Every finding on record at Miller's Merry Manor

Based on observation, interview, and record review the facility failed to ensure safe positioning, skin and wound care was provided for 2 of 4 residents reviewed (Resident 17 and Resident 34). Findings include: 1. In an interview on 5/21/24 at 2:25 PM, Resident 34 indicated they had an infected wound on their left foot. Resident 34 indicated the wound on their left foot was caused by wearing their shoes without wearing socks. Resident 34's record was reviewed on 5/21/24 at 2:40 PM. Diagnoses included diabetes, chronic kidney disease, congestive heart failure, and an unstageable pressure ulcer of the left heel. Resident 34's Quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated Resident 34 had 1 unstageable pressure ulcer with suspected deep tissue injury in evolution. The MDS indicated there were no unstageable pressure ulcers present upon Resident 34's admission to the facility. A podiatry visit note dated 8/18/22 indicated Resident 34 had a diagnosis of diabetic neuropathy (numbness, tingling, burning or decreased sensation) of their feet. The visit note indicated Resident 34's feet were cool to touch, both feet were red, and both feet were absent of hair growth. The visit note indicated the skin on Resident 34's feet was thin, shiny, and dry. The visit note indicated Resident 34 was to be examined in 2 to 3 months. A podiatry visit note dated 1/6/23 indicated Resident 34's feet were cool to touch, both feet were red, and both feet were absent of hair growth. The visit note indicated the skin on the resident's feet was thin, shiny, and dry. The visit note indicated Resident 34 was to be examined in 2 to 3 months. Resident 34's record did not include further podiatry visit notes. A Weekly Nursing assessment dated [DATE] at 3:15 AM indicated Resident 34's feet were swollen. The assessment indicated Resident 34's skin had been assessed, the resident had been turned and repositioned per the plan of care. A Skilled Nursing assessment dated [DATE] at 12:35 PM indicated pressure prevention interventions for Resident 34's lower extremities were not applicable. The assessment indicated Resident 34 had been turned and repositioned per the plan of care, but no other interventions to prevent skin breakdown had been initiated. A Pressure Injury assessment dated [DATE] at 10:16 PM indicated Resident 34 had a new in-house deep tissue pressure injury 3.5 centimeters long and 5 centimeters wide. The assessment indicated the wound had no odor, no drainage, and no eschar (dead skin). The assessment indicated the skin surrounding the wound was swollen and red. A progress note dated 1/26/24 at 10:16 PM indicated Resident 34's left heel deep tissue pressure injury had been evaluated by a Nurse Practitioner. The note indicated new orders received included skin prep to the left heel twice daily, offloading pressure injury interventions, x-ray to the left heel and doxycycline twice daily for 10 days. A physician order dated 1/1/24 with an end date of 1/15/24 indicated Resident 34 had been admitted to a skilled COVID-19 isolation unit at the facility. A physician order dated 1/16/24 indicated the facility staff was to monitor Resident 34's foot and extremity skin condition every day for 30 days post COVID-19. The staff was to monitor for changes in color, temperature, and skin integrity. A physician order dated 1/26/24 indicated Resident 34 was to have an x-ray of their left foot and heel. A physician order dated 1/26/24 indicated Resident 34 was not to wear shoes. A physician order dated 1/26/24 indicated Resident 34's left heel was to be monitored every shift until resolved. The left heel was to be monitored for signs of infection, increased pain or unusual changes. A physician order dated 1/26/24 and discontinued 2/23/24 indicated Resident 34 was to have skin prep to the left heel every shift. A physician order dated 1/26/24 indicated Resident 34 was to be administered doxycycline (an antibiotic) two times a day for 10 days for cellulitis. A physician order dated 5/3/24 indicated Resident 34 was to be administered doxycycline two times a day for 10 days for wound healing. A physician order dated 2/23/24 and discontinued on 4/19/24 indicated Resident 34 was to have a povidone and iodine solution applied to their left heel two times a day for wound care. A physician order dated 4/19/24 and discontinued on 5/3/24 indicated Resident 34 was to have a povidone and iodine solution applied to their left heel two times a day for wound care. The left heel wound was to be cleansed, covered with an ABD (thick pad) and wrapped with gauze. A physician order dated 5/3/24 and discontinued on 5/17/24 indicated Resident 34's left heel wound was to be cleansed, silver ointment applied, covered with an ABD and wrapped with gauze every day. A physician order dated 5/17/24 indicated Resident 34's left heel wound was to have collagenase ointment applied, covered with an ABD and wrapped with gauze every day. A physician order dated 5/17/24 indicated a wound culture from Resident 34's left heel was to be collected due to drainage and odor. A physician order dated 5/21/24 indicated Resident 34 was to be administered amoxicillin (an antibiotic) every 8 hours for 10 days for wound infection. Resident 34's care plan dated 3/29/22 indicated the resident had diabetes. The target goal was to have no episodes of high or low blood sugar through 7/30/24. Interventions included floating heels while in bed and foot care by a licensed nurse or podiatrist as needed. Interventions did not include diabetic foot care such as heel protectors or visual inspection of Resident 34's feet. Resident 34's care plan dated 3/29/22 indicated the resident was at risk for skin breakdown and pressure ulcers due to heart failure, kidney disease and diabetes. Risk factors did not include diabetic neuropathy. The target goal was to avoid skin breakdown through 7/30/24. Interventions included floating heels while in bed, monitoring skin daily during care, and weekly skin assessment by the nurse. Interventions did not include diabetic foot care such as visual inspection or heel protectors. Resident 34's care plan dated 1/26/24 indicated the resident had an unstageable pressure injury to the left heel that presented dark, hardened, non-blanchable, intact eschar related to end stage renal disease and diabetes. The target goal was for the wound to reduce in size without complications through 7/30/24. Interventions included floating heels while in bed, povidone-iodine treatments, and weekly assessments by a nurse. Interventions did not include diabetic foot care such as visual inspection or heel protectors. In an interview on 5/22/24 at 12:25 PM the Director of Nursing (DON) indicated skin assessments were documented weekly on every resident. The DON indicated skin assessments were documented daily while residents required skilled daily assessments. The DON indicated the skin assessments referred to all the resident's skin including their feet. The DON indicated facility Certified Nurse Aides (CNAs) inspect each resident's skin while performing resident showers. The DON indicated the CNAs report new skin issues to the nurses. The DON indicated the CNAs document skin inspections by hand onto shower sheets. The DON indicated the shower sheets were not scanned into the resident's medical record. The DON indicated shower sheets from January 2024 were not available as the shower sheets were only kept for 1 month. The DON indicated the facility did not have a specific assessment for diabetics or diabetic foot care. The DON indicated most diabetics are treated by the facility podiatrist for foot care. The DON indicated they were not aware of when Resident 34 had most recently been evaluated by the podiatrist. The DON indicated the podiatrist was at the facility the previous Friday and would look to see if Resident 34 had been seen by the podiatrist. In an interview on 5/22/24 at 1:00 PM the DON indicated the facility did not have a diabetic foot care policy. The DON indicated they were not able to provide further documentation of the condition of Resident 34's left heel prior to 1/16/24. The DON indicated they believed the sudden development of Resident 34's left heel pressure injury was related to the resident having had Covid-19 and pneumonia in January 2024. A current facility policy dated 8/14/14 provided by the DON on 5/22/24 at 12:50 PM indicated interventions would be implemented according to individual resident risk factors. The policy indicated individual resident risk factors would guide the interventions that would best reduce the risks of the development of pressure ulcers, diabetic ulcers, arterial ulcers, and venous ulcers. The policy indicated the interventions would promote the most effective healing of existing ulcers. The policy indicated heel protection devices should elevate the heels above the bed. The policy indicated the skin on the heels should be inspected on a regular basis. 46756 2. During an observation on 5/21/24 at 12:01 PM Resident 17 was observed semi-reclined in a wheelchair with her neck hyperextended backward. A grey, rounded neck cushion was observed on the back and sides of her neck. Qualified Medicine Aide (QMA) 3 was seated next to Resident 17 physically assisting her to eat and drink by bringing food to her mouth by spoon, bringing a cup to her lips and pouring fluids into her mouth. Resident 17 was observed coughing several times. During an observation on 5/22/24 at 11:57 AM, Resident 17 was observed in the dining room, semi-reclined in a wheelchair, her neck hyperextended backward, with a grey neck cushion in place. Certified Nurse Aide (CNA) 4 was seated next to Resident 17 assisting her with eating and drinking. Resident 17's record was reviewed on 5/22/24 at 10:11 AM. Diagnoses included unspecified dementia, unspecified severity, with psychotic disturbance, abnormal posture, dysphagia, oropharyngeal phase. Resident 17's current quarterly Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) was not conducted because she was rarely or never able to make herself understood. The MDS indicated Resident 17 had severely impaired ability to make daily decisions and was unable to perform any of the effort to perform tasks of bringing eating utensils or liquids to her mouth. Resident 17's current care plan titled Brace Program indicated the resident had a problem of needing assistance to apply a brace for positioning, with a goal date of 6/24/24. Interventions included applying a blue collar around Resident 17's neck. Resident 17's current care plan titled Risk for Aspiration indicated Resident 17 had swallowing difficulties and frequently leaned her head back during eating, with a goal date of 6/24/24. Interventions included monitoring coughing or choking with meals and monitoring breath sounds as needed. No progress notes from 5/21/24 or 5/22/24 were available for review. Occupational therapy notes dated 10/17/23 indicated Resident 17 should have a blue collar support device in place during eating. A restorative program in the Kardex indicated a blue collar should be applied before meals and removed after meals. A current CNA assignment sheet, provided by Registered Nurse (RN) 2 for Resident 17 did not include any instructions regarding any support device to be worn while eating or drinking. In an observation and interview on 5/22/24 at 12:08 PM, Resident 17 was observed in her room, a tan neck cushion with grey gripper socks placed over the ends in place behind her neck. Certified Occupational Therapy Assistant (COTA) 6 indicated she did not know what happened to the grey neck cushion Resident 17 was using at lunch. She indicated Resident 17 had a blue cervical collar in the past, but she had not seen it in a long time, so she gave staff the tan cushion. She indicated the therapy department had not been notified of any occurrences of Resident 17 coughing while eating or drinking. In an interview on 5/22/24 at 12:51 PM, RN 2 indicated she was on duty on 5/21/24 and had not been notified of any coughing or choking during lunch that day. In an interview on 5/22/24 at 12:56 PM, CNA 4 indicated CNA assignment sheets provide the staff information needed to care for a resident, including any devices used for positioning. She indicated the kiosk was only used for documentation of activities of daily living, intakes, bowel movements, behaviors and it would not be used to find instructions for resident care. She indicated any coughing or choking during eating or drinking should be reported to the nurse. A current policy titled Feeding Dependent Resident Procedure dated 3/1/2001 provided by the Administrator on 5/22/24 at 2:28 PM did not address positioning or use of positioning devices. A current policy titled Therapy Screening Procedure dated 10/17/23 provided by the Administrator on 5/22/24 at 2:28 PM indicated nursing staff should document a resident's decline in the medical record and complete a therapy notification form. 3. During a record review on 5/21/24 at 12:40 PM a Nursing New Skin Alteration assessment dated [DATE] indicated Resident 17 had bug bites on her upper arm and chest. No number of areas, description of areas or measurement of areas was available for review. No physician's orders regarding treatment of the areas were available for review. No care plans pertaining to the areas were available for review. No progress notes or skin assessment forms pertaining to follow-up assessments of the area were available for review. In an interview and observation on 5/21/24 at 3:15 PM, RN 2 indicated she was on duty when a CNA notified her of red skin areas on Resident 17's arm and chest. Resident 17 had 4 areas on her left upper arm and one on her neck, each round, about 3 centimeters in diameter with a darkened center about 3 millimeters in diameter. She indicated she and Nurse Practitioner 8 looked at the areas and believed they were bug bites. She indicated she did not find any bugs in the room currently or at the time of the discovery of the skin areas. During an interview on 5/22/24 at 11:41 AM, the Director of Nursing (DON) indicated upon finding a new skin area, the area should be assessed, measured, and documented. She indicated follow-up assessments should also be documented. A current policy titled Skin Management Program, dated 8/14/14, provided by the Director of Nursing on 5/22/24 at 11:27 AM indicated the plan of care should be updated as changes occur. The policy also indicated skin alterations will be monitored and assessed by the staff nurse, with the DON or designee overseeing completion of documentation. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure procedures were maintained per facility policy to prevent infection and to promote comfort during the healing of pressure injuries for 1 of 1 resident reviewed (Resident 34). Findings include: In an interview on 5/21/24 at 2:25 PM, Resident 34 indicated they had an infected wound on their left foot. Resident 34 indicated they had been taking antibiotics for the wound infection. Resident 34 indicated the wound on their left foot was caused by wearing new shoes without wearing socks. Resident 34's record was reviewed on 5/21/24 at 2:40 PM. Diagnoses included diabetes, chronic kidney disease, congestive heart failure, and an unstageable pressure ulcer of the left heal. A Pressure Injury assessment dated [DATE] at 10:16 PM indicated Resident 34 had a new in-house deep tissue pressure injury 3.5 centimeters long and 5 centimeters wide. The assessment indicated the wound had no odor, no drainage, and no eschar (dead skin). The assessment indicated the skin surrounding the wound was swollen and red. A physician order dated 5/17/24 indicated Resident 34's left heel wound was to have collagenase ointment applied, covered with an ABD (type of gauze pad) and wrapped with gauze every day. A progress note dated 5/17/24 at 11:19 AM indicated Resident 34's left heel wound had been debrided and a wound culture was collected. A physician order dated 5/21/24 indicated Resident 34 was to be administered amoxicillin (an antibiotic) every 8 hours for 10 days for wound infection. On 5/22/24 at 10:24 AM Resident 34's left heel dressing change was observed. Registered Nurse (RN) 2 explained the procedure to Resident 34. RN 2 did not provide a pain assessment for Resident 34. Dressing supplies were observed to be on a clean barrier on an over bed table. Certified Nurse Aide (CNA) 5 held Resident 34's foot above a clean barrier on the resident's bed. RN 2 donned gloves and removed the previous dressing. RN 2 placed the prior dressing in a trash bag, removed their gloves and washed their hands. RN 2 washed and dried their hands within 15 seconds. RN 2 donned gloves and cleansed the wound with wound cleanser. RN 2 did not inquire if Resident 34 was experiencing pain from the procedure. RN 2 removed their gloves and washed their hands. RN 2 washed and dried their hands within 15 seconds. RN 2 donned gloves and applied the ointment, placed the ABD pad, wrapped the wound with gauze, and secured with tape. RN 2 placed their gloves in a trash bag, tied the trash bag and walked to the bathroom. RN 2 touched the bathroom door with an ungloved hand after placing the trash bag in the trash can. RN 2 did not wash their hands after disposing of the trash. RN 2 placed Resident 34's ointment into a clear plastic bag after disposing of trash, touching the bathroom door, and not washing their hands. In an interview on 5/22/24 at 10:32 AM Resident 34 indicated the dressing change to their left heel pressure injury had been a little bit painful. In an interview on 5/22/24 at 1:24 PM RN 2 indicated Resident 34 had not been assessed for pain prior to, during, or after the dressing change procedure. RN 2 indicated Resident 34 did not appear to be in pain. RN 2 indicated Resident 34 has repeatedly denied the need for pain control prior to their dressing changes in the past. A current facility policy dated 7/14/14 provided by the DON on 5/22/24 at 10:30 AM indicated gloves should be changed and hands washed after removing the previous dressing, after cleansing the wound and before applying medication and dressing to the wound. A current facility policy dated 10/27/16 provided by the DON on 5/22/24 at 11:10 AM indicated the entire handwashing procedure should take 40 to 60 seconds. The policy indicated the hands should be washed with soap, water and rubbing action for at least 20 seconds. The policy indicated handwashing assists in the prevention of disease and infection. A current facility policy dated 4/10/24 provided by the DON on 5/22/24 at 12:50 PM indicated a pain assessment would be completed with all wound assessments. 3.1-40

Based on observation, interview and record review, the facility failed to ensure standard precautions for infection prevention were maintained during a dressing change for 1 of 1 resident reviewed (Resident 34). Findings include: In an interview on 5/21/24 at 2:25 PM, Resident 34 indicated they had a wound on their left foot. Resident 34 indicated the wound on their left foot was caused by wearing their shoes without socks. Resident 34 indicated they had started taking antibiotics due to an infection in the wound. Resident 34's record was reviewed on 5/21/24 at 2:40 PM. Diagnoses included diabetes, chronic kidney disease, congestive heart failure, and an unstageable pressure ulcer of the left heel. Resident 34's Quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) was 15 (cognitively intact). The MDS indicated Resident 34 had 1 unstageable pressure ulcer with suspected deep tissue injury in evolution. The MDS indicated there were no unstageable pressure ulcers present upon Resident 34's admission to the facility. A physician order dated 1/26/24 indicated Resident 34 was to be administered doxycycline (an antibiotic) two times a day for 10 days for cellulitis. A physician order dated 5/3/24 indicated Resident 34 was to be administered doxycycline two times a day for 10 days for wound. A physician order dated 5/17/24 indicated Resident 34's pressure ulcer to the left heel was to have collagenase ointment applied, covered with an ABD (thick gauze pad) and wrapped with gauze every day. A physician order dated 5/21/24 indicated Resident 34 was to be administered amoxicillin (an antibiotic) every 8 hours for 10 days for wound infection. On 5/22/24 at 10:24 AM Resident 34's left heel dressing change was observed. Dressing supplies were observed to be on a clean barrier on an over bed table. Certified Nurse Aide (CNA) 5 held Resident 34's foot above a clean barrier on the resident's bed. Registered Nurse (RN) 2 donned gloves and removed the previous dressing. RN 2 placed the prior dressing in a trash bag, removed their gloves and washed their hands. RN 2 washed and dried their hands within 15 seconds. RN 2 donned gloves and cleansed the wound with wound cleanser. RN 2 removed their gloves and washed their hands. RN 2 washed and dried their hands within 15 seconds. RN 2 donned gloves and applied the ointment, placed the ABD pad, wrapped the wound with gauze, and secured with tape. RN 2 placed their gloves in a trash bag, tied the trash bag and walked to the bathroom. RN 2 touched the bathroom door with an ungloved hand after placing the trash bag in the trash can. RN 2 did not wash their hands after disposing of the trash. RN 2 placed Resident 34's ointment into a clear plastic bag after disposing of trash, touching the bathroom door, and not washing their hands. In an interview on 5/22/24 at 10:35 AM RN 2 indicated they did not realize they had not washed their hands after placing the trash in the trash can. RN 2 indicated they did not realize they had touched surfaces or placed the ointment into a plastic bag after handling trash and failing to wash their hands. RN 2 indicated they did not realize they had washed and dried their hands within 15 seconds. RN 2 indicated they would have to review the facility handwashing policy to be certain but believed proper handwashing should take about 20 seconds. In an interview on 5/22/24 at 10:30 AM the DON indicated RN 2 had made them aware of the handwashing concerns that had been observed while RN 2 changed Resident 34's left heel wound dressing. The DON indicated they were aware of Resident 34 being prescribed antibiotics for the left heel wound infection on 1/26/24, 5/3/24 and 5/21/24. The DON indicated Resident 34's left heel wound was slow healing due to the resident having had Covid-19 in January 2024. A current facility policy dated 7/14/14 provided by the DON on 5/22/24 at 10:30 AM indicated gloves should be changed and hands washed after removing the previous dressing, after cleansing the wound and before applying medication and dressing to the wound. A current facility policy dated 10/27/16 provided by the DON on 5/22/24 at 11:10 AM indicated the entire handwashing procedure should take 40 to 60 seconds. The policy indicated the hands should be washed with soap, water and rubbing action for at least 20 seconds. 3.1-18(a) 3.1-18(b) 3.1-18(b)(1)

Based on observation, interview and record review, the facility failed to ensure personal possessions were labeled and stored for only individual use for 2 of 6 residents reviewed (Resident 8 and Resident 48). Findings include: During an observation of room [ROOM NUMBER] on 5/11/23 at 10:12 AM, Resident 8 and Resident 48 were residing in the room as roommates with a shared bathroom. In the bathroom, two bottles of [NAME] body wash, a bottle of Softsoap body wash and a bottle of [NAME] de Terre shampoo were observed sitting on the grab bar inside the shower. None of the items had names or markings identifying their owner. During an observation of the bathroom in room [ROOM NUMBER] on 5/12/23 at 8:23 AM, two bottles of [NAME] body wash, a bottle of Softsoap body wash, a bottle of [NAME] de Terre shampoo and two mesh body scrubbers were observed sitting on the grab bar inside the shower. A bottle of Biotene mouth rinse was observed on the sink. None of the items had names or markings identifying their owner. During an observation and interview on 5/12/23 at 8:26 AM Licensed Practical Nurse (LPN) 2 indicated personal items should be kept in Resident's individual closets or personal storage areas. She indicated the unmarked personal items should be marked with a resident's name to ensure they are only used by the owner of the item. During an interview on 5/12/23 09:55 AM, the Director of Nursing (DON) indicated personal items should be labeled and stored in resident's personal storage areas. She indicated personal items should not be stored in a shared bathroom. During a record review beginning 5/12/23 at 2:20 PM, a Minimum Data Set (MDS) dated [DATE] indicated Resident 8 had diagnoses including unspecified fracture of the lumbar spine, arthritis, and unspecified urinary incontinence. The MDS also indicated resident 8 was alert, oriented, and received substantial assistance with showering tasks. An MDS dated [DATE] indicated Resident 48 had diagnoses including fibromyalgia, low back pain and muscle weakness. The MDS also indicated Resident 48 was alert, oriented, and received moderate assistance with showering tasks. A current policy titled General Instructions for Cleaning Supplies/Equipment dated 11/10/16 was received from the Administrator on 5/12/23 at 1:25 PM. During an interview at that time the Administrator indicated the policy was current and no additional policies were available pertaining to storage of personal items. The policy indicated items intended for personal use should be stored in the resident's bedside drawer or closet. 3.1-9(a)

Based on interview and record review, the facility failed to ensure medication was administered per physician's order as specified for a specific condition for 1 (Resident 13) of 7 residents reviewed for medications. Findings include: A record review on 5/17/23 at 10:40 AM indicated Resident 13 had a diagnosis of epilepsy (a seizure disorder). A Comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had no cognitive impairment. The MDS also indicated the resident had a diagnosis of a seizure disorder. A physician order dated 11/4/22 indicated the resident was to be administered lorazepam every 6 hours as needed (PRN) by mouth for seizures. This order was discontinued on 2/4/23. A physician order dated 2/14/23 indicated lorazepam was to be administered PRN every 6 hours by mouth for seizures. The order was limited to 120 days. The resident's care plan indicated interventions for seizure activity included administration of medication as ordered. The resident's Medication Administration Record (MAR) dated February 2022 indicated the resident had been administered PRN lorazepam by mouth on 2/3/23 and 2/4/23 for seizure activity. Progress notes dated February 2023 did not include documentation of seizure activity. The resident's MAR dated March 2023 indicated the resident had been administered PRN lorazepam on 3/4/23, 3/11/23, 3/12/23, 3/20/23, 3/26/23, 3/27/23, and 3/28/23 for seizure activity. Progress notes dated March 2023 did not include documentation of seizure activity. The resident's MAR dated April 2023 indicated the resident had been administered PRN lorazepam by mouth on 4/7/23 for seizure activity. Progress notes dated April 2023 did not include documentation of seizure activity. During an interview on 5/18/23 at 11:27 AM, RN 3 indicated seizure activity should be documented in the progress notes. She indicated she was unaware of Resident 13 having had any seizure activity for the last year. During an interview on 5/18/23 at 2:31 PM, MD 4 indicated he prescribed PRN lorazepam for seizures on 2/14/23 for a duration of 120 days. During an interview on 5/18/23 at 2:31 PM, the Director of Nursing (DON) indicated she was unaware of lorazepam being prescribed on a PRN basis specifically for seizures. A current policy titled First Aid-Convulsions dated 1/1/09 provided by RN 4 on 5/18/23 at 12:06 PM indicated documentation of convulsions should include the length of the episode, type of movements, and level of consciousness. A current policy titled Medication Administration Procedure dated 8/29/16 provided by the DON on 5/19/23 at 9:25 AM indicated administration of PRN medications are to include documentation of the reason being administered. 3.1-48(b)

Based on interview and record review the facility failed to ensure behavior tracking was completed for 5 out of 5 residents reviewed. (Resident 16, Resident 18, Resident 25, Resident 37, and Resident 45) Findings include: 1. A record review for Resident 16, started on 5/5/22 at 1:18 PM, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 16's MDS (Minimal Data Set) dated 2/15/22, section for mood indicated feeling down, depressed, or hopeless, poor appetite or overeating, and trouble concentrating. In section for behavior of MDS indicated no behaviors. Resident 16 had a BIMS (Brief Interview for Mental Status) with a score of 2, indicated severe cognitive impairment. Resident 16's care plan indicated a focus on behavior initiated on 12/12/21 with an intervention of document mood behavior #1 anxiety such as excessive nervousness, restlessness, excessive worrying evidenced by resident reports of I'm shaking in my boots, Please don't leave me. Interventions were to assess for unmet needs, pain, hunger, thirst etc. provide gentle reassurance, encourage relaxing breaths, and offer hand message with lotion. In the month of April from 4/1/22 to 4/30/22 Resident 16's documentation of behaviors, indicated missing documentation for 23 out of 90 opportunities. In the month of May 5/1/22 to 5/8/22 Resident 16's documentation of behaviors had 6 out of 24 missed documentation opportunities. A rounding providers psych progress note dated 5/4/22, indicated to continue to monitor for response of medication, safety, moods, sleep, appetite, behaviors, and note any trends in moods and behaviors. An interview with LPN 2 (licensed practical nurse), on 5/5/22 at 10:16 AM, on the secured unit indicated that all [CONDITION(S)] medications require monitoring of side effects and behaviors. LPN 2 indicated that side effects are monitored and documented by nursing staff and known behaviors are documented by CNAs in the behavior tracker. LPN 2 indicated any new or increased behavior is documented in progress notes. An interview with SS (social services) on 5/10/22 at 10:32 AM indicated that the evaluation of behaviors is only as good as the documentation of behaviors. 2. A record review for Resident 18, started on 5/5/22 at 1:30PM, indicated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 18's MDS assessment, indicated a BIMS score of 3 on 2/28/22; severe cognitive impairment. Resident 18's care plan indicated a focus on behavior initiated 4/1/21. An intervention was to document mood, behavior and medication side effects . The documentation of behavior tracker from point of care, dated 4/1/22 to 4/30/22, indicated missing documentation for 23 of 90 opportunities. In the month of May (May 1, 2022, to May 8, 2022) behavior documentation indicated 6 missed documentations of 24 opportunities. A rounding providers psych progress note dated 5/5/22,indicated to continue to monitor for response of medication and note any trends in moods and behaviors. 3. A record review for Resident 25, started on 5/5/22 at 1:56 PM, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 25's MDS assessment from 9/7/21, indicated a BIMS score of 8; moderate cognitive impairment. Resident 25's most recent care plan indicated a focus of behavior initiated on 12/4/20. An intervention was to document mood and behavior. The documentation of behavior tracker from point of care dated 4/1/22 to 4/30/22 indicated missing documentation for 21 of 90 opportunities. In the month of May (May 1, 2022, to May 9, 2022) behavior documentation indicated 6 behaviors were documented with 27 missed opportunities. A behavior [CONDITION(S)] med quarterly review dated 3/14/22, indicated a review of frequency and evaluation of behavior documented on behavior tracker. A rounding providers psych progress note dated 5/4/22, indicated to continue to monitor safety, moods, sleep, and behaviors. 4. A record review for Resident 37, started on 5/5/22 at 2:18 PM, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 37's MDS assessment from 3/18/22, indicated a BIMS score of 3; severe cognitive impairment. Resident 37's most recent care plan indicated a focus on behavior initiated on 3/11/22. An intervention was to document mood and behavior regarding mood as well as delusions. The documentation of behavior tracker from point of care dated 4/1/22 to 4/30/22 indicated missing documentation for 24 of 90 opportunities regarding the behavior of excessive nervousness. The behavior documentation of delusions indicated missing documentations for 24 of 90 opportunities. In the month of May (May 1, 2022, to May 8, 2022) behavior documentation indicated 6 missed documentation of 24 opportunities for both behaviors excessive nervousness and delusions. A behavior [CONDITION(S)] med quarterly review dated 3/28/22, indicated a review of frequency and evaluation of behavior documented on behavior tracker. A rounding providers psych progress note dated 5/5/22, indicated to continue to monitor safety, moods, sleep, trends, and behaviors. 5. The clinical record of Resident 45 was reviewed on 5/9/22 at 9:54 AM. Resident 45's record indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Sheet (MDS) dated [DATE] section for mood indicated feeling tired or having little energy, trouble concentrating on things, such as reading the newspaper or watching television and being short-tempered, easily annoyed. The resident's section for behavior on the MDS indicated verbal behavioral symptoms directed towards others that occurred 1 to 3 days a week. The resident had a Brief Interview for Mental Status (BIMS) score of 99 and was not interviewable. Resident 45's current care plan indicated a focus on behavior: resident display mood issues as exhibited by excessive worrying, excessive crying, tearfulness; screaming, yelling, screaming at staff initiated on 1/28/20. The interventions for documented behavior mood behavior #1: excessive worry, excessive crying, tearfulness included 1) assess for unmet needs: pain, hunger, thirst, etc., 2) spend 1:1 time consoling and talking with her, 3) offer hand or back massage with lotion and 4) provide soft blanket, stuffed animal, etc. The interventions for documented behavior mood behavior #2: screaming, yelling, swearing at staff included 1) assess for unmet needs: pain, hunger, thirst, etc., 2) during care, go slow and explain each task, 3) offer hand, back massage with lotion and 4) use alternative caregiver as needed. Behavior mood #1 and behavior mood #2 with interventions were to be documented every shift per the care plan. Mood/ behavior tracking documentation behavior #1 and mood behavior #2 from the April and May indicated teh following: dated 4/1/22 to 4/30/22, Resident 45's documentation of mood behavior #1 indicated missing documentation for 20 out of 90 documentation opportunities. Dated5/1/22 to 5/8/22, Resident 45's documentation of mood behavior #1 indicated missing documentation for 4 out of 24 documentation opportunities. Dated 4/1/22 to 4/30/22, Resident 45's documentation of mood behavior #2 indicated missing documentation for 21 out of 90 documentation opportunities. Dated 5/1/22 to 5/8/22, Resident 45's documentation of mood behavior #2 indicated missing documentation for 4 out of 24 documentation opportunities. On 5/10/22 at 11:30 AM, the [CONDITION(S)] Medication Use Nursing Policy & Procedure Manual was received from the Administrator. The [CONDITION(S)] Medication Use Nursing Policy & Procedure, according to the administrator, was used for a behavior policy and procedure manual. The [CONDITION(S)] Policy & Procedure manual indicates specific behavior monitoring which causes the resident to represent a danger to self or others, cause resident distress, cause resident impairment in functional abilities, or symptoms identified as being due to [CONDITION(S)] or [CONDITION(S)] . will be documented in the clinical record as they occur along with the results of the interventions used to reduce the behavior or symptoms. According to the American Health Information Management Association website (2019), facilities must maintain clinical records on each resident in accordance with accepted professional standards and practices. These professional standards and practices consisted of accurate, complete and consistent medical record documentation for all providers regardless of their professional function, work setting, or population served. 3.1-37

Based on record review and interviews, the facility failed to ensure nursing communication from the facility to the [CONDITION(S)] center for 1 of 1 resident reviewed. (Resident 6) Findings include: The record review for Resident 6 began on 5/6/22 at 9:26 AM. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) Assessment, dated 4/26/22, indicated Resident 6 had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive impairment). The MDS indicated that Resident 6's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 6's care plans included a care plan, initiated on 10/28/21, Focus: [CONDITION(S)]: I receive [CONDITION(S)] 3 times weekly due to renal (kidney)failure. Goal: I will have no S/S (signs or symptoms) of complications to shunt site (access site for [CONDITION(S)]). Interventions/Tasks: Administer medications and diet as ordered by nephrologist (kidney doctor). Monitor labs as ordered and report to MD (medical doctor)/clinic. No BP (blood pressure) right arm. Observe for complications with renal failure such as sluggishness, fatigue, mental dullness, elevated BP and notify MD. Observe for s/s of infection to shunt site i.e., (for example) redness, warmth, pain, swelling, drainage, and notify MD. See nutritional care plan. Serve diet as ordered. A care plan for Resident 6, initiated on 10/28/21, indicated Focus: Renal: I have chronic, renal insufficiency (inadequate kidney function), [CONDITION(S)] [CONDITION(S)]. Goal: I will have no S/S of complications related to renal insufficiency. Interventions/tasks: Administer meds as ordered. Monitor and report labs as ordered. Monitor nutritional intake and weights. Monitor vitals weekly and PRN (as needed). See nutritional plan of care. Resident 6's care plans did not include intervention/task for communication between the facility nursing staff and the [CONDITION(S)] center staff. A review of the communication form referenced in the facility's [CONDITION(S)] plan and procedure, titled, Facility/[CONDITION(S)] Communication Form, provided by the DON on 5/10/22 at 3:10 PM, contained the following information to be completed: Facility, Resident Name, Date of service; Facility information: V/S ( vital signs) T (temperature), P (pulse, number of heart beats per minute), R (respirations, breathing rate per minute), B/P (blood pressure), vascular access site (area on resident where [CONDITION(S)] lines are inserted to provide access to a resident's blood so the blood can be filtered), ( Please note site, condition of site, bruit (sound heard when listening to resident's access site with a stethoscope)/thrill ( vibration felt when touching a resident's access site), and condition of dressing). Describe any changes since the last treatment (falls, condition changes, medication changes, skin concerns, behavior changes, nutritional concerns, or social concerns, etc.). Any additional questions or concerns for [CONDITION(S)]? Nurse's name, Date/time: [CONDITION(S)] Unit Information: Pre-treatment ( before [CONDITION(S)]) weight, pre-treatment B/P, pre-treatment temperature, post- treatment (after [CONDITION(S)]) weight, post-treatment B/P, post-treatment temperature, vascular access site, medication administered during treatment, any changes in condition during treatment (temperature, chills, weakness, prolonged bleeding time, any pertinent labs, etc.), post treatment instructions, any new physician orders? yes, no, if yes, describe, nurse's signature, date/time. A review of Resident 6's [CONDITION(S)] book included a facility admissions record (face sheet) dated October 29,2021, [CONDITION(S)] center provider rounding notes, dated 2/25/22, 3/25/22, and 4/20/22, [CONDITION(S)] center tracking my numbers plan notes, dated February 2022, March 2022, and April 2022, Resident 6's patient lab reports, from the [CONDITION(S)] center, containing lab results for February, March, and April 2022, a physician appointment notification, dated 12/16/21,and a facility transfer/discharge report,dated 12/16/21. Resident 6's [CONDITION(S)] book contained Facility/[CONDITION(S)] Communication Forms with no documentation. The Facility/[CONDITION(S)] Communication Forms indicated the following information to be completed: Facility, Resident Name, Date of service; Facility information: V/S (vital signs), T (temperature), P (pulse, number of heart beats per minute), R (respirations, breathing rate per minute), B/P (blood pressure), vascular access site (area on resident where [CONDITION(S)] lines are inserted to provide access to a resident's blood so the blood can be filtered), (Please note site, condition of site, bruit (sound heard when listening to resident's access site with a stethoscope)/thrill ( vibration felt when touching a resident's access site), and condition of dressing). Describe any changes since the last treatment (falls, condition changes, medication changes, skin concerns, behavior changes, nutritional concerns, or social concerns, etc.). Any additional questions or concerns for [CONDITION(S)]? Nurse's name, Date/time: [CONDITION(S)] Unit Information: Pre-treatment ( before [CONDITION(S)]) weight, pre-treatment B/P, pre-treatment temperature, post- treatment (after [CONDITION(S)]) weight, post-treatment B/P, post-treatment temperature, vascular access site, medication administered during treatment, any changes in condition during treatment (temperature, chills, weakness, prolonged bleeding time, any pertinent labs, etc.), post treatment instructions, any new physician orders? yes, no, if yes, describe, nurse's signature, date/time. The Facility/[CONDITION(S)] Communication Form found in Resident 6's [CONDITION(S)] book was the same form referenced in the facility's current policy titled, [CONDITION(S)] Policy and Procedure and Communication Form. Resident 6's [CONDITION(S)] book also contained [CONDITION(S)] Communication Forms. The forms indicated the following information to be completed: date, resident name, pre-[CONDITION(S)] weight, pre-[CONDITION(S)] vital signs, B/P, temperature, pulse, respirations, labs done during [CONDITION(S)], medication administered during [CONDITION(S)], post-[CONDITION(S)] vital signs, B/P, temperature, pulse, respirations, post-[CONDITION(S)] weight, pre and post [CONDITION(S)] shunt site assessment, resident tolerance of [CONDITION(S)], recommendations from the [CONDITION(S)] staff/physician, signature/title, enclose copies of any labs, new care plans since last [CONDITION(S)] treatment, etc. The [CONDITION(S)] Communication Forms contained in Resident 6's [CONDITION(S)] book contained communication from the [CONDITION(S)] center to the facility. The [CONDITION(S)] Communication Form did not indicate any communication from the facility to the [CONDITION(S)] center. A review of Resident 6's [CONDITION(S)] Communication Forms dated January 2022, dated 1/3/22, 1/5/22, 1/12/22, 1/17/22,1/21/22,1/26/22, 1/29/22, and 1/31/22 indicated documentation and communication from the [CONDITION(S)] center to the facility. No nursing communication, related to Resident 6, from the facility to the [CONDITION(S)] center was found. A review of Resident 6's [CONDITION(S)] Communication Forms dated February 2022, dated, 2/5/22, 2/8/22, 2/9/22, 2/14/22, 2/16/22, 2/18/22, 2/23/22, 2/25/22, and 2/28/22 indicated documentation and communication from the [CONDITION(S)] center to the facility. No nursing communication, related to Resident 6, from the facility to the [CONDITION(S)] center was found. A review of Resident 6's [CONDITION(S)] Communication Forms dated March 2022, dated 3/2/22, 3/4/22, 3/7/22, 3/11/22, 3/14/22, 3/16/22, 3/25/22, 3/28/22, and 3/30/22 indicated documentation and communication from the [CONDITION(S)] center to the facility. A review of one Facility/[CONDITION(S)] Communication Form for resident 6, dated 3/18/22, indicated facility information crossed off and marked as error, [CONDITION(S)] information documented. No nursing communication, related to Resident 6, from the facility to the [CONDITION(S)] center was found. A review of Resident 6's [CONDITION(S)] Communication Forms dated April 2022, dated 4/1/22, 4/4/22, 4/6/22, 4/8/22, 4/15/22, 4/18/22, 4/20/22, 4/22/22, 4/25/22, 4/27/22, and 4/29/22, indicated documentation and communication from the [CONDITION(S)] center to the facility. No nursing communication, related to Resident 6, from the facility to the [CONDITION(S)] center was found. A review of Resident 6's [CONDITION(S)] Communication Forms dated May 2022, dated 5/2/22 and 5/6/22, indicated documentation and communication from the [CONDITION(S)] center to the facility. No nursing communication, related to Resident 6, from the facility to the [CONDITION(S)] center was found. A review of Resident 6's assessments dated January, February, March, April, and May 2022 was completed. The review of Resident 6's January 2022 assessments indicated no documentation of any nursing assessment communication from the facility nursing staff to the [CONDITION(S)] center. The review of Resident 6's February 2022 assessments indicated no documentation of any nursing assessment communication from the facility nursing staff to the [CONDITION(S)] center. The review of Resident 6's March 2022 assessments indicated no documentation of any nursing assessment communication from the facility nursing staff to the [CONDITION(S)] center. The review of Resident 6's April 2022 assessments indicated no documentation of nursing assessment communication from the facility nursing staff to the [CONDITION(S)] center. The review of Resident 6's May 2022 assessments indicated no documentation of nursing assessment communication from the facility nursing staff to the [CONDITION(S)] center. A review of Resident 6's progress notes for January, February, March, April, and May 2022 was completed. The review of Resident 6's January 2022 progress notes indicated no documentation of nursing assessment communication from the facility nursing staff to the [CONDITION(S)] center. The review of Resident 6's February 2022 progress notes indicated no documentation of nursing assessment communication from the facility nursing staff to the [CONDITION(S)] center. The review of Resident 6's March 2022 progress notes indicated no documentation of nursing assessment communication from the facility nursing staff to the [CONDITION(S)] center. The review of Resident 6's April 2022 progress notes indicated no documentation of nursing assessment communication from the facility nursing staff to the [CONDITION(S)] center. The review of Resident 6's May 2022 progress notes indicated no documentation of nursing assessment communication from the facility nursing staff to the [CONDITION(S)] center. A review of Resident 6's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of Resident 6's January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of Resident 6's February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of Resident 6's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of Resident 6's April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of Resident 6's May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 6's Treatment Administration Record (TAR) for January, February, March, April, and May 2022 was completed. The review of Resident 6's January 2022 TAR indicated no documentation of nursing assessment communication from the facility nursing staff to the [CONDITION(S)] center. The review of Resident 6's February 2022 TAR indicated no documentation of nursing assessment communication from the facility nursing staff to the [CONDITION(S)] center. The review of Resident 6's March 2022 TAR indicated no documentation of nursing assessment communication from the facility nursing staff to the [CONDITION(S)] center. The review of Resident 6's April 2022 TAR indicated no documentation of nursing assessment communication from the facility nursing staff to the [CONDITION(S)] center. The review of Resident 6's May 2022 TAR indicated no documentation of nursing assessment communication from the facility nursing staff to the [CONDITION(S)] center. In an interview RN 4 on 5/9/22 at 10:27AM., she indicated when she sent Resident 6 to [CONDITION(S)], she checked the resident's weight and documented the weight in the weight book. RN 4 indicated she treated Resident 6's arm with [MEDICATION(S)], helped Resident 6 to the lobby where Resident 6 was picked up to be transported to [CONDITION(S)]. RN 4 indicated Resident 6 took a suitcase of personal items with him to [CONDITION(S)]. RN 4 indicated she did not fill out any forms and sent Resident 6's [CONDITION(S)] book with him. RN 4 indicated Resident 6 did not return from [CONDITION(S)] until the next shift. An interview was conducted with the DON on 5/9/22 at 12:06 PM. The DON indicated when Resident 6 was sent for [CONDITION(S)], the facility staff gave his morning medication, sent a snack with Resident 6 or his wife, took his suitcase, facility staff sent Resident 6's [CONDITION(S)] binder (book) with the resident. The DON indicated the [CONDITION(S)] binder was the whole form of communication with the [CONDITION(S)] center. The [CONDITION(S)] center staff had been invited to Resident 6's care plan meetings but did not attend. The [CONDITION(S)] book contained the concerns, questions, updates, how [CONDITION(S)] visits went, vital signs & weights from the [CONDITION(S)] center. The facility staff did not assess the resident prior to leaving for [CONDITION(S)]. A printed report, with resident's orders, diet, any changes was sent in the binder to the [CONDITION(S)] center, only if Resident 6 had changes. The staff did not document regarding what information was sent in the [CONDITION(S)] book. When facility staff noticed anything going on with the resident before leaving for [CONDITION(S)], the facility staff would call the [CONDITION(S)] center & document the call in Resident 6's progress notes. On return from [CONDITION(S)], staff checked Resident 6's dry weight, and the fistula for bruit & thrill. Any information would be documented in a [CONDITION(S)] assessment under the assessment tab, but the facility would not send anything with the resident unless there is a change in condition. An RN (registered nurse) at the [CONDITION(S)] facility sent a note to acknowledged communication between the facility and [CONDITION(S)]. The [CONDITION(S)] book was their communication. In the history of the facility, they had not written a progress note regarding communication with [CONDITION(S)] because it was care planned. The facility sent the updated MAR, TAR & orders in Resident 6's [CONDITION(S)] binder each time Resident 6 went to [CONDITION(S)]. The nurse was responsible for having the MAR's, TAR's & orders in the [CONDITION(S)] book. No MARs or TARs were available in the [CONDITION(S)] book for review. On 5/10/22 at 11:40 AM, the DON provided a document titled, Clinical Notes Report. The report contained a note, dated 5/10/22 11:21, documented by a registered nurse at the [CONDITION(S)] center, Extended care facility, the facility sends communication binder with current and updated orders with patient to [CONDITION(S)] thrice weekly on Monday, Wednesday, and Friday. Communication binder is reviewed per nursing staff every [CONDITION(S)] treatment. In an interview on 5/10/22 at 12:22 PM, the DON indicated The [CONDITION(S)] center does not keep communication information sent. The facility did not always send the MAR & TAR. The facility sent the MD orders so the [CONDITION(S)] center could review. The NP (nurse practitioner) at the [CONDITION(S)] center reviewed weekly, the MD (medical doctor) reviewed monthly. All communication with the [CONDITION(S)] caenter was in the book. On 05/10/22 at 1:00 PM, the DON provided a document titled, the facility Progress Note, with highlighted areas that indicated 4/15/22 10:32 List New/changed order(s) or plan of care: DC Calcium Acetate, reason for change: [CONDITION(S)] order, Effective date 3/23/22 14:48 Reason for change: Phosphorus levels changed, 1445 at [CONDITION(S)],3/18/22 13:54 [MEDICATION(S)] 800mg daily, reason for change: [CONDITION(S)] doctor request, 2/28/22 12:42 reason for change: [CONDITION(S)] order. The DON indicated that this showed communication with the [CONDITION(S)] center. This document indicated communication received from the [CONDITION(S)] center to the facility. No documentation noted of communication from the facility to the [CONDITION(S)] center. A review of the current [CONDITION(S)] Policy and Procedure and Communication Form, provided by the DON on 5/9/22 12:48PM indicated a policy statement: .To coordinate with the renal clinic and physician the care and management of [CONDITION(S)] services for those residents requiring them. To ensure that care and services related to [CONDITION(S)] therapy is consistent with standards of nursing practice. Key Points included: 7. Routine communication via written and/or telephone will occur between the facility charge personnel and the clinic personnel to ensure that the care is continuous and consistent. Communication between the renal clinic and the facility will be documented in the resident's medical record 3.1-37(a)

Based on interview and record review the facility failed to ensure side effects were monitored for 1 of 6 residents reviewed. (Resident 3) Findings include: A record review, started on 5/5/22 at 9:10 AM, indicated resident had the following diagnoses, [CONDITION(S)] and Alzheimer's disease. An order for [MEDICATION(S)] was started on 6/23/20, it was reduced on 5/19/21 from 10 mg to 5mg daily. Resident 3's most recent depression scale (PHQ9) score was an 8 per Behavior [CONDITION(S)] Med Quarterly Review. Resident 3's MDS (Minimal Data Set) section D (mood) assessment (4/27/22) indicated feeling down, depressed, hopeless for 12 to 14 days in the 2 week period. The assessment indicated moving or speaking slowly that others could notice or the opposite for 12 to 14 days in the 2 week period. and trouble with sleep. Resident 3's MAR (Medication Administration Record) dated April 2022 indicated no monitoring of side effects for antidepressant medications. An interview with DON, on 5/9/22 at 12:02 PM, with social services and administrator present indicated when Resident 3 returned from the hospital in January 2022 the order to monitor for side effects was not reinstated upon return. She indicted [CONDITION(S)] medication side effects and the effectiveness of medication should be monitored. A policy titled [CONDITION(S)] Medication Use provided by DON on 5/9/22 at 11:55 AM with start date of 2/18/19 indicated Drug: Antidepressant Medication .Side effects monitoring: Monitor daily on Psych Med Admin record . 3.1-48(a)(3)

Based on interview and record review, the facility failed to provide an environment free of inappropriate behavior for 3 of 3 residents. ( Resident A, Resident B, Resident C). Findings include: A review of Resident A's record on 1-13-22 at 11:42 AM, indicated a BIMS (Brief interview of Mental Status) score of 9 out of 15. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review on 1-13-22 at 10:15 AM, indicated on 12-30-21 at 4:40 PM Resident A was interviewed by the AIT (Administrator in Training). Resident A indicated The agency aide came into the room and asked if the resident was ready for a bed bath. At this time, a Miller's employee walked into the room. The agency aide yelled at this staff member Don't walk up behind me. Resident A mentioned the aides left the room but they could hear the agency aide using vulgar language at the Miller's employee. Resident A indicated management walked up and intervened. In an interview on 1-13-22 at 11:10 AM Resident A indicated they felt safe in the facility, and the aide should not have been yelling at their staff like that. A review of Resident B's record on 1-13-22 at 11:43 AM, indicated a BIMS score of 15 out of 15. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review on 1-13-22 at 10:25 AM, indicated on 12-30-21 at 4:30 PM Resident B was interviewed by the AIT. The AIT asked Resident B what the resident had heard or witnessed. Resident B indicated they were in their room and overheard a Miller's employee and the agency aide talking. Resident B indicated the agency aide yelled at the Miller's employee to not walk up behind her. Resident B then overheard agency staff using vulgar language to the Miller's staff member. Resident B stated management came and intervened. Resident B indicated they were ok, felt safe and they did not appreciate hearing that kind of language. In an interview on 1-13-2022 at 11:08 AM Resident B indicated she felt safe in the facility. She stated she knew the yelling was not directed at her, but the aide had no business yelling at the staff that took good care of them. A review of Resident C's record on 1-13-22 at 11:50 AM, indicated a BIMS score of 15 out of 15. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review on 1-13-22 at 10:45 AM, indicated on 12-30-21 at 4:50 PM Resident C was interviewed by the AIT. The AIT asked Resident C what they saw or heard. Resident C indicated the agency aide walked in and asked him and his roommate if they were ready for their showers. The resident indicated the Miller's employee then walked in. The agency aide yelled at the Miller's employee Don't walk up behind me, I'm not a child. Resident C indicated the Miller's employee moved the conversation out of the room into the hall, but they overheard vulgar language being used by the agency aide. Resident C indicated management walked up and stopped the incident. In an interview on 1-13-22 at 11:12 AM, Resident C indicated they felt safe as the big boss took care of it. During a record review on 1-13-22 at 10:55 AM, incident number 124 was filed by the Administrator. The incident was dated 12-20-21 at 4:30 PM. A brief description of the incident indicated the Administrator escorted an agency staff member from facility premises for inappropriate and vulgar behavior that took place in a patient care area. During a record review on 1-13-22 at 11:05 AM, a facility in-service was conducted on 1-3-22 titled: Professional expectations & residents rights . Miller's Health Systems is committed to conducting its business ethically and in conformance with all federal and state laws, regulations, interpretations thereof, and its Code of conduct. All employees are expected to follow the company's professional expectations; as well as procedures in reporting actual or potential wrongdoing, including actual or potential violation of law, regulation, policy or procedure. All employees are expected to conduct themselves in a professional manner while at work, with consideration, kindness and understanding residents, visitors, and fell ow workers In an interview with the Administrator on 1-13-22 at 12:29 PM, she indicated the facility does not have a policy on Resident's Rights but they do provide a copy of Resident's Rights dated 2019 to new employees. A document titled Resident's Rights dated 2019 was provided by the Administrator on 1-13-22 at 12:29 PM. The document indicated . The resident has a right to a safe, clean, comfortable and homelike environment, including, but not limited to, receiving treatment and supports for safe daily living Past non compliance ciation was corrected on January 4, 2022 fter the facility implements a systematic plan that included the following actions: The facility removed the staff responsible for the event, completed interviews with all residents in the area of the event, reeducated staff regarding appropriate communication with and in [NAME] tof residents, and institued daily audits of staff treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] This Federal citation is related to complaint IN 109. 3.1-3(a)

Based on interview and record review, the facility failed to ensure infection control practices were followed in regards to preventative measures for the spread of Covid-19 this had the potential to affect 14 of 50 residetns residing in the facility. Findings include: On 12/16/2020 at 1:30 p.m., the Director of Nursing (DON) provided a copy of the facility LTC (Long Term Care) Respiratory Surveillance Line List. Nurse 1 was listed with the following information: Signs and symptoms (s/s) onset date was 12/9/2020; cough and Myalgia (body aches) were documented as yes being present as well as headache; a PCR (polymerase chain reaction) test was collected on 12/7/2020. On 12/16/2020 at 1:35 p.m., the DON was interviewed. She indicated the PCR test collected on Nurse 1 was sent out on 12/7/2020. She indicated Nurse 1 worked on 12/7/2020. The DON indicated she spoke to Nurse 1 at the facility on 12/9/2020 and Nurse 1 sounded congested. The DON indicated Nurse 1 thought it was just the weather. The DON indicated she then collected a POC (point of care) test which provided instant results of positive for COVID - 19. The DON indicated she sent Nurse 1 home immediately. The DON indicated later in the day on 12/9/2020, the PCR result returned with a positive result for COVID-19 as well. She indicated Nurse 1 worked on a hall with 14 residents. On 12/16/2020 at 1:40 p.m., the Employee Screening: Fit for Duty log was reviewed for Nurse 1. The log indicated the following: On 12/7/2020 Nurse 1 was screened by a staff member who logged Nurse 1's temperature. Documentation was lacking on the form for the answer to the screening question of Are you currently ill. The screening question of Do you have symptoms of a cold, cough, shortness of breath, or temporarily lost your sense of taste or smell? Do you have symptoms of nausea/vomiting or diarrhea? was marked with a yes answer. On the form in the same location of the yes answer column, was STOP in the center of a stop sign shape and below was printed send home. The entry was signed by Nurse 1. The next entry on the form, dated 12/9/2020, was signed by a different screener. This entry also had yes marked for the question Do you have symptoms of a cold, cough, shortness of breath, or temporarily lost your sense of taste or smell? Do you have symptoms of nausea/vomiting or diarrhea? This entry was also signed by Nurse 1. On 12/16/2020 at 2:00 p.m., Office Assistant 2 was interviewed. She indicated she screened staff and/or anyone coming into the building at the front reception desk. She indicated she took the staff and/or visitors temperature, logged the temperature on the Employee Screening: Fit for Duty form. She indicated she then asked the staff and/or visitor the screening questions and marked the answers on the form. She indicated she then had the staff and/or visitor to sign the form entry. She indicated if the staff and/or visitor had answered any of the screening questions with a yes answer, she would not permit them to enter. Office Assistant 2 indicated she would immediately contact either the DON and/or the Administrator to make then aware questions had been answered which required their attention. On 12/16/2020 at 2:35 p.m., the DON was interviewed. She indicated she had documented on the LTC Respiratory Surveillance Line List Nurse 1's onset of signs and symptoms was on 12/9/2020 because that was when the DON thought Nurse 1's signs and symptoms began. The DON indicated she was unaware of Nurse 1 having documented on the Employee Screening: Fit for Duty log, that she had signs and symptoms on 12/7/20 and 12/9/20. The DON indicated neither she and/or the Administrator had been made aware Nurse 1 had answered the screening questions as yes on 12/7/20 and/or 12/9/20 on the Employee Fit For Duty Screening log. She indicated if the employee answered any of the screening questions as yes on the Fit for Duty Form, the employee was sent home immediately and the reception desk staff should have notified the DON and/or Administrator. The DON indicated Nurse 1 did work on 12/7. She further indicated Nurse 1 should not have been permitted to work on 12/7 due to her having answered the screening questions as yes. She indicated the staff who were stationed at the front reception desk were trained on the correct procedure for screening staff and/or visitors in to the facility. On 12/16/2020 at 2:40 p.m. the DON was interviewed. She indicated it was the Business Office Manager's responsibility to review the Employee Screening: Fit for Duty Logs weekly but this had not been done. On 12/16/2020 at 2:50 p.m., the DON provided a current copy of the facility policy and procedure for Staff Screening Policy, date 11/6/2020. The policy included, but was not limited to, the following: Policy: To prevent introduction of COVID-19 into our facilities .All staff will be screened prior to entering the facility by using the Employee Screening - Fit for Duty screening log .All staff will be screened by a trained employee screener .All staff will be questioned if they are currently ill or having any symptoms of COVID-19 (cold, cough, shortness of breath, loss of taste or smell, nausea, vomiting or diarrhea or other symptoms of COVID-19). If staff answer yes, employee must be sent home and directed to be tested for COVID - 19 .Staff must answer all questions and validate answers by signing the screening form before leaving the screening area and reporting for duty . 3.1-18(a)

Based on interview and record review, the facility failed to ensure post therapy restorative programs were available and offered a restorative program. Because the facility did not have a restorative program, this had the potential to affect 58 of 63 residents in the facility. Findings include: On 10/29/19, an interview was conducted with Resident 55. Resident 55 indicated when she was in the therapy program in the facility, she was walking some but now she is in a wheelchair all of the time when out of her room. On 11/1/19, at 9:00 AM, Resident 55's record was reviewed and indicated she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. On 9/25/19, Resident 55's most recent MDS (minimum data set) indicated she had a BIMS (brief interview for mental status) score of 15, which indicated she was cognitively intact. A Physical Therapy (PT)-Therapist Progress & Discharge Summary from 8/27/19, indicated Resident 55 was in PT from 7/5/19-8/27/19. The report indicated Resident 55 attended 10 of 11 therapy sessions since the previous report and the one missed session was due to the resident having diarrhea. Under the section short term goals history for gait tasks, Resident 55 had a goal for distances-surfaces: The patient will progress during gait training to 100 feet on level surfaces and requiring stand by assist with standard walker with verbal instruction/cues in order to increase level of independence. This goal was noted as not met due to deficits in endurance. The start of goal status as of 7/5/19 was: The patient refused to attempt ambulation this date. As of 7/31/19, Resident 55: The patient ambulates 40 feet on level surfaces and requiring contact guard assist with front wheel walker and with verbal, tactile and visual cues for safety. The end of goal statue for Resident 55 on 8/27/19 indicated: The patient ambulates 90 feet on level surfaces and requiring supervision with standard walker and with verbal instruction/cues for safety. Under the section long term goals, Analysis of Functional Outcome/Clinical Impression: Patient is being discharged from therapy due to ceased progress. Patient was unable to meet all the set goals due to lack of strength, endurance and poor participation. The Discharge Plans & Instructions: Patient will remain in the facility with caregiver assistance. On 11/1/19, at 10:52 AM, an interview was conducted with the Therapy Department Director who indicated if the facility had a restorative program, she would have discharged Resident 55 to a restorative program after discharge from therapy on 8/27/19. The Therapy Department Director indicated she would recommend almost all the residents when they are discharged from therapy to be put in a restorative program if the facility had a restorative program. The therapist indicated any resident in the facility not on Skilled case load could benefit from a retorative program. On 11/1/19, at 12:40 PM, an interview was conducted with the DNS (Director of Nursing Services). The DNS indicated the facility does not have a restorative program. The DNS indicated Resident 55 does not have any type of post therapy program. The DNS indicated Resident 55 should have a walk to dine program. The DNS indicated the facility does not have restorative program policy. On 11/1/19, at 12:49 PM, an interview was conducted with the MDS nurse who indicated they try to get Resident 55 to walk out to meals with staff with her walker but the resident is not cooperative a lot of the time. On 11/1/19, at 12:52 PM, an interview was conducted with the MDS nurse who indicated Resident 55 is not on a walk to dine program. The MDS nurse indicated they have no documentation of Resident 55 walking to the dining room with her walker. On 11/1/19, at 2:31 PM. the ADNS (Assistant Director of Nursing) brought a policy titled Restorative Nursing Program Procedures, dated 9/1/2004. The policy indicated: 2. Restorative Nursing Program Procedures: [NAME] Purpose. 1. To provide services which promote the highest level of functioning in activities of daily living. 2. Restorative nursing services include: a. Passive and active range of motion exercises. b. Assistance and instruction in activities of daily living. c. Maintenance programs after formal therapy programs. d. Use of self help devices. e. Ambulation programs for gait training and transfers. f. Bowel and bladder training and/or incontinence management. B. Procedure: 1. Nursing Driven Restorative Programs: a. All residents with be assessed for appropriateness and placed on an informal or formal restorative program based upon their functional needs/capabilities. b. The restorative program will be written by nursing staff as determined through the assessment process. c. The program may be informal and a routine part of the daily care but not documented on a restorative grid. d. The program may be a formal restorative program documented on the restorative grid/record by nursing. e. Nursing will review the progress or regress of the formal restorative programs at least quarterly and make narrative note in the clinical record. On 11/1/19, at 2:31 PM, an interview with the ADNS indicated the facility does not have a formal restorative program. On 11/4/19, at 10:27 AM, an interview was conducted with the MDS nurse who indicated the facility has a non-formal restorative program. The MDS nurse indicated Resident 55 was not assessed for any type of restorative program. The MDS nurse indicated Resident 55 refused to walk to the dining room at times. The MDS nurse indicated there was no documentation of Resident 55 having walked to the dining room, or documentation of refusal to walk to the dining room, or documentation of having been offered the opportunity to walk to the dining room. On 11/4/19, at 11:12 [NAME]M., an interview was conducted with the MDS nurse who indicated no resident in the facility had been assessed for any type of restorative program. 3.1-42(a)(2)

Based on observation, record review and interview, the facility failed to ensure the physician's order for a gastrostomy tube ([DEVICE])was followed for 1 of 1 resident reviewed (Resident 41). Findings include: The Physician's Orders dated 1/08/19, indicated the following [DEVICE] orders: Resident 41's medications were to be administered through a [DEVICE] (a tube inserted directly into the resident's stomach). The [DEVICE] is flushed with 30 (milliliters) ml of water before and after the medication was administered, then 5 ml of water was to be given between each medication. During medication administration an observation of the following was conducted on 10/30/19 at 11:30 [NAME]M., Registered Nurse (RN) 2 had checked Resident 41's medications and had crushed 5 pills individually and poured each crushed pill separately into 5 individual graduated plastic medication cups (a cup with markings for measurement of ml). RN 2 poured 30 ml of water into each of the 5 graduated plastic medication cups and also poured water into a plastic drinking cup. After RN 2 had donned gloves and checked the resident's [DEVICE]'s placement and residual RN 2 flushed the [DEVICE] with 30 ml of water and then poured of the graduated medication cup with a pill and 30 ml of water added and then flushed the [DEVICE] again. RN 2 continued to flush the tube and administer the pill with 30 ml of water already added and then flushed the resident's [DEVICE] 4 more times. RN2 did not flush the resident's [DEVICE] with 5 ml of water between each medication. On 11/04/19 at 1:52 P.M., an interview was conducted with RN 2 indicated she had poured 30 ml of water into 5 individual medication cups and had flushed Resident 41's [DEVICE] with 30 ml before and after the medication was administered. 3.1-44(a)(2)

Based on interview and record review the facility failed to ensure antibiotic administration was documented for 1 of 2 residents reviewed for infections (Resident 210). Findings include: The clinical record for Resident 210 was reviewed on 10/29/19 at 11:21 [NAME]M. [DIAGNOSES REDACTED]. A physician's orders [REDACTED].M., 1 P.M., and 9 P.M.) for a left knee infection. A Medication Administration Record [REDACTED].M., indicated Resident 210 did not have a documented dose of [MEDICATION NAME] on (MONTH) 1 (1 P.M. dose), (MONTH) 10 (1 P.M. dose), (MONTH) 11 (5 [NAME]M. dose), (MONTH) 15 (1 P.M. dose), (MONTH) 24 (9 P.M. dose) or on (MONTH) 29 (1 P.M. dose), 2019. A care plan problem indicated Resident 210 had an infection to her left knee. Interventions included, but were not limited to, administering medications as ordered. The DNS was interviewed on 11/1/19 at 1:21 P.M. During the interview the DNS indicated the [MEDICATION NAME] was given, but should have been documented as administered for the above dates and times. A policy, dated 4/15/14, was provided by the DNS on 11/1/19 at 10:31 [NAME]M., titled Charting Procedure and she indicated it was the policy currently used by the facility. The policy indicated 1. Purpose: To accurately document in an organized manner all pertinent information related to the resident in the medical record .D. CHARTING AND ASSESSMENT PRINCIPLES: 1. The following guidelines should assist the nurse in appropriate documentation for charting. a. Be complete, concise and factual. 3.1-50(a)

Based on interview and record review the facility failed to ensure Physician's orders were followed for 1 of 5 residents reviewed for medications (Resident 1). Findings include: The clinical record for Resident 1 was reviewed on 10/10/18 at 11:49 A.M. [DIAGNOSES REDACTED]. A Physician's order dated 9/21/18, indicated Resident 1 was to be weighed daily and the Physician was to be notified if the resident had a weight gain of 2 pounds in 1 day and 4 pounds in 5 days. Daily weight records provided Licensed Practical Nurse 4 on 10/15/18 at 1:40 P.M., indicated Resident 1 was not weighed on 9/25, 9/26 or 10/7, (YEAR). The Director of Nursing Services (DNS) was interviewed on 10/15/18 at 1:36 P.M. During the interview the DNS indicated there was no further documentation that Resident 1's daily weights had been taken on the above dates. She also indicated Resident 1's weight should have been taken daily and it had not been. 3.1-35(g)(1)

Based on observation, record review and interview, the facility failed to ensure a therapy recommendation was followed for 1 of 2 residents reviewed who had received Therapy services . (Resident 8) Findings include: The following observations were conducted of Resident 8: On 10/09/18 at 3:14 P.M., Resident 8 was observed in the resident's room sitting in a wheelchair. Resident 8 had a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to her right hand and there was not a splint or a palm protector in the resident's right hand. On 10/11/18 at 11:10 A.M., Resident 8 was observed in the hallway sitting in a wheelchair. The resident was appropriately dressed and had a palm protector in her right hand. On 10/12/18 at 12:43 P.M., Resident 8 was observed in the Main Dining Room eating lunch. The resident did not have a palm protector in her right hand. The Clinical Record of Resident 8 was reviewed on 10/15/18 at 9:30 A.M., indicated [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 8 was mildly cognitively impaired and had decreased range of motion to the resident's right side of her upper and lower body. The OT-Therapist Progress & Discharge Summary dated 10/1/18, indicated Resident 8 and .caregiver . were educated on how to apply and remove the resident's palm protector. The Order Summary Report included active Orders dated 10/15/18, and indicated there was not a physician's orders [REDACTED]. The (MONTH) (YEAR), Treatment Administration Record indicated there was no documentation for Resident 8's palm protector. There was no Care Plan for Resident 8's palm protector. A form received from the Director of Nursing Service (DNS) on 10:55 A.M., and during an interview conducted with the DNS indicated the form was the current CNA assignment sheet. The CNA assignment sheet indicated there was no documentation of Residnet 8's palm protector. On 10/15/18 at 9:25 A.M., during an interview, Certified Occupational Therapy Assistant (COTA) 3 indicated Resident 8 was discharged from Occupation Therapy (OT) on 10/1/18, with a recommendation for a palm protector. The COTA indicated the Certified Nursing Assistant (CNA) was to apply the palm protector in the morning and was to remove the palm protector at bedtime. The COTA indicated Resident 8 was educated on how to apply the palm protector with the assistance of a CNA. On 10/15/18 at 10:07 A.M., during an interview, CNA 2 indicated after she assisted Resident 8 with morning care the CNA 2 applies the palm protector to the resident's right hand. CNA 2 incated the resident had never refused to allow CNA 2 to apply the palm protector. The CNA 2 indicated Therapy had educated her on the use of Resident 8's palm protector. On 10/15/18 at 1:04 P.M., during an interview conducted with the DNS indicated the Therapy Department had not communicated to the Nursing Department that Resident 8 was suppose to have a palm protector in the resident's right hand. 3.1-42(a)(1)

Based on interview and record review the facility failed to follow physician's orders for 2 of 6 residents reviewed. (Resident 95 and Resident 120) Findings include: 1. The clinical record for Resident 95 was reviewed on 10/30/17 at 4:02 P.M. [DIAGNOSES REDACTED]. An order, dated 6/9/17, indicated the physician should be notified if any blood sugar check was greater than 400. Medication Administration Records (MAR), dated August and September 2017, provided by the Assistant Director of Nursing (ADON) on 11/6/17 at 2:53 P.M., indicated Resident 95's blood sugar checks were over 400 and the physician was not notified on the following dates and times: 8/1/17: 5:00 P.M.: Blood Sugar (B.S.): 458; 8/6/17: 8:00 P.M.: B.S- 497; 8/12/17: 8:00 P.M.: B.S.-454; 8/13/17: 12:00 P.M.: B.S- 430; 8/14/17: 12:00 P.M.: B.S- 456; 8/15/17: 12:00 P.M.: B.S.-402; 8/16/17: 12:00 P.M.: B.S- 477; 8/16/17: 5:00 P.M.: B.S.-419; 8/16/17: 8:00 P.M.: B.S.-401; 8/17/17: 8:00 P.M.: B.S.-486; 8/22/17: 12:00 P.M.: B.S.-414; 8/23/17: 12:00 P.M.: B.S.-500; 8/25/17: 12:00 P.M.: B.S.-422; 8/25/17: 5:00 P.M.: B.S.-469; 8/27/17: 5:00 P.M.: B.S.-490; 8/28/17: 5:00 P.M.: B.S.-451: 8/29/17: 5:00 P.M.: B.S. 512; 8/30/17: 5:00 P.M.: B.S.-445; 9/3/17: 5:00 P.M.: B.S.-458; 9/4/17: 5:00 P.M.: B.S.-418; 9/7/17: 5:00 P.M.: B.S.-401; 9/8/17: 12:00 P.M.: B.S.-487; 9/12/17: 12:00 P.M.: B.S.-422; 9/16/17: 5:00 P.M.: B-S.-442; The ADON was interviewed on 11/6/17 at 2:33 P.M. During the interview the ADON indicated the physician's orders should have been followed and the physician should have been contacted for blood sugar checks that were over 400. He also indicated there was no documentation to indicate this had been done. A policy was provided by the Minimum Data Set Nurse (MDS Nurse), on 11/6/17 at 3:20 P.M., titled Blood Glucose Monitoring dated 7/1/09. She indicated it was the policy currently used by the facility. The policy indicated, C. Each resident shall have specific physician orders for the following: I. Parameters for physician notification both for high and low readings, and Assessment protocols to be followed at readings below 70 and greater than 200 (unless physician has specified a stricter parameter). 2. The clinical record for Resident 120 was reviewed on 11/3/2017 at 10:42 A.M. [DIAGNOSES REDACTED]. An order, dated 9/21/17, indicated Resident 120 was to receive 400 milligrams of ceftaroline (antibiotic) intravenously (IV) every 12 hours for 21 days. A Medication Administration Record [REDACTED].M. and 6:00 P.M. and on 9/23/17 at 6:00 A.M. and 6:00 P.M. There was no documentation on the MAR indicated [REDACTED].M. or 6:00 P.M. and on 9/25/17 at 6:00 A.M. or 6:00 P.M. Kidney function labs drawn on 9/25/17 at 10:45 A.M., indicated Resident 120 ' s BUN was elevated at 44 (normal value 7-22) and the creatinine was elevated at 4.3 (normal value 0.5-1.0). An order, dated 9/25/17 at 5:00 P.M., indicated Resident 120 was to receive 200 milligrams of IV antibiotics on 9/25/17 at 6:00 P.M. The resident was to also receive 2 liters of normal saline at 125 milliliters per hour after the dose of antibiotics was given. Another 200 milligram dose of IV antibiotics were ordered to be given on 9/26/17 at 6:00 A.M. The normal saline was to be completed at 120 milliliters an hour. When the normal saline was complete, a BUN and creatinine was to be drawn and the results were to be called to the physician. The order did not specify which antibiotic was to be given. A MAR, dated September 2017, provided by Medical Records, indicated Resident 120 received a 200 milligram dose of [MEDICATION NAME] (ceftaroline) on 9/26/17 at 6:00 A.M. There was no documentation indicating Resident 120 received the physician ordered antibiotic dose on 9/24/17 at 6:00 A.M. or 6:00 P.M, or on 9/25/17 at 6:00 A.M. or 6:00 P.M. There was no documentation to indicate Resident 120 received 2 liters of normal saline at 125 milliliters per hour starting after a dose of antibiotics on 9/25/17 at 6:00 P.M. Kidney function labs drawn on 9/26/17 at 10:20 A.M., indicated Resident 120 ' s BUN was elevated at 45 (normal value 7-22) and the Creatinine was elevated at 5.0 (normal value 0.5-1.0). The Director of Nursing (DON) was interviewed on 11/7/17 at 12:43 P.M. During the interview the DON indicated documentation regarding the administration of the antibiotics or normal saline were not found, so there was no record to prove the resident had received the medication as ordered by the physician. 3.1-35(g)(1)

Based on observation and interview the facility failed to ensure staff washed hands during blood sugar checks This deficiently potentially affected 2 of 2 residents observed during blood sugar checks (Resident 37 and Resident 63). Findings include: During a continuous observation on 11/3/17 at 11:24 A.M. to 11:35 A.M. the following occurred: At 11:24 A.M., Registered Nurse (RN) 3 put on gloves, cleaned Resident 37 ' s finger and then used a lancet to draw blood from the finger. She then placed blood from Resident 37 ' s finger in the blood sugar test strip. After the monitor produced the blood sugar check results, she threw away the blood sugar test strip, removed her gloves and threw them in the trash. She then left the room, went back to the medication cart, cleaned and placed a sanitizing wrap around the blood sugar monitor and grabbed a different monitor. She was not observed to use hand sanitizer or wash hands after performing the blood sugar check on Resident 37. At 11:30 A.M., RN 3 put on gloves, cleaned Resident 63 ' s finger and then used a lancet to draw blood from the finger. She then placed blood from Resident 63 ' s finger in the blood sugar test strip. After the monitor produced the blood sugar check results, she threw away the blood sugar test strip, removed her gloves and threw them in the trash. She left the room, went back to the medication cart and then cleaned and placed a sanitizing wrap around the blood sugar monitor. She was not observed to use hand sanitizer or wash hands after performing the blood sugar check on Resident 63. At 11:35 A.M., RN 3 drew up 4 units of insulin (diabetic medication) for Resident 37 at the medication cart. She took the insulin to Resident 37 ' s room, cleaned the residents arm and administered the insulin subcutaneously. RN 3 was not observed to use hand sanitizer or wash hands before administering the insulin. RN 3 did use hand sanitizer after administering the insulin. The Assistant Director of Nursing (ADON) was interviewed on 11/06/2017 at 2:34 P.M. During the interview, the ADON indicated hands should be washed with soap and water after performing a blood sugar check and in-between resident contact. He also indicated hands should be washed anytime they come in contact with blood or bodily fluids. A policy was provided by the Minimum Data Set Nurse (MDS Nurse), on 11/6/17 at 3:20 P.M., dated November 6, 2017, and she indicated it was the policy currently used by the facility. The policy indicated that A. SPECIFIC TIMES HANDS MUST BE WASHED: III. Before and after direct resident contact. 3.1-18(1)

Based on interview and record review, the facility failed to ensure family notification was completed for 1 of 3 residents reviewed with a change in condition. (Resident V) Findings include: Resident V's record was reviewed 8-25-2017 at 11:43 A.M. Resident V's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. There was no indication on either physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED].M. and had received [MEDICATION NAME] 0.5 mg on July 29, and 30 at 8 PM and on July 31 at 3 PM. A date of 7-31 with the time of 8 P.M. and the indication of i (meaning 1) was entered into the record but not initialed. A review of the Controlled Substance Record for [MEDICATION NAME] indicated the medication had been signed out as given at 8 P.M.,but not at 3 P.M. In an interview on 8-25-2017 at 1:43 PM, QMA 1 indicated she could not remember when the medication had been given. A review of progress notes dated 7-28 through 7-31 indicated there was no entry to indicate the family had been notified of the orders or of the administration of the medication. In an interview on 8-25-2017 at 10:40 AM, the Director of Nursing indicated whenever staff receives an order, they should note it on the order sheet or in the progress note record that family had been notified of the order. 3.1-5(a)(3)

Based on observation, interview and record review, the facility failed to revise the plan of care for fall interventions for 4 of 4 residents reviewed for accidents (Resident B, Resident C, Resident D, and Resident E). Findings include: 1. On 6/21/17 at 12:34 P.M., Resident B's record was reviewed. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 6/2/17, indicated Resident B had severely impaired cognition, was wheelchair bound, and required assistance with all of her ADL's (Activities of Daily Living). A Nursing Occurrence Initial Assessment, dated 2/27/17, indicated Resident B had been assisted to the bathroom with assist of two staff members when she stopped walking and was lowered to the floor. A Therapy Notification form, dated 2/27/17, indicated Resident B to be screened by physical therapy due to fall. A Physical Therapy Plan of Care (Evaluation Only), dated 2/28/17, indicated Resident B was referred to therapy due to recent decline in function. Discharge plans indicated the resident was not picked up on therapy due to poor potential for progress and caregivers educated on patient having wheelchair mobility for safety. The recommendation indicated to use a reclining wheelchair for Resident B. The care plan had not been revised to include that intervention. A Nursing Occurrence Initial Assessment, dated 3/2/17, indicated Resident B had fallen from her w/c (wheelchair) while she reached forward to get a cup dropped on the floor. The resident sustained [REDACTED]. A Facility-Post Occurrence IDT (Interdisciplinary Team) and fall risk assessment form, dated 3/2/17, indicated IDT recommendations were to not place resident in wheelchair. A physican's for a geri-chair was obtained on 3/9/2107. The care plan did not include this intervention. The care plan did not have fall interventions included in the care plan for falls that occurred on 2/27/17 and 3/2/17. Resident B remained in the w/c she had fallen from on 3/2/17 until a new w/c was ordered and provided to the resident on 4/4/17. 2. On 6/22/17 at 8:30 A.M., the record for Resident C was reviewed. [DIAGNOSES REDACTED]. An Admission MDS assessment, dated 6/6/17, indicated a BIMS score of 15. This indicated Resident C had no cognitive impairment. The MDS indicated the resident required extensive assistance of 1 staff member for toileting due to an unsteady gait. On 6/21/17 at 11:21 A.M., Resident C was observed sitting in her room in a w/c. The resident had on oxygen and was noted to be short of breath while talking. Resident C indicated she had a recent fall followed by a stay at the hospital. She indicated she fell because it took too long for staff to answer her call light so she got out of bed and tried to go to the bathroom herself. A Nursing Occurrence Initial Assessment, dated 6/9/17 at 4:50 a.m., indicated Resident C was found sitting on the floor with her oxygen tubing off and on the floor. Resident C indicated she was trying to go to the bathroom. A Facility-Post Occurrence IDT (Interdisciplinary Team) and fall risk assessment form, dated 6/9/17 indicated a root cause of the fall was the resident did not call for help. IDT recommendations were to reinforce to use call light. The care plan was not updated with fall interventions for the fall that occurred on 6/9/17. 3. On 6/21/17 at 2:53 P.M., Resident D's record was reviewed. [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 6/6/17, indicated Resident D had severely impaired cognition. The MDS indicated the resident was dependent on 2 staff members for transfers and toileting. Resident D was occassionally incontinent of bowel and bladder. Nursing Occurrence Initial Assessment reports, dated 1/7/17 at 7:30 P.M. and 3/24/17 at 7:00 P.M., indicated Resident D had falls while attempting to toilet himself after supper. The care plan did not have fall interventions for the fall that occurred on 1/7/17. The fall intervention for 3/24/17 was to put resident in recliner chair after supper. A Facility-Post Occurrence IDT (Interdisciplinary Team) and fall risk assessment form to determine the root cause of the 3/24/17 fall was not completed. The care plan did not indicate that Resident D required assistance with toileting nor was he on a toileting plan. Nursing Occurrence Initial Assessment, dated 5/27/17 at 7:00 P.M., indicated Resident D slid out of his w/c when he attempted to open an exit door. A Facility-Post Occurrence IDT (Interdisciplinary Team) and fall risk assessment dated [DATE] indicated root cause of the fall was that Resident D was attempting to open a door. IDT recommendations were to attempt to keep the resident away from doors. The care plan did not have fall interventions for the fall that occurred on 5/27/17. The care plan did not indicate that Resident D required assistance with toileting nor was he on a toileting plan. 4. On 6/21/17 at 12:21 P.M., Resident E's record was reviewed. [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 5/4/17, indicated Resident E had severely impaired cognition and recurrent behaviors of physical and verbal abuse of others. Resident E was ambulatory with supervision and wandered daily on the secured unit. A Nursing Occurrence Initial Assessment, 5/30/17 at 1:00 P.M., indicated Resident E had been found on the floor, bleeding to her face, and purple bruising and swelling to the bridge of her nose. A Nurse Note, dated 6/1/17 at 2:57 P.M., indicated Resident E was transferred to the hospital due to abnormal labs, irregular heart rythym, and [MEDICAL CONDITION] to legs. Resident E returned to the facility on [DATE] with new anti-pyschotic and an anti-anxiety medication orders. A Nursing Occurrence Initial Assessment, dated 6/10/17 at 6:30 P.M., indicated Resident E was found on the floor in front of the television. She sustained a quarter sized bump to her head. A Plan of Care, initiated on 7/27/16, indicated Resident E was at risk for falls due to dementia,[MEDICAL CONDITION](high blood pressure) and balance issues. A fall intervention, dated 6/21/17, indicated avoid placing resident in wheelchair unless medically necessary. There was no indication Resident E's [MEDICAL CONDITION] medication was addressed on the fall care plan. On 6/22/17 at 2:23 P.M., the DON (Director of Nursing) was interviewed. During the interview, the DON indicated Resident E had been placed in a w/c on 6/10/17 due to weakness and fell out of the w/c onto the floor. The DON indicated the fall intervention to prevent further falls, was to avoid placing the resident in a w/c which was not put onto the plan of care until 6/21/17. On 6/22/17 at 5:02 P.M., the DON provided a current copy of the facility's fall policy, titled Fall Management Procedure which stated: 1. Purpose A. To assess all residents for risk factors that may contribute to falling and to provide planned interventions identifed by the team as appropriate for resident use in maintaining or returning to the highest level of physical, social, and psychosocial functioning as possible .2 Procedure B. The Interdisciplinary health care plan team will review the risk factors and determine if further assessment is indicated .D Update the plan of care each time there is a change in intervention and communicate it to staff .3 Post Fall Investigation .I. Investigate the circumstances surrounding the fall II. Determine if previously implemented interventions are in need of revision or discontinuation III. Determine what new or revised interventions will be implemented to reduce the risk of further falls and/or injuries from falls. This Federal tag relates to Complaint IN 858. 3.1-35(d)(2)(B)

Based on observation, interview and record review, the facility failed to assess a non-pressure related wound for 1 of 1 residents reviewed for non-pressure related wounds (Resident 83). Findings include: On 12/15/16 at 12:31 P.M., Resident 83's record was reviewed. Resident 83 was admitted to the facility following a fall with a fractured right ankle. Current [DIAGNOSES REDACTED]. Slough or eschar may be present on some parts of the ulcer bed. Often includes undermining and tunneling) to right buttock. On 12/14/16 at 2:46 P.M., Resident 83 was observed lying in a low bed on his left side, with prevalon boots on his feet/heels. On 12/15/16 at 10:12 A.M., Resident 83 was observed lying in a low bed on his right side. A family member was visiting and indicated Resident 83 was lying in bed on his side because he had a sore on his bottom. On 12/15/16 at 1:25 P.M., Resident 83's record was further reviewed and indicated the following: On 8/2/16, a nursing admission assessment indicated Resident 83 had a skin alteration other than wound (skin tear, laceration, bruise, lesion, rash, excoriation, abrasion, burn, scar, or any other skin alteration). Description of the skin alteration other than wound indicated Resident 83 had a bruise to the right and left arm from iv sticks at hospital. There were no other bruises or non-pressure related wounds noted on the assessment. On 8/3/16 at 1:56 P.M., a Medicare nursing assessment indicated Resident 83's skin was assessed as being pink or normal skin tone and no new skin issues noted during the assessment. On 8/4/16 at 6:41 A.M. and 2:32 P.M., a Medicare nursing assessment indicated Resident 83's skin was assessed as being pink or normal skin tone and no new skin issues noted during the assessment. On 8/5/16 at 12:46 A.M., and 4:46 P.M., a Medicare nursing assessment indicated Resident 83's skin was assessed as being pink or normal skin tone and no new skin issues noted during the assessment. On 8/5/16 at 9:39 A.M., a Medicare nursing assessment indicated Resident 83's skin was assessed and no new skin issues noted during the assessment. On 8/6/16 at 10:53 A.M., a Medicare nursing assessment indicated Resident 83's skin was assessed as being pale and no new skin issues noted during the assessment. On 8/7/16 at 11:41 A.M., a Medicare nursing assessment indicated Resident 83's skin was assessed as being pale and no new skin issues noted during the assessment. On 8/10/16 at 1:12 P.M., a Nursing-New Skin Alteration Assessment indicated Resident 83 had a new skin alteration described as: Light purple area to R buttock measures 3cm (centimeters) by 3cm, skin intact On 8/10/16 at 3:56 P.M., a Non-pressure wound assessment indicated the date originally noted was 8/2/16. Resident 83's non-pressure wound assessment indicated it was a traumatic injury wound, new, and located on the mid right buttocks. The wound measured 3cm x 3cm x 0cm and was irregular in shape. Further, the wound was blistered with attached edges and pale purple in color. Treatment and Notification was documented as none at this time. TAR (Treatment Administration Sheet) for August 2016 indicated Resident 83's non-pressure wound had a treatment started on 8/12/16 which was to wash the open area on right buttock with soap and water, allow to dry and change every 3 days. The TAR did not indicate Resident 83's right buttock wound had been assessed prior to 8/12/16. On 8/13/16 at 1:00 P.M., a Nursing-New Skin Alteration Assessment indicated a new wound on Resident 83's right buttock measuring 2.6cm x 1cm with no depth documented. The wound was red to purple in color with a small amount of pinkish drainage. On 8/13/16 at 1:45 P.M., A physician order [REDACTED]. On 12/16/16 at 11:49 A.M., the MDS (Minimum Data Set) nurse were interviewed. During the interview, the MDS nurse indicated Resident 83's right buttock wound was not assessed as being present on the admission MDS dated [DATE]. On 12/19/16 at 10:50 A.M., the facility's wound nurse was interviewed. During the interview, the wound nurse indicated Resident 83's right buttock wound was a result of bruising that occurred when the resident fell and fractured his right ankle. The wound nurse was not able to locate documentation to indicate Resident 83's right buttock wound was present upon admission and had been assessed. On 12/19/16 at 10:50 A.M., the DON (Director of Nursing) provided a current copy of the facility's policy titled Wound and Non-wound Assessment and Documentation which included the following: 3. NON-WOUND SKIN ALTERATIONS A. All non-wound skin alterations .will be completed on the Nursing-New skin alteration assessment . The non-wound area will be placed on the TAR with instructions to monitor at least daily until it is healed . Bruises will be monitored at least daily x 7days for complications such as pain that may indicate need for further assessment 3.1-37(a)