered it abuse if one resident hit another resident. Interview with LPN #3, on 08/22/19 at 10:26 AM, revealed she worked on 08/04/19 and was at the Nurse's Station when Resident #1 came to South Hall, where Resident #2 resides. Resident #1 reported to her that Resident #2 hit him/her. LPN #2 stated she went to speak with Resident #2 and Resident #2 was sitting with Resident #4, who advised her that is not what happened. LPN #3 stated Resident #4 witnessed the incident and reported Resident #1 and Resident #3 were having a conversation and Resident #3 told Resident #1 no to a question about a clock, and Resident #1 got up and threw ambeer on Resident #2 and called the resident a name. LPN #3 stated Resident #2 did have ambeer on him/her. LPN #3 stated she then went to North Hall, where Resident #1 resides, and reported the information to LPN #4. LPN #3 reported Resident #1 came to the desk and said he/she was going to call the police and said Resident #2 hit him/her and seemed to be getting more agitated. Further interview with LPN #3 revealed LPN #4 told Resident #1 to go to his/her room so he/she could calm down. Continued interview with LPN #3 revealed she thought Resident #1's supervision should have been increased. She stated staff nurses could implement increased supervision but usually call the DON or physician for that directive. LPN #3 stated she then returned to her assigned hall. Further interview with LPN #3 revealed she was unaware of the subsequent altercation between Resident #1 and Resident #3 until after it had occurred. Per interview, LPN #3 would consider a resident having ambeer thrown on him/her to be abuse and would consider a resident hitting another resident abuse. Interview with LPN #4, on 08/21/19 at 3:42 PM, revealed she received information from LPN #3 regarding Resident #1 an Resident #2 altercation and Resident #1 told her he/she did not throw ambeer on Resident #2 and said Resident #2 hit him/her. LPN #4 indicated Resident #1 did not have any marks on him/he and that a witness said Resident #2 did not hit Resident #1. LPN #4 stated Resident #1 was in front of Nurse's station cursing and church was being held in the dining room. Per interview, LPN #4 told Resident #1 he could not curse and requested that Resident #1 go to his/her room and calm down and for safety as there were other residents at the desk, and told Resident #1 she would call his/her sister as she could usually calm Resident #1. Further interview with LPN #1 revealed talking to his/her sister did not calm Resident #1, and she spoke with the sister who said to send him out for evaluation if needed. Further interview revealed Resident #1's roommate was doing a puzzle in the room. LPN #4 indicated she went to call the Director of Nursing (DON) and Executive Director per protocol, and had SRNA #3 trying to calm Resident #1, but thought SRNA #3 walked away from the room. Per interview, LPN #4 indicated she was on phone with hospital and heard staff yell about Resident #1 and Resident #3 and went to separate them but did not witness contact. LPN #4 stated Resident #1 came out of the room and was in the hallway and Resident #3 just happened to be coming down hallway and she did not know exactly what happened. LPN #4 indicted Resident #1 was not on one to one observation at that time. LPN #4 stated Resident #1 has a child mind and has more like a temper tantrum and that she had never seen Resident #1 this upset. She stated Resident #3's nurse came to assess the resident and Resident #1 was sent to the Emergency Department. Resident #1 returned from the emergency department and was placed on one to one observation. Per interview with LPN #4, residents have the right to be free from abuse and neglect and she indicated the facility in-serviced on this every couple of months. Interview with LPN #1, on 08/22/19 at 11:29 AM, revealed she assessed Resident #3 after the incident with Resident #1 on 08/04/19 and found no new issues. LPN #1 stated Resident #3 had a spot of blood on his/her arm and she assumed Resident #3 bumped it on the wheelchair and once she cleaned the area there was nothing there and it did not look like an open area. Further interview with LPN#1 revealed she was not aware of any prior incidents between Resident #1 and Resident #3. Per interview, if a resident hits another resident she would consider t

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, comfortable environment and to help prevent the development and transmission of communicable diseases and infections for sixteen (16) of twenty-two (22) sampled residents (Residents #5 #12, #13, #18, #19 #21, #30, #36, #44, #48, #49, #57, #66, #74, #88, and #140). Record review revealed there was no documented evidence the annual Purified Protein Derivative (PPD) skin test ([MEDICATION NAME] Skin Test) results for Resident #13 and Resident #74 were documented in the medical record. In addition, observation on [DATE] of the West Unit medication cart used for rooms ,[DATE], revealed the cart contained expired PDI Sani-Cloth bleach germicidal disposable wipes accessible for use; the West Unit medication cart used for rooms ,[DATE], contained expired PDI Sani-Cloth bleach germicidal disposable wipes accessible for use; and the West Unit medication storage room, contained two (2) boxes of PD Sani-Cloth bleach germicidal disposable wipes accessible for use. There were fourteen (14) residents on the West Unit with orders for Finger Stick Blood Sugars (FSBS) related to [DIAGNOSES REDACTED].#5 #12, #18, #19 #21, #30, #36, #44, #48, #49, #57, #66, #88, and #140). The findings Include: Review of the facility Admission of Residents and Follow-Up, Policy, last revised [DATE], revealed Screening for tubercle bacilli infection annually will consist of Purified Protein Derivative (PPD) skin tests using five (5) units of PPD injected intradermally. A skin test reaction of greater than ten (10) mm (millimeters) induration is generally considered positive. Further review of the Policy, revealed the results of all skin tests will be documented on a [MEDICAL CONDITION] Summary Record maintained for each resident. 1. Review of Resident #74's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Immunization/PPD/Chest X-Ray document, revealed Resident #74 was administered an annual PPD skin test on [DATE]; however, there was no documented evidence the PPD skin test was read with results documented in the medical record. 2. Review of Resident #13's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident TB Screening And Immunization Record revealed Resident #13 was administered an annual PPD skin test on [DATE]; however, there was no documented evidence the PPD skin test results were read with results documented in the medical record. Interview with the Staff Development Coordinator (SDC)/Infection Control Nurse (ICN), [DATE] at 05:28 PM, revealed she started in this position on [DATE]. She stated residents were to receive two (2) step PPD skin tests on admission. Per interview, thereafter, an annual PPD skin test was to be administered as per regulation. Continued interview revealed it was her expectation PPD skin tests be administered and results documented in the medical record in millimeters (mm) of induration. Further interview with the SDC/ICN, revealed if PPD skin test results were not read and documented in the medical record, the facility would not know if a resident had been exposed to [MEDICAL CONDITION]. Interview with the Director of Nursing (DON) on [DATE] at 5:15 PM, revealed two (2) step PPD skin testing was done on admission unless the resident had a prior reaction to the testing, and then a chest X-Ray would be completed. Continued interview revealed the expectation was that the PPD skin test or Chest X-Ray be performed annually thereafter. Per the DON, PPD skin test were to be administered and the results were to be documented in the electronic medical record in millimeters (mm) of induration. The DON further stated Resident #74 and Resident #13 were administered annual PPD skin tests; however, the PPD skin test results were not read or documented. Continued interview revealed it was important to read PPD skin test results and document the results appropriately, and if this was not done, there could be a [MEDICAL CONDITION] outbreak in the facility. Interview with the Administrator, on [DATE] at 5:57 PM, revealed PPD's were administered on admission and annually. Per interview, there was the potential for a negative outcome if the PPDs were not administered and results read and documented if a resident was positive for [MEDICAL CONDITION]. Continued interview revealed it was his expectation staff follow facility Policies and regulations, related to reading the PPD skin test results timely, and documenting results on the Immunization Tab in the electronic charting system utilized by the facility. 2. Review of the facility'sCleaning and Disinfection of the Glucometer Policy, revised ,[DATE], revealed the Equipment used for cleaning and disinfecting the glucometer included a Super Sani-Cloth or Sani-Cloth Plus. Observation on [DATE] at 8:27 AM, of the West Unit medication cart used for rooms ,[DATE], revealed one (1) box, that contained 40 PDI Sani-Cloth bleach germicidal disposable wipes. Observation on [DATE] at 8:40 AM, of the West Unit medication cart used for rooms ,[DATE], revealed seven (7) PDI Sani-Cloth bleach germicidal disposable wipes with an expiration date of ,[DATE] and two (2) PDI Sani-Cloth bleach germicidal disposable wipes with an expiration date of ,[DATE]. Observation on [DATE] at 9:13 AM, of the West Unit medication storage room, revealed two (2) boxes of PDI Sani-Cloth bleach germicidal disposable wipes with an expiration date of ,[DATE]. Box #1 contained seventeen (17) expired wipes and box #2 contained forty (40) expired wipes. Review of the medical records on the West Unit revealed there were fourteen (14) residents with orders for Finger Stick Blood Sugars (FSBS) related to [DIAGNOSES REDACTED]. Review of Resident #5's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED].#5's (MONTH) 2019 physician's orders [REDACTED].>Review of Resident #12's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #18's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #19's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #19's (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #21's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #21's (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #30's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #30's (MONTH) 2019 physician's orders [REDACTED].>Review of Resident #36's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #36's (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #44's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #44's (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #48's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #48's (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #49's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #49's (MONTH) 2019 physician's orders [REDACTED].>Review of Resident #57's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED].#57's (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #66's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #66's (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #88's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #88's (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #140's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #140's (MONTH) 2019 physician's orders [REDACTED]. Interview on [DATE] at 9:21 AM, with Licensed Practical Nurse (LPN) #3, revealed the expired wipes on the West Unit should have been discarded when expired. She stated the supplies in the medication storage room were checked weekly by nursing staff to ensure supplies were not expired. She stated she was unsure why the expired wipes were not noticed and removed. Interview on [DATE] at 1:55 PM, with the Director of Nursing (DON), revealed it was her expectation nursing staff examine the supplies in the medication storage rooms and medication carts at least weekly and check the expiration dates prior to using the supplies. Per interview, the nursing staff should have disposed of the expired PDI Sani-Cloth bleach germicidal disposable wipes on the West Unit and ordered new wipes. Further interview revealed the wipes were used to clean the glucometers and if expired wipes were used, this could result in the glucometers not being sanitized properly. (A glucometer is a device used to measure blood sugar). Interview on [DATE] at 2:20 PM, with the Executive Director (ED), revealed it was his expectation the nursing staff remove any expired supplies. He stated nursing staff was to check medication carts and storage rooms at least weekly to ensure supplies were not expired. He stated expired Sani-Cloth disposable wipes should not be accessible for use because using expired wipes could result in the glucometers not being sanitized properly.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to revise the Comprehensive Plan of Care for two (2) of twenty-two (22) residents (Resident #41 and Resident #20). Resident #20's Nutrition Comprehensive Care Plan dated 12/01/18, revealed the resident was at nutritional risk. Per record review, the resident had a severe weight loss of 17.6 percent in one (1) month, from 05/07/19 until 06/10/19 and the Registered Dietician (RD) made dietary recommendations on 06/10/19, related to the weight loss. However, the Comprehensive Care Plan was not revised related to the actual weight loss, nor was the Care Plan revised related to ensuring dietary recommendations were followed with approval from the Physician. There was no documented evidence the facility acted on the RD's dietary recommendations dated 06/10/19 for Resident #20, and the resident continued to lose weight. Additionally, Resident #41's Nutrition Comprehensive Care Plan dated 12/10/18, revealed the resident was at nutritional risk. Per record review, the resident had a significant weight loss of 5.9 percent in one (1) month from 05/09/19 until 06/10/19, and the RD made dietary recommendations on 06/10/19, related to the weight loss. However, the Comprehensive Care Plan was not revised related to the actual weight loss, nor was the Care Plan revised related to ensuring dietary recommendations were followed with approval from the Physician. There was no documented evidence the facility acted on the RD's dietary recommendations dated 06/10/19 for Resident #41, and the resident continued to lose weight. The Findings Include: Review of the Policy titled Care Planning and Interventions, revised 07/23/09, revealed the Interdisciplinary team meets on a scheduled basis and develops an individualized care plan. Interdisciplinary means that professional disciplines, as appropriate, work together to provide the greatest benefit to the resident. The care plan addresses the identified cause of impaired nutritional status, treatment objectives with measurable outcomes. Further review of the Policy, revealed the care plan is updated as needed, but no less than quarterly as conditions change, goals are met, interventions are determined to be ineffective or need to be revised, specific treatable causes of nutrition-related problems (anorexia, impaired chewing, ect.) are identified. If nutritional goals are not achieved, different or additional pertinent approaches are considered and implemented as indicated. Additional review of the Policy, revealed the care plan includes nutritional interventions that address underlying risks and causes of weight loss such as the need for eating assistance, reduction of medication side effects, and/or additional food the resident may prefer or need. Further review of the Policy, revealed the care plan addresses insidious, abrupt, or sudden decline in intake or insidious weight loss. 1. Review of Resident #20's clinical record revealed the facility admitted the resident on 09/19/18 and readmitted the resident on 03/27/19 with diagnoses, including [MEDICAL CONDITION] Fibrillation, Dementia, [MEDICAL CONDITION], Cognitive Communication Deficit, Unspecified, [MEDICAL CONDITION], Dysphagia, and Deficiency of Vitamins. Review of the Comprehensive Care Plan, dated 12/01/18, revealed Resident #20 was at nutritional risk. The goal with a target date of 07/17/19, revealed the resident would sustain no significant weight loss through next review date. There were several interventions including provide diet as ordered; nursing staff to observe and report to the physician significant weight loss; food substitutes offered as needed and provide dining room/meal accommodations; allow adequate time to eat, provide a quiet, calm setting; referral to the RD as needed; weight results observed; notify Physician of any complications; encourage resident to go to the dining room for all meals; vitamins as ordered; suction resident as needed; encourage to be up for meals; liquids honey thickened; use weighed utensils, ergo cup, and divided plate. Review of Resident #20's Quarterly Minimum Data Set (MDS) Assessment, dated 03/27/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of zero zero (0) out of fifteen (15), indicating severe cognitive impairment. Continued review of the MDS Assessment, revealed the facility assessed Resident #20 as coughing or choking during meals or when swallowing medications. Per the MDS Assessment, the facility assessed Resident #20 as 68 inches tall with a weight of 175 pounds. Continued review of the MDS Assessment, revealed the facility assessed the resident as having a weight loss of five (5) percent or more in the last month or loss of ten (10) percent or more in the last six (6) months without being on a physician prescribed weight loss program. Review of the Weights and Vitals Summary, revealed in (MONTH) 2019 the resident received weekly weights and the resident's weight on 03/25/19 was 174 pounds. Resident #20 continued to receive weekly weights in (MONTH) 2019, and on 04/27/19, the residents weight was 170 pounds. Review of the physician's orders [REDACTED]. 5,000 unit capsule give one (1) by mouth one (1) time a day. Further review of the Weights and Vitals SummaryWeights and Vitals Summary, revealed in (MONTH) 2019, the resident received weekly weights and on 05/07/19, the resident's weight was 169.8 pounds. However, on 05/14/19, Resident #20's weight decreased to 145.3 pounds, which was a severe weight loss of 14 percent in one (1) week. Review of Resident #20's RD Note, dated 05/16/19, revealed the resident's current weight was 145.3 pounds, indicating a significant weight loss of 14 percent in seven (7) days. Additional review revealed the weight loss was undesirable and the resident's medications included [MEDICATION NAME] as appetite stimulant and [MEDICATION NAME] (diuretic). According to the Note, the resident received puree diet with Honey Thick Liquids, fortified cereal at breakfast, two (2) eggs for lunch, fortified potatoes at lunch, fortified soup at dinner and whole milk three (3) times a day. Further review of the Note, revealed the resident's PO (by mouth) intake was declining at 30% (percent) average intake. Per the Note, the resident was hallucinating and would eat only when he/she wanted to eat, the resident was known to refuse supplements, and the family refused tube feeding. Continued review of the Note, revealed continue with current plan of care. Additional review of Resident #20's Weights and Vitals Summary, revealed weekly weights continued in (MONTH) 2019 and (MONTH) 2019, and on 06/10/19, the resident weighed 140 pounds, which was a further weight loss of 5.3 pounds since 05/14/19. Resident #20 had a severe weight loss of 17.6 percent from 05/07/19 until 06/10/19, in one (1) month. Review of the RD Note dated 06/10/19, revealed Resident #20 had lost an undesirable amount of weight of 17.6 percent in one (1) month and per the nursing notes, some of the discrepancy could be related to the method of obtaining weights. Pertinent medical information included: receiving a diuretic; [MEDICATION NAME]; B 12; potassium chloride; Vitamin D; Vitamin C; and receiving [MEDICATION NAME] 15 mg (appetite stimulant). Current Diet: Regular/Home Thick Liquids. Current interventions include the following: fortified cereal at breakfast, two (2) eggs at lunch, fortified potatoes at lunch, fortified soup at dinner, whole milk three (3) times a day, divided plate, weighted utensils, and ergo cup with all meals. Intake at meals was less than 22 percent, which indicated a decline since last review on 04/25/19 by usual facility RD. Per the Note, Resident #20 was currently on Restorative Dining. Additional review of the Note, revealed Resident #20's current intake was providing less than 697 Kilocalories and less than 30 grams of protein a daily. RD recommendations included the following: discontinue fortified soup at dinner, whole milk three (3) times a day (honey thickened liquids). Further recommendations included: start on fortified potatoes at dinner; send honey thickened milk and juice with all meals; and start frozen house supplements twice a day with lunch and dinner. According to the Note, the Goal was weight maintenance and adequate oral intake through next review. However, the resident's Nutrition Care Plan was not revised related to the resident's actual weight loss. In addition, the Care Plan was not revised to ensure dietary recommendations were followed with approval from Physician. There was no documented evidence the the facility acted on the RD's dietary recommendations dated 06/10/19 for Resident #20. Additional review of Resident #20's record, revealed the resident was weighed on 06/17/19 after the dietician's recommendations, and at that time the resident had a further weight loss of 1.4 pounds, as indicated by a weight of 138.6 pounds. Observation on 06/20/19 at 4:50 PM, revealed State Registered Nurse Aide (SRNA #4) and SRNA #5 weighed Resident #20 using a Hoyer Lift and Sling. The Hoyer Lift and Sling were calculated to zero prior to assisting the resident into the sling to lift the resident clear of the bed. The resident's weight was observed to be 134.6 pounds, revealing the resident lost an additional four (4) pounds since the previous weight, on 06/17/19. Post Survey phone interview with the RD, on 07/02/19 at 3:09 PM, revealed she made dietary recommendations on 06/10/19 after she assessed and evaluated Resident #20. Per interview, on 06/10/19, she was covering for the facility consulting RD. Further interview revealed after writing up her recommendations on the Nutrition Recommendations Form, she presented a copy to the nursing supervisors on each wing, the Dietary Manager, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON). Per interview, a copy was also provided to the Health Information Manager in order for the recommendations to be given to the Physician to review. Additional interview revealed the RD's last day was 06/10/19 and she had no way to follow-up to make sure the Physician received the recommendations; however, she stated the DON was aware of Resident #20's weight loss. 2. Review of Resident #41's clinical record revealed the facility admitted the resident on 12/03/18 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, initiated 12/10/18, revealed Resident #41 was at nutritional risk. The goal with a target date of 06/26/19, revealed the resident would sustain no significant weight loss through the next review. There were several Interventions including provide therapeutic diet as ordered; report significant weight loss to the Physician; provide dining room/meal accommodations and allow adequate time to eat; refer to SLP (speech language Pathologist) and RD for screening as needed; and restorative dining. Review of the Quarterly MDS Assessment, dated 04/06/19, revealed the facility assessed the resident as having a BIMS of zero (0) out of fifteen (15), indicating severe cognitive impairment. Further review revealed the facility assessed the resident as having a height of 62 inches, and weight of 188 pounds; as receiving a therapeutic diet; and as having no significant weight loss or gain. Review of Resident #41's Weights and Vitals Summary, revealed on 04/06/19 the resident weighed 188 pounds. Review of physician's orders [REDACTED]. Further review of Resident #41's Weights and Vitals Summary, revealed on 05/09/19, the resident weighed 186.7 pounds, indicating a 1.3 pound weight loss since 04/06/19. Review of physician's orders [REDACTED]. Additional review of Resident #41's Weights and Vitals Summary, revealed on 06/10/19, the resident weighed 175.7 pounds, which was a 5.9 percent weight loss since 05/09/19. This was a significant weight loss in one (1) month. Review of Resident #41's Nutrition/Dietary Note, dated 06/10/19, completed by the RD, revealed the resident's current weight on 06/10/19 was 175.7 pounds for a 5.9 percent weight loss in less than thirty (30) days, with usual body weight 186 pounds, on 12/03/18. Per the Note, Resident #41's current interventions included: NAS (No Added Salt) Regular/Thin liquid diet; and restorative dining for self-feeding; Pertinent medical information: positive for diuretic; positive for DM (Diabetes Mellitus); positive for dementia; positive for dysphagia; and skin intact. Per the Note, the resident was consuming fifty-five percent (55%) intake of meals per the recorded documentation, which was providing about 1238 kilocalories (kcal) and about 53 grams protein. Continued review of the Nutrition/Dietary Note, revealed the resident was referred to ST (speech therapy) on 06/06/19 and supervision and cueing was required at meals. Further review of the Note, revealed the resident's estimated needs were 2000 kcal, 25 kcal/kg (kilocalorie/kilogram), 80 grams protein (one (1) g/kg (gram/kilogram), 2000 milliliters fluid (one (1) ml/kcal (milliliter/kilocalorie). Additional review of the Note, revealed the resident's intake was insufficient to meet estimated needs at this time and the RD made the following recommendations: liberalize diet to Regular/Thin; start fortified cereal at breakfast, 313 kilocalories/ 11 grams protein, start House Supplement 120 ml BID (twice a day). However, the resident's Nutrition Care Plan was not revised related to the resident's actual weight loss. In addition, the Care Plan was not revised related to ensuring dietary recommendations were followed after Physician approval. There was no documented evidence the facility acted on the RD recommendations from 06/10/19 to liberalize diet to Regular/Thin; start fortified cereal at breakfast; and start House Supplement at 120 mls twice a day. Observation on 06/20/19 at 11:55 AM, revealed Resident #41 was in restorative dining, and the resident's meal ticket stated Regular NAS (No Added Salt), Regular texture. Interview with State Registered Nurse Aide (SRNA) #8, the staff assisting at restorative dining, revealed there was pepper only on the resident's tray. Therefore, the resident had not received the diet as per the recommendations of the RD on 06/10/19, for Regular Diet. Observation on 06/20/19 at 4:40 PM, revealed SRNA #4 and SRNA #5 weighed Resident #41 and the resident's weight was observed to be 172 pounds, revealing a further weight loss of 3.7 pounds since 06/10/19. Interview with the RD, on 06/20/19 at 11:02 AM, revealed she had been covering as the dietitian for three (3) weeks. Per interview, she saw Resident #41 on 06/10/19 related to weight loss. She stated on 06/10/19, her recommendations for Resident #41 were to liberalize diet to regular thin, added fortified cereal at breakfast, and house supplement 120 mls twice a day, to be given with medications. She further stated when she made a recommendation related to weight loss, she would complete a Nutrition Recommendations sheet to give to to the Dietary Manager, but she was unaware of the process in which the Physician was notified of her dietary recommendations. Per interview, she did not know if her recommendations were implemented for Resident #41, as she no longer worked at the facility. Interview with the Dietary Manager, on 06/20/19 at 4:16 PM, revealed the RD transcribed her dietary recommendations to a Nutrition Recommendations Form and these Forms came to him from the RD. Per interview, he made copies and distributed them to the Director of Nursing (DON); the Licensed Practical Nurse (LPN) Trainer; the Health Information Manager, and kept a copy for Dietary. Per interview, the Health Information Manager had the Physicians to sign the dietary recommendations as agree or disagree and then brought the signed copies back to him. Further interview with the Dietary Manager, revealed the RD was at the facility on 06/10/19 and gave him copies of the Nutrition Recommendations Forms completed by the RD on that date. Per interview, the Dietary Manager distributed the Forms to the Health Information Manager on 06/11/19; however, he had not received the Forms back as of this date, regarding Resident #20 and Resident #41. Continued interview revealed sometimes the Nutrition Recommendation Forms were returned to him with the Physician's decision documented related to the recommendations in two (2) to three (3) days; or sometimes it took as long as five (5) days. Interview with the Health Information Manager, on 06/20/19 at 2:10 PM, revealed when she received the copy of the Nutrition Recommendations Forms from the Dietary Manager, she took them to the Medical Director, and then to the other Physicians on Mondays, Wednesdays, and Fridays. Continued interview revealed she then brought back the Nutrition Recommendations Forms after the Physician reviewed them, and gave them to the LPN Trainer. Per interview, she could not recall if she had received information back from the Physician related to RD recommendations written on 06/10/19 for Resident #20 and Resident #41. Interview with the Director of Nursing (DON), on 06/20/19 at 1:45 PM and at 5:02 PM, revealed the process after a dietary recommendation was made, was for a copy of the Nutrition Recommendations (dietary recommendation) to be sent to the Dietary Manager, and then he provided a copy to the Health Information Manager, who had the Physicians to sign as agreeing or disagreeing with the recommendations. She stated the LPN Trainer then entered the approved recommendations into the medical record as physician's orders [REDACTED].#20 and Resident #41. Additional interview, revealed she acknowledged Care Plans should be revised as needed to remain current with problem/concern, and necessary interventions. Interview with the Administrator, on 06/20/19 at 5:37 PM, revealed he was not aware the Nutrition Recommendations from 06/10/19 for Resident #20 and Resident #41 had not been returned to the facility and documented/implemented as physician's orders [REDACTED]. Continued interview revealed he acknowledged Nutrition Care Plans should be revised as per policy.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure residents maintained acceptable parameters of nutritional status for two (2) of six (6) sampled residents reviewed for Nutrition out of a total sample of of twenty-two (22) residents (Resident #20 and Resident #41). Resident #20 had a severe weight loss of 17.6 percent in one (1) month, from 05/07/19 until 06/10/19. Although the Registered Dietician (RD) was aware of the weight loss and made dietary recommendations on 06/10/19, there was no documented evidence the facility acted on the dietary recommendations even though the resident continued to lose weight. Additionally, Resident #41 had a significant weight loss of 5.9 percent in one (1) month from 05/09/19 until 06/10/19. Although the RD was aware of the weight loss and made dietary recommendations on 06/10/19, there was no documented evidence the facility acted on the dietary recommendations in an attempt to prevent further weight loss. The findings include: Review of the facility Nutrition Assessment Process, Policy, revised 07/23/09, revealed the Interdisciplinary Team ensures acceptable nutritional status, as defined by parameters of body weight, hydration, and protein levels, is maintained, unless a resident's clinical condition demonstrates this is not possible. The emphasis is on the prevention and/or early detection of the development of any nutritional concerns. Further review of the Policy, revealed upon admission, annually, and when there is a Comprehensive Assessment (Minimum Data Set Assessment) completed, the Director of Food and Nutrition Services or the designee and/or a RD (Registered Dietitian) completes the Nutrition Data Collection/Assessment, which includes personal and cultural food preferences, along with snack patterns and dislikes, and usual body weight is obtained if possible. In addition, the RD completes the nutrition assessment and visits the resident before completing the assessment. Medications and nutritional supplements may affect or be affected by the intake or utilization of nutrients. To the extent possible, consideration of these interactions is individualized. Additional review of the Policy, revealed if follow up is required after the RD completes the assessment, he or she uses the Nutrition Assessment Recommendations form, and includes the resident's name and room number, and includes the recommendation and rationale for the recommendation where indicated. In the responsibility column, the RD marks the department (Nursing or Food and Nutrition Services) that is responsible for the follow up. Per Policy, the completed form is given to Nursing or the Director of Food and Nutrition Services and recommendations are addressed in a timely manner (within seventy-two (72) hours). 1. Review of Resident #20's medical record revealed the facility admitted the resident on 09/19/18 and readmitted the resident on 03/27/19 with diagnoses, including [MEDICAL CONDITION] Fibrillation, Dementia, [MEDICAL CONDITION], Cognitive Communication Deficit, Unspecified, [MEDICAL CONDITION], Dysphagia, and Deficiency of Vitamins. Review of Resident #20's Comprehensive Care Plan, dated 12/01/18, revealed the resident was at nutritional risk. The goal with a target date of 07/17/19, revealed the resident would sustain no significant weight loss through the next review date. Interventions included: provide diet as ordered; nursing staff to observe and report to the physician significant weight loss; food substitutes offered as needed and provide dining room/meal accommodations; allow adequate time to eat, provide a quiet, calm setting; referral to the RD as needed; weight results observed; notify Physician of any complications; encourage resident to go to the dining room for all meals; vitamins as ordered; suction resident as needed; encourage to be up for meals; liquids honey thickened; use weighed utensils, ergo cup, and divided plate. Resident #20 was assessed by the facility, per the Quarterly Minimum Data Set (MDS) Assessment, dated 03/27/19, as having a Brief Interview for Mental Status (BIMS) of zero zero (0) out of fifteen (15), indicating severe cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed Resident #20 as coughing or choking during meals or when swallowing medications. Per the MDS Assessment, the facility assessed the resident as 68 inches tall with a weight of 175 pounds. Further review of the MDS Assessment, revealed the facility assessed the resident as having a weight loss of five (5) percent or more in the last month or loss of ten (10) percent or more in the last six (6) months without being on a physician prescribed weight loss program. Review of Resident #20's Weights and Vitals Summary, revealed in (MONTH) 2019 the resident received weekly weights and the resident's weight on 03/25/19 was 174 pounds. The resident continued to receive weekly weights in (MONTH) 2019, and on 04/27/19, the residents weight was 170 pounds. Review of Resident #20's physician's orders [REDACTED]. 5,000 unit capsule give one (1) by mouth one (1) time a day. Continued review of the Weights and Vitals SummaryWeights and Vitals Summary, revealed in (MONTH) 2019, the resident received weekly weights and on 05/07/19, the resident's weight was 169.8 pounds. However, on 05/14/19, the resident's weight decreased to 145.3 pounds, which was a severe weight loss of 14 percent in one (1) week. Review of Resident #20's RD Note, dated 05/16/19, revealed the resident's current weight was 145.3 pounds, showing a significant weight loss of 14 percent in seven (7) days. Further review revealed the weight loss was undesirable and the resident's medications included [MEDICATION NAME] as appetite stimulant and [MEDICATION NAME] (diuretic). Per the Note, the resident received puree diet with Honey Thick Liquids, fortified cereal at breakfast, two (2) eggs for lunch, fortified potatoes at lunch, fortified soup at dinner and whole milk three (3) times a day. Per the Note, the resident's PO (by mouth) intake was declining at 30 percent average intake. Further review of the Note, revealed the resident was hallucinating and would eat only when he/she wanted to eat, and the resident was known to refuse supplements. The family refuses tube feeding. Additional review of the Note, revealed continue with current plan of care. Additional review of the Weights and Vitals Summary, revealed weekly weights continued in (MONTH) 2019 and (MONTH) 2019, and on 06/10/19, the resident weighed 140 pounds, which was a further weight loss of 5.3 pounds since 05/14/19. The resident had a severe weight loss of 17.6 percent from 05/07/19 until 06/10/19, in one (1) month. Review of Resident #20's RD Note dated 06/10/19, revealed the resident had lost an undesirable amount of weight of 17.6 percent in one (1) month and per the nursing notes, some of the discrepancy could be related to the method of obtaining weights. Pertinent medical information: receiving a diuretic; [MEDICATION NAME]; B 12; potassium chloride; Vitamin D; Vitamin C; and receiving [MEDICATION NAME] 15 mg (appetite stimulant). Diet presently: Regular/Home Thick Liquids. Current interventions include fortified cereal at breakfast, two (2) eggs at lunch, fortified potatoes at lunch, fortified soup at dinner, whole milk three (3) times a day, divided plate, weighted utensils, and ergo cup with all meals. Intake at meals was less than 22 percent, which showed a decline since last review on 04/25/19 by usual facility RD. The resident is currently on Restorative Dining. Further review of the Note, revealed Resident #20's current intake was providing less than 697 Kilocalories and less than 30 grams of protein a daily. RD Recommendations included: discontinue fortified soup at dinner, whole milk three (3) times a day (honey thickened liquids). Start on fortified potatoes at dinner; send honey thickened milk and juice with all meals; and start frozen house supplements twice a day with lunch and dinner. Per the Note, the Goal was weight maintenance and adequate oral intake through next review. However, there was no documented evidence the the facility acted on the RD's dietary recommendations dated 06/10/19. Additional review of the record, revealed Resident #20 was weighed on 06/17/19 after the dietician's recommendations, and at that time Resident #20 had a further weight loss of 1.4 pounds, as indicated by a weight of 138.6#. Observation on 06/20/19 at 4:50 PM, revealed SRNA #4 and SRNA #5 weighed Resident #20 using a Hoyer Lift and Sling. The Hoyer Lift and Sling were calculated to zero prior to placing the resident in the sling to lift the resident clear of the bed. The weight was observed at 134.6 pounds, revealing the resident lost an additional four (4) pounds since the previous weight, on 06/17/19. Post Survey phone interview with the RD, on 07/02/19 at 3:09 PM, revealed she made recommendations on 06/10/19 after she assessed and evaluated Resident #20. Per interview, on 06/10/19, she was filling in for the facility consulting RD. Continued interview revealed after writing up her recommendations on the Nutrition Recommendations Form, she presented a copy to the nursing supervisors on each wing, the Dietary Manager, the Licensed Practical Nurse (LPN) Trainer and the Director of Nursing (DON). Per interview, a copy was also provided to the Health Information Manager in order for the recommendations to be given to the Physician for review. Further interview revealed the RD's last day was 06/10/19 and she had no way to follow-up to make sure the Physician received the recommendations. Continued interview revealed the DON was aware of Resident #20's weight loss. Post Survey phone interview with the Physician, on 07/02/19 at 10:12 AM, revealed he could not recall if he had signed as approving recommendations made by the RD on 06/10/19 related to Resident #20. Further interview revealed he did speak with nursing staff after 06/10/19 concerning Resident #20's weight loss. 2. Review of Resident #41's medical record revealed the facility admitted the resident on 12/03/18 with [DIAGNOSES REDACTED]. Review of Resident #41 Comprehensive Care Plan, initiated 12/10/18, revealed the resident was at nutritional risk. The goal with a target date of 06/26/19, revealed the resident would sustain no significant weight loss through next review. Interventions included: provide therapeutic diet as ordered; report significant weight loss to the Physician; provide dining room/meal accommodations and allow adequate time to eat; refer to SLP (speech language Pathologist) and RD for screening as needed; and restorative dining. The facility assessed Resident #41 per the Quarterly MDS Assessment, dated 04/06/19, as having a BIMS of zero (0) out of fifteen (15), indicating severe cognitive impairment. Continued review revealed the facility assessed the resident as having a height of 62 inches, and weight of 188 pounds; as receiving a therapeutic diet; and as having no significant weight loss or gain. Review of the Weights and Vitals Summary, revealed on 04/06/19 Resident #41 weighed 188 pounds. Review of Resident #41's physician's orders [REDACTED]. Further review of the Weights and Vitals Summary, revealed on 05/09/19, the resident weighed 186.7 pounds, indicating a 1.3 pound weight loss since 04/06/19. Review of Resident #41's physician's orders [REDACTED]. Additional review of the Weights and Vitals Summary, revealed on 06/10/19, the resident weighed 175.7 pounds, which was a 5.9 percent weight loss since 05/09/19. This was a significant weight loss in one (1) month for Resident #41. Review of the Nutrition/Dietary Note, dated 06/10/19, completed by the RD, revealed Resident #41's current weight on 06/10/19 was 175.7 pounds for a 5.9 percent weight loss in less than thirty (30) days, with usual body weight 186 pounds, on 12/03/18. According to the Note, Resident #41's current interventions included: NAS (No Added Salt) Regular/Thin liquid diet; and restorative dining for self-feeding; Pertinent medical information: positive for diuretic; positive for DM (Diabetes Mellitus); positive for dementia; positive for dysphagia; and skin intact. Per the Note, Resident #41 was consuming fifty-five percent (55%) intake of meals per the recorded documentation, which was providing about 1238 kilocalories (kcal) and about 53 grams protein. Continued review of the Nutrition/Dietary Note, revealed Resident #41 was referred to ST (speech therapy) on 06/06/19 and supervision and cueing was required at meals. Additional review of the Note, revealed the resident's estimated needs were 2000 kcal, 25 kcal/kg (kilocalorie/kilogram), 80 grams protein (one (1) g/kg (gram/kilogram), 2000 milliliters fluid (one (1) ml/kcal (milliliter/kilocalorie). Per the Note, the resident's intake was insufficient to meet estimated needs at this time and the RD made the following recommendations: liberalize diet to Regular/Thin; start fortified cereal at breakfast, 313 kilocalories/ 11 grams protein, start House Supplement 120 ml BID (twice a day). There was no documented evidence the facility acted on the RD recommendations from 06/10/19 to liberalize diet to Regular/Thin; start fortified cereal at breakfast; and start House Supplement at 120 mls twice a day. Observation on 06/20/19 at 11:55 AM, revealed Resident #41 was in restorative dining, and the resident's meal ticket stated Regular NAS (No Added Salt), Regular texture. Therefore, the resident did not receive the diet as per the recommendations of the RD on 06/10/19, for Regular Diet. Observation on 06/20/19 at 4:40 PM, revealed SRNA #4 and SRNA #5 weighed Resident #41 and the resident's weight was 172 pounds, revealing a further weight loss of 3.7 pounds since 06/10/19. Interview with the RD, on 06/20/19 at 11:02 AM, revealed she had been covering as the dietitian the last three (3) weeks. Per interview, she saw Resident #41 on 06/10/19 related to his/her weight loss. Per interview, on 06/10/19, she made recommendations to liberalize the resident's diet to regular thin, added fortified cereal at breakfast, and house supplement 120 mls twice a day, to be given with medications. She further stated when she made a recommendation related to weight loss, she would complete a Nutrition Recommendations sheet to give to to the Dietary Manager; however, she was unaware of the process in which the Physician was notified of her dietary recommendations. Per interview, she did not know if her recommendations were implemented for Resident #41, as she no longer worked at the facility. Interview with the Dietary Manager, on 06/20/19 at 4:16 PM, revealed the RD transcribed her dietary recommendations to a Nutrition Recommendations Form, and then gave him the Forms. Per interview, he then made copies and distributed them to the Director of Nursing (DON); the Licensed Practical Nurse (LPN) Trainer; the Health Information Manager, and kept a copy for Dietary. Further, the Health Information Manager then had the Physicians to sign the dietary recommendations as agree or disagree and then brought the signed copies back to him. Continued interview with the Dietary Manager, revealed the RD was at the facility on 06/10/19 and gave him copies of the Nutrition Recommendations Forms completed on that date. Per interview, the Dietary Manager then distributed the Forms to the Health Information Manager on 06/11/19; however, he had not received the Forms back as of this date, regarding Resident #20 and Resident #41. Continued interview revealed it was important for the RD recommendations to be acted on timely in order to ensure proper nutritional interventions were implemented, but sometimes the turn around time from the date the RD made the recommendations to the date the recommendations were approved and sent back to him took as long as five (5) days. Interview with the Health Information Manager, on 06/20/19 at 2:10 PM, revealed after she received the copy of the Nutrition Recommendations Forms from the Dietary Manager, she took them to the Medical Director, and then to the other Physicians on Mondays, Wednesdays, and Fridays. Addtional interview revealed she then brought back the Nutrition Recommendations Forms after the Physician reviewed them, and gave them to the LPN Trainer. Per interview, she could not remember if she had received information back from the Physician related to RD recommendations written on 06/10/19 for Resident #20 and Resident #41. Interview with the Director of Nursing (DON), on 06/20/19 at 1:45 PM and at 5:02 PM, revealed after a dietary recommendation was made, a copy of the Nutrition Recommendations (dietary recommendation) was to be sent to the Dietary Manager, and then he provided a copy to the Health Information Manager, who had the Physicians to sign as agreeing or disagreeing with the recommendations. She stated the LPN Trainer who was on leave at this time, then entered the approved recommendations into the medical record as a physician's orders [REDACTED]. However, she stated the Nutrition Recommendations from the 06/10/19 RD visit for Resident #20 and Resident #41 were still awaiting approval from the Physician. Further interview revealed it was her expectation the Nutrition Recommendations have a seventy two (72) hour turn around time from the time the RD made the dietary recommendations until the physician's orders [REDACTED]. Interview with the Administrator, on 06/20/19 at 5:37 PM, revealed he was not aware the Nutrition Recommendations from 06/10/19 for Resident #20 and Resident #41 had not been returned to the facility and implemented as physician's orders [REDACTED]. Further interview revealed if the RD made a dietary recommendation, it was for a reason. Per interview, if dietary recommendations were not implemented, this could lead to potentially negative outcomes for the residents. Continued interview revealed someone should have noticed the Nutrition Recommendations dated 06/10/19 had not been completed and turned over to the Dietary Manager or HIM/Medical Records staff.

Based on observation, interview, and review of facility Policy, it was determined the facility failed to ensure proper storage of drugs and biologicals. Observation of the Medication Storage Room on the West Unit, on [DATE], revealed there was an expired vial of [MEDICATION NAME] Purified Protein Derivative (PPD), with an open date of [DATE], which was accessible for use. The findings include: Review of the facility's Medication Storage & Security in the Facility Policy, revised ,[DATE], revealed medications and biologicals were to be properly stored following manufacturer's recommendations. Review of the Manufacturer's Recommendations, revealed a vial of [MEDICATION NAME] Purified Protein Derivative should be discarded thirty (30) days after opening. ([MEDICATION NAME] PPD is used to perform [MEDICAL CONDITION] Skin Tests to determine if a person is infected with [DIAGNOSES REDACTED]). Observation on [DATE] at 8:43 AM, of the Medication Storage Room on the West Unit, revealed an expired vial of [MEDICATION NAME] PPD with an open date of [DATE]. (An open date of [DATE] would give the vial an expiration date of [DATE]). Interview on [DATE] at 9:21 AM, with Licensed Practical Nurse (LPN) #3, revealed the expired vial of [MEDICATION NAME] PPD should have been discarded thirty (30) days after the vial was opened. She stated use of expired [MEDICATION NAME] PPD could result in inaccurate test results. Interview on [DATE] at 1:55 PM, with the Director of Nursing (DON), revealed a vial of TB testing solution expired thirty (30) days after opening. She stated the nurses should be checking the open date and expiration date of medications prior to use, and should discard any out of date medications. She further stated using outdated TB test solution could result in false positive or false negative TB skin tests. Interview on [DATE] at 2:10 PM, with the Executive Director (ED), revealed any medication that was expired should be discarded. He stated it was his expectation nursing staff check expiration dates of any medication in the medication carts and medication rooms.