Every finding on record at Mountain View Post Acute

Based on observation, interview, and record review, the facility failed to maintain a sanitary and safe environment for one of three residents (Resident 2) on enhanced barrier precaution (EBP - Enhanced Barrier Precautions, infection control measures, specifically focused on reducing the spread of multidrug-resistant organisms (MDROs)) when a License Vocational Nurse (LVN 3) did not perform hand hygiene after contact with Resident 2's foley catheter (a thin, flexible tube used to drain urine from the bladder). This failure had the potential for cross contamination and infection (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) which can jeopardize the health and safety of Resident 2. Findings: During a review of Resident 2's admission Record (contains patient demographics), the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included hypertension (elevated blood pressure), type 2 diabetes mellitus with hyperglycemia (a condition where body cannot produce enough insulin), chronic obstructive pulmonary disease (COPD- a group of lung diseases characterized by airflow obstruction and limited lung capacity) , protein-calorie malnutrition (a condition characterized by a deficiency of both protein and energy) dysphagia, oropharyngeal phase (difficult swallowing). During an observation on June 2, 2025, at 10:40 AM, with LVN 3, in Resident 2's room, there was sign at the door that indicated Resident 2 was on EBP. LVN 3 was wearing gloves and touching Resident 2's foley catheter tube and bag. LVN 3 then removed the gloves and handshake Resident 2, then walked out of the room without performing hand hygiene towards the nurse's station. During an interview on June 2, 2025, at 10:47 AM, with the LVN 3, LVN 3 stated, Oh sorry, next time, I will sanitize my hands. The LVN 3 acknowledged the resident is in EBP. During a concurrent interview and record review with Infection Preventionist (IP), on June 3, 2025, at 2:45 PM, the IP reviewed the facility's policy and procedure (P&P), titled Enhanced Barrier Precautions, revised on March 10, 2025. The P&P indicated 4. High-contact resident care activities include: . g. Device care or use: .urinary catheters. The IP stated, for resident on EBP the expectation is for staff to perform hand hygiene after touching foley catheter and after removing gloves. The IP further stated when residents had foley, staff needs to wear appropriate PPE (PPE- personal protective equipment such as gloves and gown) and wash hands. During a concurrent interview and record review with the Director of Nursing (DON) on June 3, 2025, at 4:31 PM, The DON reviewed the facility's policy and procedure (P&P) titled Hand hygiene, revised on December 12, 2022. The P&P indicated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. The DON stated his expectation is for staff to wear appropriate PPE and to wash hands.

Based on observation, interview, and record review, the facility failed to safeguard residents' confidential information for one of three sampled residents (Resident 50) when Licensed Vocational Nurse (LVN 4) left the computer screen containing Resident 50's medical information unattended and visible to others on June 4, 2025. This failure resulted in Resident 50's clinical records to be exposed to anyone and had the potential for an unauthorized person to access the information. Findings: During a review of Resident 50's admission Record (patient demographics), the admission Record indicated Resident 50 was admitted to the facility on [DATE], with diagnoses that included, fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), cardiomegaly (a condition where the heart is larger than normal), acute respiratory failure with hypoxia (a condition where the respiratory system fails to adequately oxygenate the blood). During an observation on June 4, 2025, at 6:08 AM, LVN 4 entered room [ROOM NUMBER] to administer medication to a resident in bed C, leaving the computer screen up and unattended, in the hallway, with Resident 50's information visible to others. During an interview on June 4, 2025, at 6:15 AM, with LVN 4, LVN 4 stated, I usually minimize or close the screen, I've been a nurse for ten years, so I've picked up a lot of bad habits. You caught me on that. During an interview with Registered Nurse Supervisor (RN), on June 4, 2025, at 7:38 AM, the RN stated her expectation is when staff need to walk away from the computer, staff must either change the screen or close the computer screen. During a concurrent interview and record review with the Director of Nursing (DON) on June 4, 2025, at 8:40 AM, the DON reviewed the facility's policy and procedures (P&P) titled Safeguarding of Resident Identifiable Information, revised December 19, 2022, the P&P indicated, It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information and to safeguard against destruction or unauthorized release of information and records . 7. Computer screens showing clinical record information may not be left unattended and readily observable or accessible by other residents or visitors. The DON acknowledged LVN 4, Should not have done that, and the policy was not followed.

Based on observation, interviews, and record review, the facility failed to ensure that rehabilitation services were rendered in accordance with federal regulations for one of two sampled residents (Resident 48), when Resident 48 received physical therapy (PT- a treatment focused on improving movement, mobility, and physical function) and occupational therapy (OT- a therapy aimed at helping individuals perform daily activities and improve functional independence) services without a physician's order. This failure had the potential to result in uncoordinated and ineffective care, which could negatively impact Resident 48's rehabilitation and overall treatment plan. Findings: During a review of Resident 48's admission Record (clinical record with demographic information), the admission Record indicated, Resident 48 was readmitted to the facility on [DATE], with diagnoses of acute pulmonary edema (condition where fluid suddenly builds up in the lungs, making it difficult to breathe), and muscle weakness. During an observation on June 3, 2025, at 12:48 PM in the gym (Rehabilitation Room), the physical therapist assistant (PTA) assisted Resident 48 with sitting to standing transfers. The PTA provided verbal instructions, guiding Resident 48 through the movement. Resident 48 was able to stand and maintain balance while holding both hands on the front-wheeled walker (FWW, a mobility aid with two wheels designed to provide support and stability while walking). During an observation on June 5, 2025, at 10:18 AM at the gym, the occupational therapist assistant (OTA) guided Resident 48 through two sets of 10 exercises, raising both arms up and down. The OTA provided verbal instructions throughout the session. Resident 48 successfully completed the exercises. During a concurrent record review and interview on June 5, 2025, at 1:00 PM, the Director of Rehab (DOR), the DOR reviewed the PT and OT evaluation and treatment plan, which indicated, . Certification period [a designated timeframe during which a healthcare service or treatment is authorized and meets regulatory or professional standards] of 5/12/25 [May 12, 2025] - 6/10/25 [June 10, 2025] . The DOR confirmed that Resident 48 is currently receiving PT and OT services. A review of Resident 48's clinical records of active physician orders was conducted. There was no documented evidence of a physician's order for PT or OT treatment. Additionally, there was no documented evidence that a physician had been notified of Resident 48's PT and OT services. (Resident 48 received PT and OT services for 25 days without a physician's order or oversight). During an interview on June 5, 2025, at 1:30 PM with the Director of Nurses (DON), the DON stated that he was not aware of the regulation requiring the facility to obtain a physician's order for PT and OT services and treatment. The DON further stated the facility's usual practice is to treat the evaluation and plan of treatment as a physician's order. Furthermore, the DON acknowledged that the facility does not have a formal policy or procedure outlining this process.

Based on observation, interview, and record review, the facility failed to ensure the post fall protocol was implemented in accordance with the facility ' s policy and procedure for one of three residents (Resident 1) reviewed for falls, when the Interdisciplinary Team (IDT ( a group of healthcare professionals from different disciplines working towards a common goal for a resident) did not conduct a review of Resident 1 ' s fall which occurred on October 23, 2024. This failure had the potential for Resident 1 to be at risk of further falls which could increase Resident 1 ' s risk of injuries. Findings: A review of Resident 1's Admission Record (a document that gives a summary of resident's information), indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that include Muscle weakness, abnormalities of gait and mobility, repeated falls. During an observation and interview on October 28, 2024, at 12:56 PM with Resident 1, in Resident 1 ' s room, Resident 1 was eating in bed, with the head of the bed elevated. Resident 1 stated she fell recently but could not remember how she fell , she further stated she believes she got stiches on her head from the fall. During a review of a facility provided document titled Change of Condition/Fall, it indicated Resident 1 had a fall incident on October 23, 2024. During an interview on October 28, 2024, at 2:25 PM with the Director of Nursing (DON 1), the DON 1 stated resident 1 fall was unwitnessed, and the interdisciplinary team failed to assess after Resident 1 fall. During a review of facility Policy and Procedure (P&P) titled, Fall Prevention Program dated 12/19/2022 indicated, .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . 3 The nurse and/or interdisciplinary team will initiate interventions on the resident's care plan, in accordance with the resident's level of risk .

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from misappropriation (deliberate misplacement or wrongful use of a resident ' s belongings without consent) of property when Resident 1 ' s debit card was used by the facility Business Office Manager to pay for Resident 1 outstanding balance rather than for Resident 1 ' s personal necessities like clothing and shoes as indicated in the agreement with the bank. This failure had the potential for Resident 1 ' s personal needs not being med and further misappropriation of Resident ' s property. Findings: During an interview on October 28, 2024, at 1:07 PM, with Resident 1. Resident 1 acknowledged that he gave the facility permission to use his debit card to cover personal expenses like clothing and shoes. During a review of Resident 1 ' s clinical records, the face sheet (contains demographic information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included Hypercapnia (a condition where there is too much carbon dioxide (CO2) in the blood), chronic obstructive pulmonary disease (COPD - is a common lung disease that makes it difficult to breathe). A review of Resident 29's History and Physical, dated July 26, 2023, indicated Resident 1 had the capacity to understand and make decisions. During an interview on October 28, 2024, at 12:19 PM, with the Business Office Manager (BOM 1), the BOM 1 stated the bank issues a debit card for the resident in order to pay for resident personal items such as clothing and shoes, and she told the bank that resident will get everything he needed at a Department Store. She was aware that the activity and spending would be closely monitor by the bank. She claimed she never mentioned to the bank that the money will be used to pay for resident 1 ' s outstanding balance. She further explains that because resident had such a significant outstanding balance and they are only receiving small amount from resident 1 ' s social security, they had been charging the card to pay for resident 1 past due balance instead of the clothing and shoes that Resident 1 need. She acknowledged that this was against the terms of the bank agreement, that the situation can be seen as neglect of resident needs. During a telephone interview on October 29, 2024, at 8:34 AM with the Administrator (Admin 1), the Admin1 stated since the resident put the card on file for the facility, his understanding is that the debit card is to be used for resident 1's personal costs, including paying off the resident 1's past due balance. A review of the facility policy and procedure (P&P) titled, Resident Trust Funds indicated, .2) Management of Personal Funds: A resident has the right to manage their own financial affairs. However, upon written authorization the facility must hold, safeguard, manage and account for a resident ' s personal funds. Before the facility can involve itself in the management of a resident ' s trust fund, the Resident Fund Management Service form needs to be completed. This form Resident Fund Management Service needs to then be mailed to National Data care and Resident added into the RFMS accounting system. A review of Resident 1 ' s Resident Fund Management Service dated June 11, 2024, indicated, .Resident fund account .Transferring account (automatic transfer of care cost payment due the facility.) with $35 monthly allowance amount .Direct Deposit - Please enroll my indicated recurring benefit payments for direct deposit Social Security .

Based on observation, interview, and record review, the facility failed to accurately assess resident medication and report to physician when one of three sample resident (Resident 1) did not receive medication for Type 2 Diabetes Mellitus (Type 2 DM - a chronic disease that causes high levels of blood sugar) from August 11, 2024, until September 12, 2024. This failure had the potential to jeopardize the health and well-being of Resident 1 who is medically compromised. Findings: During review of Resident 1 ' s admission record (It contains important information about the patient such as their personal details, the reason for their admission, and their medical history), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that include Type 2 DM. During an interview on October 15, 2024, at 2:31 PM, with the License Vocational Nurse (LVN 1), the LVN 1 stated resident 1 did not receive Metformin (a medication that treats type 2 DM) from August 11, 2024, until the day it was ordered, September 12, 2024. She further explains that the resident's family informed her that the resident needed to take metformin for diabetes mellitus type 2, but the MAR (Medication administration Record) only calls for a blood sugar check to be performed prior to meals; there is no indication that the blood sugar check is for Type 2 DM; instead, she assumed it was for an infection the resident had. During an interview on October 15, 2024, at 2:51 PM, with the registered nurse (RN 1), the RN 1 identified herself as resident 1's admittance nurse. She claimed that she would not have been aware that the resident was taking Metformin for type 2 diabetes if the family had not informed her. She added that the patient's diagnosis in the admission record included Type 2 DM, but she did not ask the doctor if the resident was taking medication for the condition. During a review of Blood Sugar Summary the record indicated on August 24, 2024, at 8:40 PM, resident ' s blood sugar level was 462 mg/dL (a blood sugar level of 462 mg/dL is considered dangerously high and requires immediate medical attention). During a review of Order Summary Report the record indicated, Metformin HCI oral table 1000 mg given 1000 mg by mouth one time a day for DM was ordered on September 12, 2024. During a review of facility policy and procedure (P&P) titled Admission of a Resident dated December 19, 2022, indicated, .The admission process is intended to obtain all the information possible about the resident, for the development of comprehensive plans of care, and to assist the resident in becoming comfortable in the facility. Residents are admitted to the facility under orders of the attending physician .

Based on interviews and record reviews, the facility failed to adhere to its Medicare denial process policy when it did not promptly notify one of three sampled residents (Resident 1) about the Skilled Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: CMS -10055) This document provides information to the patient so they can decide whether or not to get the care that may not be paid for Medicare. Additionally, Resident 1 did not receive timely notification about the Notice of Medicare Non-Coverage (NOMC)which is a notice that a Medicare provider or health plan must give to beneficiaries at least two days before covered services end, along with information on how to request an expedited appeal, as the coverage was coming to an end. This failure resulted in Resident 1 ' s representative not being promptly informed of her appeal rights and financial liability for services no longer covered by Medicare. Findings: During a review of the facility-provided document tiled Notice of Medicare Non-Coverage, it was noted that the effective date of coverage for skilled nursing services will end on 8/31/2024. Additionally, the document indicated that the responsible party for the resident signed the document on 9/18/2024. During a review of the facility-provided document titled Activity Report, it was noted that there was no indication of whether Resident 1 ' s responsible party was informed about SNF ABN prior to the resident termination of Resident 1 ' s Medicare insurance coverage. Additionally, the document did not specify whether Resident 1 ' s responsible party was informed about the appeal process at least two days prior to the end of the Medicare insurance coverage. During a telephone interview on 10/09/2024 at 8:46 a.m. with the Business Office Director (Director)1, Director 1 confirmed that the responsible party for Resident 1 was offered the opportunity to sign both the SNF ABN and NOMC form. However, the responsible party for Resident 1only signed the NOMC form on 9/18/2024, which was 18 days after the expiration of Resident 1 ' s Medicare insurance coverage. When asked whether the SNF ABN form should have been offered at least 2 days prior to the end of the Medicare insurance coverage, Director 1 concurred. During a review of the facility ' s policy and procedure (P&P) titled, Medicare Denial Process, dated October 8, 2018, the P&P indicated, Medicare beneficiaries will be properly notified when it is determined that they do not meet the requirements for covered services under the Medicare program.

Based on observation, interviews, and record review, the facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights are answered in a timely manner for two of three sampled residents (Residents 1 & 2). This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Residents 1 & 2) when their requests for assistance with activities of daily living were not responded to promptly. Findings: During the review of Resident 1 ' s admission record (It contains important information about the patient such as their personal details, the reason for their admission, and their medical history), the document indicated Resident 1 was admitted on [DATE], with a diagnosis that included abnormalities of gait and mobility (a change in walking pattern that can be caused by injury, disease, or neurological issues), shortness of breath (the feeling of unable to breathe normally or feeling suffocated). During interview and observation with Resident 1 on September 24, 2024, at 10:14 a.m. Resident 1 stated the staff does not respond to call lights promptly and has to wait for half an hour at times. During the review of Resident 2 ' s admission record, the document indicated Resident 2 was admitted to the facility on was admitted to the facility on [DATE], with a diagnosis that included generalized muscle weakness (a decrease in muscle strength that can make it difficult to move arms, legs, or other body parts), and repeated falls (two or more falls in a year or over a given timeframes). During an interview and observation with Resident 2 on September 24, 2024, at 10:18 a.m. Resident 2 stated half the time, the staff don ' t respond when she asks for help. Resident 2 also mentioned that it seems to take forever for them to respond when she uses her call lights. During an interview on September 24, 2024, at 11:21 a.m. with the registered nurse supervisor (RN) 1, regarding the appropriate response time to call light. RN 1 stated it should be answered as soon as physically possible. During an interview on September 24, 2024, at 11:39 a.m. with the facility administrator (ADM)1, ADM 1, did not provide a specific response when discussing Residents 1 & 2 concerns about call light not being responded to promptly. During a review of the facility ' s policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, revised December 19, 2022, indicated, Staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

Based on observations, interviews, and record review the facility failed to ensure staff followed safe Infection control practices when: 1. Three staff members, one Certified Nursing Assistant (CNA 1), the Activities Director (AD), and the Infection Preventionist (IP), were wearing acrylic nails longer than the tip of the fingers, on June 11, 2024. 2. One resident's (Resident 35) urinary catheter bag (a bag connected to a flexible tube inserted into the bladder and collects urine), was on the floor, on June 13, 2024. 3. One resident's (Resident 33's) urinary catheter tubing (the tubing which connects an indwelling urinary catheter to a urinary drainage bag) was dragging on the floor, on June 11, 2024. These failures had the potential to result in cross-contamination (spread of bacteria) causing serious infections to 42 vulnerable residents. Findings: 1. During an observation on June 11, 2024, at 10:25 AM, with Certified Nursing Assistant (CNA 1), CNA 1 was performing care to one resident while wearing long acrylic nails. CNA 1, then entered room [ROOM NUMBER] and then room [ROOM NUMBER] and performed resident care to two other residents on the [NAME] Wing of the facility. CNA 1 was wearing acrylic nails, over one inch long. CNA 1 stated, she was allowed to wear acrylic nails, as long as they are not over one inch. During an observation on June 11, 2024, at 10:27 AM, on the [NAME] Wing, with the Activities Director (AD), the AD was passing out water and snacks to the residents, from room [ROOM NUMBER]A through room [ROOM NUMBER] C. The AD was wearing acrylic nails over one inch long. During a concurrent observation and interview, on June 11, 2024, at 10:31 AM, at the nurses' station, with the Infection Preventionist (IP), the IP was sitting at the nurses' station, working on the computer and was wearing acrylic nails. The IP stated, staff is allowed to wear acrylic nails, as long as they are short. The IP further stated, the staff knows it and it is for the direct care staff. During a record review on June 11, 2024, at 10:50 AM, with the Director of Nursing (DON). The DON reviewed the Employee Handbook, undated, The Employee Handbook indicated, . Direct Patient Care, Food Services, Medical Supply Staff: . Employees are prohibited from any form of artificial fingernails or fingernail enhancements or nail changes that have been found to increase the colonization and transmission of pathogens to patients. Therefore, only well-groomed nails of reasonable length (no longer that [sic] 1/4 beyond the fingertip) are permitted for health care workers with direct patient contact or contact with patient food or medical supplies. Fingernails must be neat, of reasonable length, and may be polished. Health care professional observed wearing artificial nails or fingernail enhancement must be removed prior to next scheduled workday. The DON stated, the facility did not follow the employee handbook. During a record review on June 11, 2024, at 10:55 AM, with the Director of Nursing (DON). The DON reviewed the Employee Handbook, undated, the Employee Handbook indicated, . All employees Dress Code, . Fingernails: Fingernails must be clean and lightly manicured. Employees whose duties include direct resident care may not have long fingernails extending beyond the fingertip. Artificial and acrylic nails and acrylic overlays are not allowed to be worn by any employees whose job description includes direct resident care. The DON stated the employee handbook was not followed. 2. During a review of Resident 35's Admission Record (clinical record with demographic information), the Admission Record indicated, Resident 35 was admitted to the facility on [DATE], with diagnoses which included, acute kidney failure (kidneys suddenly become unable to filter waste), metabolic encephalopathy (dysfunction in the absence of primary structural brain disease), obstructive and reflux uropathy (disorder of the urinary tract that is obstructed urinary flow). During an observation on June 12, 2024, at 10:05 AM, with Resident 35, Resident 35 came out of his room wearing briefs, the urinary catheter drainage bag was hanging down from his left leg, and it was dragging on the floor. During an observation on June 13, 2024, at 9:15 AM, Resident 35 was coming out of his room, and stopped at the door and the urinary catheter drainage bag was on the floor. During an interview on June 13, 2024, at 10:00 AM, with the Infection Preventionist ( IP), the IP stated the tubing and urinary catheter drainage bag should not be dragging on the floor due to infection control. IP further stated, no tubing or bags should be dragging on the floor or lying on the floor. During a concurrent interview and record review on June 13, 2024, at 11:00 AM, with the DON, the facility's policy and procedure (P&P), titled, Infection Surveillance, dated December 19, 2022, was reviewed. The P&P indicated, . A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to prevention and control practices in order to reduce infections and prevent the spread of infections. 5. Surveillance activities will be monitored facility-wide, and may be broken down by department or unit, depending on the measure being observed. A combination of process and outcome measures will be utilized. ii. Observations of staff including the identification of ineffective practices, if any . The DON stated the policy was not followed. 3. A review of Resident 33's Admission Record, the Admission Record indicated, Resident 33 was admitted to the facility on [DATE], with diagnoses which included hemiparesis and hemiplegia (weakness and paralysis) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). During a concurrent observation and interview on June 11, 2024, at 11:37 AM, in the hallway, with Restorative Nursing Assistant 1 (RNA 1), Resident 33 was seen self-propelling himself in his wheelchair down the hallway while his foley catheter tubing (the tubing of an indwelling urinary catheter) was dragging on the floor. As Resident 33 wheeled down the hallway, he passed next to two staff members who were walking down the hallway in the opposite direction but neither of the two staff members assisted Resident 33 to prevent his foley catheter tubing from dragging on the floor. Restorative Nursing Assistant 1 (RNA 1) was also in the hallway and stated Resident 33's foley catheter tubing was dragging on the floor and was not supposed to be dragging on the floor. During a review of Resident 33's clinical record, a care plan (the individualized medical plan of care for a resident) titled, The resident has indwelling catheter . dated November 13, 2023, indicated, . uropathy [blockage of the urinary tract] at risk for infection .goals .the resident will show no s/sx [signs and symptoms] of urinary infection . During an interview on June 14, 2024, at 9:55 AM, with the DON, the DON stated urinary catheter tubing should not be dragging on the floor because it is a risk of infection. During an interview on June 14, 2024, at 10:38 AM, with the IP, the IP stated urinary catheter tubing should not be dragging on the floor and that it was important to prevent the tubing from dragging on the floor because it was an infection control issue and the tubing could get lodged on something or yanked on as it dragged on the floor. During a review of the facility's policy and procedure titled, Catheter Care, dated November 19, 2022, the policy indicated, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care . During a review of the facility's policy and procedure titled, Infection Prevention and Control Program, dated December 19, 2022, the policy indicated, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

Based on observations, interviews, and record review, the facility failed to ensure their walk-in refrigerator and walk-in freezer were maintained in safe operating condition when both the fridge and the freezer were identified to not be operating correctly and unable to maintain acceptable temperatures on June 10, 2024. This failure had the potential for food spoilage and increased risk for foodborne illness (illness caused by eating contaminated food) for all 42 residents who received food from the facility's kitchen. Findings: During a concurrent observation and interview on June 10, 2024, at 9:43 AM, with the Dietary Services Supervisor (DSS), in the facility's walk-in refrigerator and walk-in freezer, both the fridge and freezer felt like they were at room temperature and the facility had removed the thermometers. The facility had food stored in both the fridge and the freezer. The DSS stated the facility's walk-in refrigerator, and walk-in freezer were identified to not be working at 4:00 AM on June 10, 2024, and had broken sometime overnight. During a record review of the facility's walk-in refrigerator and walk-in freezer temperature log titled, Record of Refrigeration Temperatures, dated June 2024, the log indicated on June 10, 2024, the refrigerator temperature was documented as 55 degrees Fahrenheit ( F) and the freezer temp was documented as off. The document further indicated, Code for adequate temperature: Refrigeration: Not greater than 41 F .Freezer: Not greater than 0 F or food maintained solid . During an observation on June 11, 2024, at 8:56 AM, with the Registered Dietician (RD), the facility's walk-in refrigerator temperature was 36.3 degrees F and the walk-in freezer temperature was 38.3 degrees F. During a record review of the facility's walk-in refrigerator and walk-in freezer temperature log titled, Record of Refrigeration Temperatures, dated June 11, 2024, the log indicated the walk-in freezer temperatures from 8:30 AM, through 2:15 PM, ranged between 10 degrees F and 35 degrees F. During a concurrent interview and record review on June 14, 2024, at 11:57 AM, with the Dietary Services Supervisor, the facility's policy and procedure titled, Physical Environment: Electrical Equipment, dated December 19, 2022, was reviewed. The policy indicated, Policy: The facility will maintain all mechanical, electrical, and patient care equipment in safe operating condition .4 .Examples of essential equipment include, but are not limited to: .e. Kitchen refrigerator/freezer . The DSS stated the facility was supposed to maintain the fridge and freezer in safe operating condition and stated the facility policy was not followed.

Based on observations, interviews, and record review, the facility failed to ensure dignity was maintained for two of three residents (Resident 35 and 500) when Resident 35 and 500 had their urinary catheter drainage/collection bags (bags which collect and hold urine) not covered with dignity bags (a bag used to the cover and hold the catheter drainage/collection bag, so it is not visible). These failures resulted in the urine of both residents (Resident 35 and 500) to be visible to residents and staff within the facility which had the potential to compromise the residents' privacy and feelings of dignity and respect. Findings: 1a. During a review of Resident 35's Admission Record (clinical record with demographic information), the Admission Record indicated Resident 35 was admitted to the facility on [DATE], with diagnoses which included, acute kidney failure (kidneys suddenly become unable to filter waste), metabolic encephalopathy (dysfunction in the absence of primary structural brain disease), obstructive and reflux uropathy (disorder of the urinary tract that is obstructed urinary flow). During an observation on June 10, 2024, at 12:29 PM, Resident 35 was sitting at the edge of the bed. Resident 35's urinary catheter bag was hanging on the side of the bed. It was uncovered, with yellowish urine visible. During a further observation on June 13, 2024, at 9:00 AM, Resident 35 was lying in bed in a semi-upright position, watching television. Resident 35's urinary catheter bag was hanging on the floor, uncovered, with yellowish urine visible. During a concurrent observation and interview on June 13, 2024, at 9:15 AM, with the Infection Preventionist (IP), Resident 35 was standing in the doorway of his room, room [ROOM NUMBER]B, the urinary catheter bag was hanging on the floor, uncovered, with yellowish urine visible. The IP stated each urinary catheter bag must have a dignity bag at all times. 1b. A review of Resident 500's Admission Record, (contains demographic and medical information), indicated Resident 500 was admitted to the facility on [DATE], with diagnoses which included fournier gangrene (is a rare, life-threatening bacterial infection of your scrotum, penis, or perineum [the area between your genitals and rectum]), abnormalities of gait (walking) and mobility, and muscle weakness. During a concurrent observation and interview on June 11, 2024, at 1:53 PM, with Resident 500, Resident 500 was lying in bed and had a foley catheter (a device that drains urine from your urinary bladder into a drainage bag outside of your body). The urinary catheter drainage bag had urine in it and was not covered with a dignity bag. Resident 500 stated the facility did not offer or provide him a cover (dignity bag) for his catheter. During an interview on June 14, 2024, at 9:31 AM, with the Director of Nursing (DON), the DON stated all urinary catheter bags should be covered with a dignity bag. The DON further stated dignity bags were used for resident privacy and to maintain dignity. During a review of the facility's policy and procedure titled, Promoting/Maintaining Resident Dignity, dated December 12, 2022, the policy indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .Compliance Guidelines: .11. Maintain resident privacy. Record review with IP on June 13, 2024, at 10:00 AM, with the Director of Nurses (DON), the facility's policy and procedure (P&P), titled, Catheter Care, dated December 19, 2022, was reviewed. The P&P indicated, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. The DON stated the policy was not followed.

Based on observation, interviews, and record review, the facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS - a computerized resident assessment tool) for one of one resident (Resident 33) sampled for accidents when the Resident 33's RAI-MDS, dated [DATE], did not indicate the resident sustained a fall since admission. This failure had the potential to result in unmet care needs for Resident 33 which can potentially jeopardize the residents' health and safety. Findings: A review of Resident 33's Admission Record, (contains demographic and medical information), indicated Resident 33 was admitted to the facility on [DATE], with diagnoses which included hemiparesis and hemiplegia (weakness and paralysis) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), muscle weakness, and repeated falls. During a concurrent observation and interview on June 11, 2024, at 11:45 AM, Resident 33 was lying in bed and stated he fell a few weeks ago while in the facility. During a review of Resident 33's clinical record a document titled, Resident Care Conference Review, (meeting notes from a team of interdisciplinary members [staff from different disciplines]), dated May 10, 2024, was reviewed. The document indicated, .Areas reviewed: Falls .recent fall no injuries .floor mats recommended by rehab with verbal instructions for safety . During a review of Resident 33's physician's progress notes, dated May 23, 2024, indicated, Chief complaint/reason for this visit: Change in condition: fall, pulled foley (indwelling urinary catheter) out .This AM[morning] Pt [patient] had a fall onto his fall mat [a cushioned mat which may aid in lessening the severity of injury during a fall] on the floor, did not experience any head trauma; however, he did pull out his foley in the process . During a review of Resident 33's RAI-MDS assessment dated [DATE], the RAI-MDS assessment indicated in section J1800. Any falls since admission/Entry or Reentry . indicated no. During a concurrent interview and record review on June 14, 2024, at 9:36 AM, with Minimum Data Set Nurse 1 (MDS 1), MDS 1 stated the facility did not have a policy and procedure regarding completion of the MDS assessments and the facility followed the RAI manual in regards to completion of the MDS assessments. MDS 1 further stated she was the individual who completed Resident 33's RAI-MDS assessment dated [DATE]. MDS 1 stated when completing the MDS assessment section for falls, she reviews the facility's risk management report and also reviews progress notes in the resident's clinical record. MDS 1 stated when she reviewed the facility's risk management report when completing Resident 33's MDS assessment, dated May 24, 2024, there were no falls indicated. MDS 1 reviewed Resident 33's clinical record and stated the MDS dated [DATE], was coded incorrectly in section J1800 for falls and that it was a mistake and should have indicated the resident had a fall. MDS 1 stated the MDS was coded wrong in error. During a review of CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's manual, dated October 2023, version 1.18.11, the manual indicated on page J-34, Steps for Assessment .Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment. 4. Review nursing home incident reports, fall logs and the medical record (physician, nursing, therapy, and nursing assistant notes) Code 1, Yes: if the resident has fallen since the last assessment .

Based on observations, interviews, and record review, the facility failed to ensure one of one resident (Resident 33) reviewed for accidents had a fall mat (a cushioned mat which may aid in lessening the severity of injury during a fall) on both sides of his bed as was specified in the resident's care plan (an individualized plan for the medical care of a resident). This failure had the potential for the Resident 33 to sustain a serious injury during a fall in which the severity of the injury may have been lessened if the fall mat had been in place. Findings: A review of Resident 33's Admission Record, (contains demographic and medical information), indicated Resident 33 was admitted to the facility on [DATE], with diagnoses which included hemiparesis and hemiplegia (weakness and paralysis) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), muscle weakness, and repeated falls. During a concurrent observation and interview on June 11, 2024, at 11:45 AM, Resident 33 stated he fell a few weeks ago while in the facility. Resident 33 had only one fall mat on the left side of his bed (the side of the bed closest to the door). During a concurrent observation and interview on June 13, 2024, at 11:46 AM, with the Registered Nurse 2 (RN 2), Resident 33 was lying in bed and had only one fall mat on the left side of his bed. RN 2 stated Resident 33 had only one fall mat but he was supposed to have two fall mats, one on each side of his bed. RN 2 further stated she did not know why the Resident 33 only had one fall mat in place. During a review of Resident 33's care plan titled, [Resident 33] is at risk for falls r/t [related to] disease process generalized weakness and poor gait [walking] and balance . dated February 29, 2024, the care plan indicated, Goal .The resident will be free of minor injury through the review date .Interventions .Follow facility fall protocol . During a review of Resident 33's care plan titled, Risk for falls post fall (episodic), dated October 20, 2023, the care plan indicated, .Interventions .Fall mats placed on both sides of bed . During an interview on June 14, 2024, at 9:32 AM, with the Director of Nursing (DON), the DON stated the purpose of the resident's care plan was for staff to have basic knowledge regarding the resident's plan of care. The DON further stated the care plan interventions were supposed to be followed. During a review of Resident 33's clinical record a document titled, Resident Care Conference Review, (meeting notes from a team of interdisciplinary members [staff from different disciplines]), dated May 10, 2024, was reviewed. The document indicated, .Areas reviewed: Falls .recent fall no injuries .floor mats recommended by rehab with verbal instructions for safety . During a review of the facility's policy and procedure titled, Fall Risk Assessment, dated December 19, 2022, the policy indicated, It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents .3. A fall care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly. 4. The fall care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. During a review of the facility's policy and procedure titled, Fall Prevention Program, revised December 28, 2023, the policy indicated, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. During a review of the facility's policy and procedure titled, Comprehensive Care Plans, dated December 19, 2022, the policy indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .f. Resident specific interventions that reflect the resident's needs .

Based on observation, interviews, and record review, the facility failed to implement their fall prevention program for one of one resident (Resident 33) reviewed for accidents, in accordance with the facility's policies and procedures when the facility did not complete a post fall risk assessment (an assessment that identify the factors that cause the fall) on Resident 33, and did not review or update Resident 33's care plan (an individualized plan for the medical care of a resident) for falls, after he experienced a fall on May 24, 2024. This failure had the potential for Resident 33 to be at risk for repeated falls and for the facility to not identify potential new causative factors contributing to falls which can cause harm and injury to resident 33. Findings: A review of Resident 33's Admission Record, (contains demographic and medical information), indicated Resident 33 was admitted to the facility on [DATE], with diagnoses which included hemiparesis and hemiplegia (weakness and paralysis) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), muscle weakness, and repeated falls. During a concurrent observation and interview on June 11, 2024, at 11:45 AM, Resident 33 was lying in bed and stated he fell a few weeks ago while in the facility. During a review of Resident 33's physician's progress notes, dated May 23, 2024, it indicated, Chief complaint/reason for this visit: Change in condition: fall, pulled foley (indwelling urinary catheter) out .This AM [morning] Pt [patient] had a fall onto his fall mat on the floor, did not experience any head trauma; however, he did pull out his foley in the process . During a review of Resident 33's clinical record, there was no documented evidence a post fall risk assessment was performed by facility staff. During a review of Resident 33's care plan titled, Risk for Falls Post Fall (Episodic), dated October 20, 2023, the care plan indicated the most recent revision was dated May 8, 2024, and there was no revision or update after the residents fall on May 24, 2024. During a review of Resident 33's care plan titled, [Resident 33] is at risk for falls r/t [related to] disease process generalized weakness and poor gait [walking] and balance . dated February 29, 2024, the care plan indicated, Goal .The resident will be free of minor injury through the review date .Interventions .Follow facility fall protocol . There was no revision or update to the care plan after the residents fall on May 24, 2024. During an interview on June 13, 2024, at 10:55 AM, with the Director of Nursing (DON), the DON stated the facility performed a fall risk assessment on all residents upon admission and after any subsequent falls. The DON further stated after a fall, the Interdisciplinary team (IDT) was supposed to meet each time to discuss the incident and implement interventions which would be updated in the resident's care plan. During a concurrent interview and record review on June 13, 2024, at 11:08 AM, with the DON, Resident 33's clinical record was reviewed. The DON stated, Resident 33 should have had a post fall risk assessment done, the fall care plan should have been updated, IDT should have met regarding the incident, and a change of condition should have been initiated, but stated there was no evidence it was done. During a review of the facility's policy and procedure titled, Fall Risk Assessment, dated December 19, 2022, the policy indicated, It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents .3. A fall care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly. 4. The fall care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. During a review of the facility's policy and procedure titled, Fall Prevention Program, revised December 28, 2023, the policy indicated, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .8.l When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. C. complete an incident report .e. Review the resident's care plan and update as indicated .

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free of medication errors for 1 of 42 residents (Resident 10) when Resident 10's insulin Lispro (medication to treat high blood sugar) was not given according to physician's orders. This failure placed Resident 10 at risk for hypoglycemia (low blood sugar) and had the potential to jeopardize his health and safety. Findings: During a review of resident 10's Admission Record (clinical record with demographic information), the Admission Record indicated, Resident 10 was admitted to the facility on [DATE], with diagnoses which included, hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side (paralysis of partial or total body function on one side of the body with one-sided weakness), type 2 diabetes mellitus with hyperglycemia (a spike in blood sugar levels), urinary tract infection (an infection of the urinary system) and calculus of kidney (kidney stones). A medication administration observation for Resident 10 by a Licensed Vocational Nurse (LVN 1) was conducted on June 12, 2024, at 5:33 AM, in Resident 10's room. LVN 1 injected 2 units (U - unit of measurement) of insulin Lispro subcutaneously (medication injected in the fatty tissue, under the skin) to Resident 10's right arm. LVN 1 stated Resident 10's blood sugar was 154. During a concurrent interview and record review on June 12, 2024, at 7:30 AM, with LVN 1, LVN 1 reviewed Resident 10's physician's orders, dated April 26, 2024. The physician's orders stated, Insulin Lispro Solution 100 unit/ml (ml - milliliters, unit of measurement), inject as per sliding scale: if 131-170 = 2 units; IF BLOOD GLUCOSE 330 AND ABOVE, GIVE 8 UNITS AND CALL MD, subcutaneous before meals for DMII [type 2 diabetes mellitus]. Not to be administered sooner than 15 minutes to meals. LVN 1 stated the physician's orders for insulin Lispro was not followed. LVN 1 further stated she did not read the full order and she administered the insulin Lispro 2 hours before mealtime. During a concurrent interview and record review on June 12, 2024, at 7:40 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P), titled, Prescriber Medication Orders, dated April 2008, was reviewed. The P&P indicated, Policy: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe . Procedures: A. Elements of the Medication Order . 1. Medication orders specify the following: . a. Name of medication, b. Strength of medication, where indicated c. Dose and dosage form, d. Time or frequency of administration, e. Route of administration (If facility policies allow, orders are assumed to be P.O. [by mouth] unless otherwise specified), .g. Diagnosis or indication for use . The DON stated the policy was not followed. During a concurrent interview and record review on June 12, 2024, at 7:50 AM, with the DON, the facility's P&P titled, Medication Administration - General Guidelines, dated October 2017, was reviewed. The P&P indicated, .B. Administration .2). Medications are administered in accordance with written orders of the attending physician.10). Medications are administered within 60 minutes of schedule time (1 hour before and 1 hour after), except before or after meal orders, which are administered based on mealtimes. The DON stated the policy was not followed.

Based on observation, interviews and record review the facility failed to ensure secure storage of intravenous medications (IV - medications administered through the vein) for one of one IV medication cart, (a mobile cart used by licensed nurses to transport medications to resident rooms) when the IV medication cart was unlocked while unattended by license nurse. This failure had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 42 residents. Findings: During a concurrent observation and interview, on June 10, 2024, at 12:18 PM, at the nurses station 1, with the Registered Nurse (RN 1), the IV medication cart was parked in front of the nurses station, and it was unlocked and unattended. RN 1 was sitting down, working on the computer. RN 1 then reviewed the contents of the IV medication cart. The IV medication cart was equipped with IV supplies including syringes needles (thin, sharp hollow tubes, used to deliver and to draw fluid), antibiotics (medications to treat infections). RN 1 stated, the IV medication cart should not be left open and that it was very bad that it was open because they have residents' information printed on the medication labels. RN 1 further stated that it was also, unsafe for the ambulatory residents. During a further interview on June 10, 2024, at 12:52 PM, with RN 1, RN 1 stated she was the only one who had access to the IV medication cart and she forgot to lock it. During a concurrent interview and record review on June 12, 2024, at 12:58 PM, with the Director of Nurses (DON), the facility's policy and procedure (P&P) titled Specific Medication Administration Procedures, dated April 2008, was reviewed. The P&P indicated, . A. Medication cart is locked at all times unless in use and under the direct observation of the medication nurse. The DON stated the policy was not followed. The DON further stated, his expectations was for the nurses to lock the IV Medication cart when it's not in use.

Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen in accordance with professional standards for food service safety when: 1) There was diet and grime built on top of the stainless-steel dishwashing machine which had the potential for microorganism growth that could be transferred to the food. 2) Plastic food storage containers were stacked and stored wet, which prevented them from drying and had the potential to allow an environment where microorganisms can begin to grow. 3) There was food, black grime, and trash build-up found behind and, underneath the stove. This had the potential for microorganism growth that could inadvertently be transferred to food. These failures had the potential to cause foodborne illness in a highly susceptible population of 47 residents who received food from the kitchen. Findings: 1. During an observation and concurrent interview with the Floater on May 2, 2023, at 10:01 AM, in the Kitchen, noted dirt and grime build up on top of the stainless-steel dish washing machine. Floater stated, he cleans it once a week. During an observation and concurrent interview with the Dietary Supervisor (DS) on May 2, 2023, at 10:05 AM, in the Kitchen, there was dirt and grime build up on top of the stainless-steel dish washing Machine. DS stated her expectation are that it should be clean daily, and it was not cleaned. During an interview with Registered Dietitian (RD) on May 5, 2023, at 11:32 AM, she stated floater is responsible for cleaning the dish washing machine and her expectations are that it should be cleaned daily for outside. During a review of the facility policy with RD on May 5, 2023, at 11:35 AM, entitled Dish machine Clean up, dated 08/31/2018, the policy indicated: .Make certain all equipment is turned off, water drained, dish room clean and sanitized before leaving. RD stated policy was not followed. 2. During an observation and concurrent interview with the Dietary Supervisor (DS) on May 2, 2023, at 11:32 AM in the kitchen, plastic food storage containers were stacked and stored wet. DS stated, these containers should have been air dried before storing. During an interview with registered dietitian (RD) on May 5, 2023, at 11:40 AM, she stated, her expectations are that food storage containers should be dry before staking and storing. During a review of the facility's policy and procedure (P&P) entitled Dry Storage-Dish and utensils, revised on 02/01/2012, the P&P indicated: .Dishes must be stored to promote air drying i.e. use dish rack or trays with plastic mesh that allow air to circulate and air dry the dishes . RD stated, P&P was not followed. During a review of the FDA Federal Food Code, dated 2017, the Food Code indicated 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment, and utensils: (A) Shall be air-dried . 3. During an observation and concurrent interview with the DS on May 2, 2023, at 9:55 AM, in the kitchen, there was food, black grime, and trash build-up underneath the stove. The DS stated, her expectations are that the area should be kept clean. During an interview with RD on May 5, 2023, at 11:00 AM, she stated, her expectations are that floors should be clean under the stove. During a review of the FDA Federal Food Code, dated 2017, the Food Code indicated 4-202.16 Nonfood-Contact Surfaces. Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms.

Based on observation, interview, and record review, the facility failed to provide clean oxygen tubing when a nasal cannula (NC- a device used to deliver supplemental oxygen to ease breathing) was not changed according to their Oxygen Administration policy for three of three sampled residents (Resident 4, Resident 48, and Resident 102). This failure had the potential to place Resident 4, Resident 48, and Resident 102 at risk for respiratory infection, and inadequate delivery of oxygen due to clogging which could compromise residents' overall health condition. Findings: 1. During a review of Resident 4's face sheet (demographic data), the face sheet indicated Resident 4 was initially admitted to the facility on [DATE], with diagnoses that includes end stage renal disease (ESRD-a condition in which kidneys cannot function normally), and acute and chronic respiratory failure (a condition in which lungs cannot get enough oxygen to the blood) with hypoxia (low oxygen in the body). During an observation on May 2, 2023, at 9:45 AM, Resident 4 was observed lying in bed with NC attached to her nose with oxygen delivered at 3 liters (L-oxygen flow rate). A review of Resident 4's Order Entry (physician order), dated February 24, 2023, indicated, Resident 4 had an order to receive oxygen via NC. During a concurrent observation and interview on May 2, 2023, at 9:51 AM, in Resident 4's room, with the Certified Nurse Assistant (CNA 1), the CNA 1 verified Resident 4's NC tubing was not labeled with a date. The oxygen bag attached to the oxygen delivering machine was labeled as April 21, 2023. The CNA 1 stated, April 21, 2023, seemed to be the last date the oxygen tubing was changed. The CNA 1 further stated, she did not know how often NC should be changed. During a concurrent observation and interview on May 2, 2023, at 10:16 AM, in Resident 4's room, with the Licensed Vocational Nurse (LVN) 1, the LVN 1 verified, Resident 4's NC tubing was not labeled with date, and the oxygen bag attached to the oxygen delivering machine was labeled as April 21, 2023. The LVN 1 stated, she was not sure about the facility's policy for changing NC tubing, and April 21, 2023, seemed to be the date the NC tubing was changed. The LVN 1 further stated, NC tubing should be changed to prevent respiratory infection such as pneumonia and clogging of the tube. During an interview on May 2, 2023, at 2:35 PM, in the nursing station, with the Director of Nursing (DON), the DON stated, NC tubing needs to be changed every seven (7) days and more frequent if the tubing is contaminated. 2. During a review of Resident 48's face sheet, the face sheet indicated Resident 48 was admitted into the facility on [DATE], with diagnoses that includes chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing related problems) and dependence on supplemental oxygen. During an observation on May 2, 2023, at 10:26 AM, Resident 48 was observed lying in bed with NC attached to her nose with oxygen delivered at 2 L. Resident 48 stated, she had been using supplemental oxygen for a while. A review of Resident 48's Order Entry, dated March 16, 2023, indicated, Resident 48 had an order to receive oxygen via NC. During a concurrent observation and interview on May 2, 2023, at 10:28 AM, in Resident 48's room, with the LVN 1, the LVN 1 verified Resident 48's NC tubing and oxygen bag attached to the oxygen delivery machine were not labeled with a date to indicate the last time NC tubing was changed. The LVN 1 stated, I would change the NC tubing today. LVN further stated, NC tubing should be changed to prevent respiratory infection such as pneumonia and clogging of the tube. During an interview on May 2, 2023, at 2:35 PM, in the nursing station, with the DON, the DON stated, NC tubing needs to be changed every seven (7) days and more frequent if the tubing is contaminated. 3. During a review of Resident 102's face sheet, the face sheet indicated Resident 102 was admitted to the facility on [DATE], with diagnoses that includes hemiplegia (inability to move on one side of the body), hemiparesis (muscle weakness on one side of the body), and asthma (a condition of narrow and swelling of airways which make breathing difficult). During an observation on May 2, 2023, at 10:00 AM, Resident 102 was observed lying in bed with NC attached to his nose with oxygen delivered at 3 L. A review of Resident 102's Order Entry, dated May 2, 2023, indicated, Resident 102 had an order to receive oxygen via NC. During a concurrent observation and interview on May 2, 2023, at 10:23 AM, in Resident 102's room, with the CNA 2, the CNA 2 verified Resident 102's NC tubing was labeled as April 21, 2023. CNA 1 stated, she did not know how often NC tubing should be changed.

Based on observation, interview, and record review, the facility failed to ensure food prepared for two of two sampled residents (Resident 16 and Resident 36) on a Pureed Diet (blended to pudding consistency) was not served with a palatable lunch and the taste not comparable to the food served for residents receiving a Regular Diet (diet with no restrictions). This failure had the potential for Resident 16 and Resident 36 to experience a decrease in food intake which could lead to poor nutrition and health outcomes. Findings: During a concurrent interview and meal taste test of the lunch that was served on May 3, 2023, at 12:45 PM, in the dining room, with the Dietary Supervisor (DS), in the presence of the Registered Dietitian, sample trays of the Regular Diet and Pureed Diet for lunch were tested for palatability, appearance, texture, and temperature. The sample trays consisted of baked pork chop, wild rice pilaf, seasoned asparagus tips, green beans, bread roll, ravioli with rose sauce, and peach shortcake. The regular diet tray was flavor full, but the pureed wild rice pilaf tasted saltier, and was not comparable in flavor to the regular wild rice pilaf served. The DS stated the pureed wild rice pilaf was saltier than the regular wild rice pilaf served. During a record review of the Resident 16's clinical record, the Admission Record [contains demographic and medical information], indicated the resident was admitted to the facility on [DATE], with diagnoses of dysphagia (difficulty swallowing) and protein-calorie malnutrition (calorie intake less than recommended). Doctors order summary indicated; purred diet was ordered on October 6,2022. During a concurrent interview and record review on May 3, 2023, at 12:56 PM, with the Registered Dietician (RD 1), the RD stated, the pureed diet meals should taste like the regular diet meals for the residents. During a record review of the Resident 36's clinical record, the Admission Record [contains demographic and medical information], indicated the resident was admitted to the facility on [DATE], with diagnoses of essential hypertension (high blood pressure) and gout (pain full joints) Doctors order summary indicated, purred diet was ordered on February 14, 2023. During a concurrent interview and record review on May 3, 2023, at 12:56 PM, with the Registered Dietician (RD 1), the RD stated, the pureed diet meals should taste like the regular diet meals for the residents. During an interview on May 3, 2023, at 1:00 PM, in the room of Resident 16, Resident 36 were non interview able. During a review of the facility document titled [name of corporate] Dietitians Menus, under Week at a Glance, dated May 3, 2023, the menu indicated, baked pork chop, wild rice pilaf, seasoned asparagus tips, green beans, bread or Roll & butter or Margarine, ravioli with rose sauce, and peach shortcake and choice of Beverage will be served.

Based on observation, interview, and record review, the facility failed to develop and implement a care plan for one of eight sampled residents (Resident 1) who was on oxygen therapy. This failure had the potential to cause inaccuracy in identifying Resident 1's health care and support needs. Findings: During an observation on May 3, 2023, at 8:20 AM, Resident 1 was lying on bed, awake, and alert. Resident 1 was observed with oxygen via nasal cannula (medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) at 2.5 Liters (L - unit of measure). During a review of Resident 1's Admission Record (document that contains demographic and clinical data), the Admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included mild intermittent asthma (a respiratory condition causing difficulty of breathing), Type 2 Diabetes Mellitus (a condition characterized by elevated blood sugar) with Hyperglycemia (elevated blood sugar). During a review of Resident 1's Active Orders Summary Report on May 3, 2023, at 9:00 AM, the Active Orders Summary Report indicated May have Oxygen via nasal cannula @ 2-4 LPM (liters per minute) as needed, may titrate (measure and adjust) to maintain O2 sat (saturation), above 91% (percent). During a review of Resident 1's clinical record on May 3, 2023, at 9:15 AM, there was no care plan noted for the use of oxygen therapy. During a concurrent interview and record review with Registered Nurse (RN 1), on May 5, 2023, at 10:36 AM, Resident 1's care plan was reviewed. RN 1 verified there was no plan of care documented for the use of oxygen therapy. RN 1 stated there should have been a nursing care plan for the use of oxygen therapy. During a concurrent interview and record review with the Director of Nursing (DON), on May 5, 2023, at 10:39 AM, Resident 1's care plan was reviewed. The DON verified there was no plan of care documented or the use of oxygen therapy. The DON stated there should have been a nursing care plan for the use of oxygen therapy.

Based on observations, interviews, and record reviews, the facility failed to ensure resident food was stored, prepared, distributed and served in a sanitary manner when: 1. Tuna salad prepared from room temperature ingredients was not monitored to ensure all parts of the food reached 41 degrees Fahrenheit (øF) within four hours, 2. A storage bag containing five peeled hard-boiled was not sealed to protect the eggs from contamination. 3. The metallic surface of the table mounted can opener blade was noted with the worn off, 4. A pipe that was protruding from the wall under the dishwasher, had a gap around it approximately one half inch. This hole in the wall had the potential to allow for pest to harbor in the moist environment, 5. Wood shelves in the dry storage room, used to store resident food were significantly worn on the edges which made them rough and not easily cleanable. These failures had the potential to result in food borne illness in a highly susceptible population of 54 residents who eat at the facility. Findings: 1. During an observation in the reach-in refrigerator in the kitchen on March 7, 2016 at 10:15 AM, a larger container with approximately 14 cups of tuna salad dated March 6, 2016, was noted. The surveyor's thermometer placed in the center of the tuna salad registered 42.4 øF. The Dietary Services Supervisor (DSS) placed a facility thermometer in the tuna salad, which also register 42.4 øF. During a concurrent interview with the DSS, she stated that the tuna salad was prepared on March 6, 2016 (the day before, using canned tuna stored in the dry storage room. She further stated, I believe the (facility's) policy is to monitor tuna salad for cool down. She stated that there was no log entry to indicate the tuna had been monitored for safe cool down. According to the 2013 Food and Drug Administration Food Code, time/temperature control for safety food (TCS foods are foods that require proper temperature control to avoid harmful microorganism growth) shall be cooled within 4 hours to 41 øF or less if prepared from ingredients at ambient temperature (room temperature), such as canned tuna. Excessive time for cooling of time/temperature control for safety foods has been consistently identified as one of the leading contributing factors to foodborne illness. During slow cooling, time/temperature control for safety foods are subject to the growth of a variety of pathogenic microorganisms. If the food is not cooled in accordance with this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness. A review of the facility's Cooling Food Log dated February to March, 2016, indicated there was no log entry for the tuna salad prepared on March 6, 2016. The log included guidance to the staff on safe cooling of cooked potentially hazardous food (same as TCS food), but did not provide guidance on foods prepared from room temperature ingredients. A review of the facility policy titled Safe Food Handling, revised January 1, 2007, indicated, Perishable food is not left in the danger zone (40 øF-140 øF) more than four hours throughout the entire food handling process. Since there was no monitoring documented for the tuna salad prepared from tuna stored in the store room, and the temperature of the tuna salad was greater than 41 øF a day later, the DSS was unable to determine if the tuna salad reached 41 øF or less within four hours required by the Food Code and the facility policy. 2. During an observation of the reach-in refrigerator in the kitchen on March 7, 2016 at 10:10 AM, a storage bag containing five peeled hard-boiled eggs was noted to be open, not sealed. During a concurrent interview with the Dietary Service Supervisor (DSS), she stated that the bag should have been sealed. According to the 2013 Food and Drug Administration Food Code, food shall be protected from cross contamination by storing food in packages, covered containers or wrapping. 3. During an observation in the kitchen on March 7, 2016 at 10:30 AM, the table mounted can opener blade was noted to be worn. The metallic surface of the blade was worn off. During a concurrent interview with the Dietary Service Supervisor, she stated that the blade had been changed recently. She further stated that the blades wear out quickly and the blade should be changed. A facility policy guiding staff on ensuring the can opener blade was intact was requested. During an interview with the Dietary Services Supervisor on March 10, 2016 at 11:30 AM, she stated that the facility did not have a policy According to the 2013 Food and Drug Administration Food Code, cutting or piercing part of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is open. It further stated that multiuse food contact surfaces shall be smooth and free of crevices. Surfaces which have imperfections such as cracks, chips or pits allow microorganisms to attach and form biofilms that can release pathogens in the food. Biofilms are highly resistant to cleaning and sanitizing efforts. 4. During an observation in the kitchen on March 7, 2016 at 10:20 AM, under the dishwasher counter, a pipe, protruding from the wall was noted to have an approximately one half to three quarter inch gap between the pipe and the wall, around the pipe. During an interview with the Director of Maintenance the same day at 4:24 PM, he stated that no one had told him about the gap. He stated that the holes needed to be repaired to prevent the entry and harborage of pests in the wet environment under the dishwasher. According to the 2013 Food and Drug Administration Food Code, outer openings of a food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls, and ceiling. 5. During an observation in the dry storage room of the kitchen on March 7, 2016 at 10:00 AM, the resident food was stored on painted wood shelves that were significantly worn along the front edges of the shelves. The wood was rough and not easily cleanable. During a concurrent interview with the Dietary Service Supervisor, she stated that the shelves were painted once a year and cleaned weekly. She verified that the shelves were worn and the wood edges were not smooth and easily cleanable. A review of the facility's policy titled Sanitation/Safety/Disaster, revised January 1, 2007, indicated that for dry storage, Shelves have a cleanable surface. According to the 2013 Food and Drug Administration Food Code, nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.

Based on observation, interview, and record review, the facility failed to ensure medications were administered without significant error to 10 of 11 residents observed during medication pass and or record review in a universe of 57 residents (five sampled residents: Residents 3, 5, 9, 11 and 12) and (five unsampled residents; Residents A ,C ,E ,G and H) as follows: 1. For Resident 3, [MEDICATION NAME] (anti-acid) was administered as ordered by the physician. This failure had the potential to jeopardize the health and safety of Resident 3. 2. For Resident C, a [MEDICATION NAME] (medication used to treat chest pain by relaxing the blood vessels to allow blood to flow more easily to the heart) was removed as ordered by the physician. This failure had the potential for the [MEDICATION NAME] to be ineffective and increase the risk of physical dependence. 3. For Resident E, Insulin (medication that lowers blood sugar levels) was administered as ordered by the physician. This failure had the potential to place Resident E at risk for extreme blood sugar fluctuations potentially causing serious medical complications [REDACTED]. 4. For Resident 11, a multi-vitamin was administered as ordered by the physician. This failure had the potential to jeopardize the health and safety of Resident 11. 5. For Resident G, [MEDICATION NAME] (a medication used to treat high blood pressure) was administered as ordered by the physician. This failure had the potential to place Resident G at risk for extreme blood pressure and heart rate fluctuations potentially causing serious medical complications [REDACTED]. 6 a. For Resident 5, pantoprazole (a medication used to decrease the amount of acid in the stomach) was administered as ordered by the physician. 6 b. For Resident, a physician's order was obtained prior to administering [MEDICATION NAME] (a narcotic pain medication). These failures had the potential to jeopardize the health and safety of Resident 5. 7 a. For Resident 12, [MEDICATION NAME] (a medication that treats dementia- a medical condition with a group of symptoms that affect thinking and memory) was administered as ordered by the physician. 7 b. For Resident 12, a physician's order was obtained prior to administering [MEDICATION NAME] (a medication used to reduce blood pressure). These failures had the potential to jeopardize the health and safety of Resident 12. 8. For Resident H, Eliquis (anticoagulant- a medication that prevents blood clots in people who have an irregular heart beat) was administered as ordered by the physician. This failure had the potential to increase Resident H's risks for developing blood clots. 9. For Resident 9, [MEDICATION NAME] (an anti-depressant) was administered per manufacturer recommendations. This failure had the potential to jeopardize the health and safety of Resident 9. 10. For Resident A, Klor-clon (a medication that prevents or treats low blood levels of potassium-which is essential for the proper functioning of the heart, kidneys, muscles, nerves, and digestive system) was administered as ordered by the physician. This failure had the potential to decrease Resident A's potassium levels in the blood causing serious medical complications [REDACTED]. These failures resulted in the residents of the facility being placed at high risk for harm as a result of medication error rate of 12.9% (percentage) to include significant medication errors. The medication error rate was determined by a total number of four (4) errors out of 31 opportunities. An Immediate Jeopardy (IJ) situation was called on March 9, 2016 at 10:35 AM, in the presence of the facility's Administrator and Director of Nurses (DON) who were verbally notified of the Immediate Jeopardy situation. Specific details of the Immediate Jeopardy situation including the residents at risk due to medications not being transcribed accurately from the physician orders to the Medication Administration Record (MAR), incorrect doses of medications being administered and missed doses of prescribed medications were provided to the Administrator and the DON. At the time of the survey exit on March 11, 2016, the Administrator and the DON were notified the IJ was not removed. After the exit, monitoring had been conducted by the survey team on March 12, 2016 and March 13, 2016, facility continued to have medication errors which the team verified through observation of medication passes, staff interviews and clinical record reviews to verify physician orders. On March 14, 2016 at 8:21 AM, interviews, clinical record reviews to verify physician orders and a medication pass observation were conducted and the IJ was removed in the presence of the Administrator, Director of Nurses, the Division Director of Clinical Services and the Division Vice President. The corrective action plan included: 1. A Medication pass observation with no medication errors. 2. The Medication Administration Record (MAR) reflected the physician orders. 3. The DON conducted an in-service to the licensed staff. Findings: 1. During an observation of the medication pass process on March 8, 2016 at 8:33 AM, a Licensed Vocational Nurse (LVN 1) was observed preparing medications to administer to Resident 3. LVN 1 prepared and administered the medications to Resident 3. During a review of Resident 3's clinical record, the physician admission orders [REDACTED]. [MEDICATION NAME] 5 mg (milligrams-a unit of measurement) PO (by mouth) BID (twice a day) 9 AM, 9 PM. During an interview with LVN 1 on March 8, 2016 at 11:25 AM, LVN 1 stated that Resident 3 received [MEDICATION NAME] 20 MG (four times the ordered dose). LVN 1 stated the Assistant Director of Nurses (ADON) wrote [MEDICATION NAME] 20 MG on the Medication Administration Record ( MAR) and that was what she was following. LVN 1 stated she was not sure what the physician's order indicated. LVN 1 stated she depends on the MAR being transcribed accurately because she does not have time to check the physician order for [REDACTED]. During an interview with the ADON on March 8, 2016 at 12:41 PM, the ADON stated he transcribed [MEDICATION NAME] 5 MG PO BID on the physician admission orders [REDACTED]. The ADON stated he also transcribed [MEDICATION NAME] 20 MG PO BID on the MAR. The ADON stated he did not know why he transcribed [MEDICATION NAME] 5 MG on the physician admission orders [REDACTED]. The ADON further stated that the [MEDICATION NAME] 5 MG was not given as ordered for a total of 3 (three) days and would be considered a medication error. The facility policy and procedure titled Medication Administration dated last revised April 2, 2013, indicated under Standard: All medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help in diagnosis. 2. During an observation of the medication pass process on March 8, 2016 at 8:59 AM, LVN 1 was observed preparing medications to administer to Resident C. LVN 1 prepared and administered the medication to Resident C. Resident C was sitting up in bed in her room. LVN 1 slightly pulled down Resident C's shirt to place the [MEDICATION NAME] on her chest. LVN 1 removed a [MEDICATION NAME] dated March 7, 2016, from Resident C's right upper chest and disposed of it in the bathroom trash can. LVN 1 then dated a new [MEDICATION NAME] for March 8, 2016, removed the plastic covering, and placed it on Resident C's left upper chest. During a review of Resident C's clinical record, the facesheet (demographics) indicated the Resident C was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A clinical record review of the recapitulation (physician order summary) dated March 1, 2016 indicated [MEDICATION NAME] Patch 0.2 MG for 12 hours on and off 12 hours [MEDICATION NAME] (a route of administration through the skin). During an interview with LVN 1 on March 8, 2016 at 11:03 AM, LVN 1 stated the [MEDICATION NAME] should be on for 12 hours and off for 12 hours according to the physician's order. LVN 1 stated the evening shift nurse was responsible for removing Resident C's [MEDICATION NAME] at 9 PM. The evening nurse (LVN 5) failed to remove the patch at 9 PM, but signed the MAR to indicate she had removed the patch. LVN 1 stated it would be considered a medication error. During an interview with LVN 4 on March 8, 2016 at 11:51 AM, LVN 4 stated she was responsible for Resident C's recapitulations. LVN 4 stated the physician orders indicated [MEDICATION NAME] on at 9 AM and off at 9 PM. The [MEDICATION NAME] had been transcribed incorrectly on to the MAR. The MAR indicated [MEDICATION NAME] 9 AM on and 9 PM on' instead of 9 PM off. LVN 4 stated I missed that.(The MAR) An interview was conducted with LVN 5, the evening nurse who was responsible for not removing the [MEDICATION NAME] on March 7, 2016 at 9 PM. LVN 5 stated she was in-serviced on the five (5) rights of medication pass (right patient, right medication, right dose, right time, and right route) on March 9, 2016. During an observation on March 10, 2016 at 7:34 AM, in Resident C's room, Resident C was sitting up in her bed watching television. An observation was made of a [MEDICATION NAME] on Resident C's right upper chest. During an interview with Resident C on March 10, 2016 at 7:35 AM, Resident C stated the [MEDICATION NAME] was to be placed on at 9 AM, and removed at 9 PM. Resident C stated the evening shift nurse (LVN 5) forgot to remove the [MEDICATION NAME]. During an interview with LVN 1 on March 10, 2016 at 7:36 AM, LVN 1 stated she did not have an answer as to why the [MEDICATION NAME] was on Resident C. LVN 1 stated it would be considered a medication error. During an interview with the Director of Nurses (DON) on March 10, 2016 at 12:31 PM, the DON stated she had inserviced LVN 5 the day before (March 9, 2016) on removing the [MEDICATION NAME]. The DON stated I don't know what happened. The facility policy and procedure titled Medication Administration dated last revised April 2, 2013, indicated under Standard: All medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help in diagnosis. 3. During an observation of the medication pass process on March 9, 2016 at 6:15 AM, in Resident E's room, LVN 2 checked Resident E's blood sugar, then removed gloves and documented the blood sugar of 361 on the diabetic flow sheet. LVN 2 donned new gloves and administered [MEDICATION NAME] (long-[MEDICATION NAME] insulin) 20 units subcutaneous to Resident E's left lower abdominal area. LVN 2 did not administer the Humalog (fast-acting insulin). During an observation on March 9, 2016 at 6:51 AM, in Resident E's room, Resident E was sitting in a wheelchair eating breakfast at the bedside table. Resident E's breakfast included eggs, bacon, potatoes, bowl of cheerios and milk, blueberry muffin and an apple juice. During a review of Resident E's clinical record, the facesheet (demographics) indicated Resident E was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A clinical record review of the recapitulation (physician order summary) dated March 2016 indicated [MEDICATION NAME] 20 units Subq (subcutaneous) daily, Accuchecks (blood sugar check) AC (before meals) and HS (bedtime) with Humalog (a fast-acting insulin that works by lowering levels of sugar in the blood; once injected, the insulin takes 30 minutes to work) Sliding scale (insulin doses that are increased in increments corresponding to an increasing range of blood sugar results)subcutaneous as follows: . greater than 331 give 8 units (a value of measurement) and call MD (Medical Doctor). During an interview with LVN 2 on March 9, 2016 at 7:23 AM, LVN 2 stated she did not give 8 units of Humalog insulin to Resident E because the diabetic flow sheet did not indicate to give 8 units of Humalog insulin for a blood sugar greater than 331, the diabetic flow sheet only indicated to call the physician. LVN 2 stated whoever completed the monthly recapitulation should make sure the physician orders and the MAR including the diabetic flow sheet are correct. LVN 2 stated she followed the MAR including the diabetic flow sheet and only reviews the physician orders when there are discrepancies, or has any questions regarding the MAR. LVN 2 stated it will be considered a medication error. A clinical record review of the diabetic flow sheet dated March 2016, indicated on March 4, 2016 at 6:30 AM, Resident E's blood sugar was documented as 358 and he received 7 units of Humalog insulin. During an interview with LVN 4 on March 9, 2016 at 7:38 AM, LVN 4 stated that on March 4, 2016 at 6:30 AM, Resident E's blood sugar was documented on the diabetic flow sheet as 358 and he received 7 units of Humalog insulin. LVN 4 stated Resident E should have received 8 units of Humalog insulin per the physician order. During an interview on March 9, 2016 at 1:03 PM with LVN 6, (who transcribed the physician orders to the MAR and diabetic flow sheet) LVN 6 stated she forgot to transcribe the physician order to give 8 units of Humalog insulin for a blood sugar greater than 331 on the diabetic flow sheet. LVN 6 stated she only transcribed to call the physician for a blood sugar greater than 331 on the diabetic flow sheet. During a concurrent interview with LVN 6, LVN 6 stated on March 4, 2016 at 6:30 AM, Resident E's blood sugar was documented on the diabetic flow sheet as 358 and he received 7 units of Humalog insulin. LVN 6 stated Resident E should have received 8 units of Humalog insulin per the physician orders. A clinical record review of the diabetic flow sheet dated March 2016, indicated on March 4, 2016 at 11:30 AM Resident E's blood sugar was 418 and he received 7 units of Humalog insulin. During an interview with LVN 1 on March 9, 2016 at 2:00 PM, LVN 1 stated on March 4, 2016 at 11:30 AM, Resident E's blood sugar was 418 and she administered 7 units of Humalog insulin. LVN 1 stated Resident E should have received 8 units of Humalog insulin per the physician orders. LVN 1 stated she administered 7 units of Humalog insulin to Resident E because that was the maximum dose to give on the diabetic flow sheet. LVN 1 stated she would rather administer some insulin coverage instead of no insulin coverage at all. LVN 1 stated she was not aware that the physician order indicated to administer 8 units of Humalog insulin for a blood sugar greater than 331. LVN 1 stated it was important that the person responsible for monthly recapitulations transcribed it accurately. LVN 1 stated she was dependent on the MAR and diabetic flow sheet to be transcribed accurately because she does not review the physician orders. The facility policy and procedure titled Medication Administration dated last revised April 2, 2013, indicated under Policy: Responsibility of the nursing professional: be aware of the classification, action, correct dosage, and side effects a medication before administration. 4. During an observation of the medication pass process on March 8, 2016 at 9:40 AM, LVN 3 was observed preparing medications to administer to Resident 11. LVN 3 prepared and administered the medication to Resident 11. During a review of sampled Resident 11's clinical record, the physician admission orders [REDACTED]. MVI (multivitamin) with minerals 1 tab PO (by mouth) daily 9 AM. During an interview with LVN 3 on March 8, 2016 at 10:58 AM, LVN 3 stated that Resident 11 did not receive the multivitamin because it had not been transcribed on the MAR and it would be considered a medication error. During an interview with the Assistant Director of Nurses (ADON) on March 8, 2016 at 12:33 PM, the ADON stated he should have transcribed the multivitamin on to the MAR. The ADON stated I missed the multivitamin. The ADON stated, Resident 11 has missed several doses of the multivitamin and it will be considered a medication error. The facility policy and procedure titled Medication Administration dated last revised April 2, 2013, indicated under Standard: All medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help in diagnosis. 5. During a review of Resident G's clinical record, the facesheet (demographics) indicated Resident G was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A clinical record review of the recapitulation (physician order summary) dated March, 2016, indicated [MEDICATION NAME] 3.125 MG 9 AM Hold if SBP (systolic blood pressure-top number) is less than 110 and HR (heart rate) is less than 70 PO (by mouth) daily. A concurrent record review of the Medication Administration Record (MAR) dated March 2016 indicated that the medication [MEDICATION NAME] was not held as ordered on the following dates: a. [MEDICATION NAME] was administered on March 3, 2016 with a heart rate of 66. b. [MEDICATION NAME] was administered on March 4, 2016 with a heart rate of 68. c. [MEDICATION NAME] was administered on March 7, 2016 with a heart rate of 62. During an interview with LVN 1 on March 10, 2016 at 4:40 PM, LVN 1 stated she administered [MEDICATION NAME] to Resident G on the following dates: March 3, 4, and 7, 2016. LVN 1 stated [MEDICATION NAME] should have been held on March 3, 4, and 7, 2016 for a heart a rate of less than 70 per the physician order. LVN 1 stated she thought the order was to hold the [MEDICATION NAME] for a heart rate less than 60. The facility policy and procedure titled Medication Administration dated last revised April 2, 2013, indicated under Procedure: 3. Check Medication Administration Record (MAR). 4. read each order entirely. 6 a. During a review of the clinical record for Resident 5, the face sheet (contains demographic information) indicated Resident 5 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a review of Resident 5's physician's orders, an order dated February 12, 2016, indicated Resident 5 was to have [MEDICATION NAME] (a medication for GERD) 20 milligrams (mg) daily at 6:30 AM before breakfast. A review of the pharmacy consultation report dated February 23, 2016,was conducted. The pharmacist consultant recommended to discontinue [MEDICATION NAME] and start pantoprazole (a medication for GERD) 20 mg daily with rationale as follows: Resident 5 receives [MEDICATION NAME] (a blood thinner)and also receives [MEDICATION NAME] since October 10, 2015. Co-administration of these two medications can result in significant reductions in [MEDICATION NAME]'s active metabolite levels and antiplatelet activity. Individuals at risk of [MEDICAL CONDITION] or [MEDICAL CONDITION], who are given [MEDICATION NAME] to prevent blood clots, will not get the full anti-clotting effect if they also take [MEDICATION NAME]. A review of Resident 5's physician's order dated March 3, 2016 at 7:15 PM, indicated the nurses were to discontinue [MEDICATION NAME] and begin pantoprazole 20 mg daily. A review of the Medication Administration Record (MAR) for March 2016, indicated that Resident 5 continued to receive [MEDICATION NAME] from March 4, 2016 through March 9, 2016, after the medication had been ordered to be discontinued. A handwritten note on the MAR indicated to start [MEDICATION NAME] (brand name for pantoprazole) 20 mg daily when it arrives with an additional post-it note attached to Resident 5's MAR , to start [MEDICATION NAME] when [MEDICATION NAME] is exhausted. During an interview with a licensed vocational nurse (LVN 4), on March 9, 2016 at 6:25 AM, LVN 4 stated that usually the medication comes the same day it is ordered, but it had not arrived at the facility and the nurses would administer the medication when it was delivered. During an interview with an LVN charge nurse (LVN 3), on March 9, 2015 at 7:05 AM, LVN 3 stated that pantoprazole would begin when [MEDICATION NAME] was finished. LVN 3 was unable to find an order to substantiate postponing the discontinuation of [MEDICATION NAME] and starting of pantoprazole. LVN 3 stated that she was aware of the handwritten notes on the MAR, but stated she had not checked the physician orders. LVN 3 stated, I should have checked the orders, and clarified with the LVN who wrote on the MAR to postpone the order. 6 b. During a review of Resident 5's physician's orders, an order dated August 24, 2015, indicated [MEDICATION NAME] 5/325 mg (narcotic pain medication) was to be administered every six (6) hours as needed for pain. During a review of the Discharge Summary from the general acute care hospital dated February 12, 2016, indicated instructions for Resident 5 to stop taking [MEDICATION NAME]. A review of the physician's re-admission orders [REDACTED]. A review of the Nurses Weekly Summary, and the Controlled Drug Record (a log where narcotics are counted and signed out prior to administration) reflected that [MEDICATION NAME] had been given without a physician's order as follows: 1. February 22, 2016, the nurses documented on the Weekly Summary that [MEDICATION NAME] had been administered for pain. 2. February 26, 2016, a nurse had signed out [MEDICATION NAME] on the Controlled Drug Record for Resident 5. 3. February 29, 2016, the nurse documented on the Weekly Summary that [MEDICATION NAME] had been administered for pain. During an interview with LVN 6 on March 10, 2016 at 3:30 PM, LVN 6 stated that new orders were supposed to be written for a resident upon re-admission to the facility, even when the resident returned to the facility the next day. LVN 6 confirmed that Resident 5 was admitted to the hospital on February 11, 2016 and readmitted to the facility on [DATE]. She stated the previous orders would be discontinued when new orders were written at the time of re-admission. During an interview with the DON on March 10, 2016 at 3:45 PM, the DON confirmed that [MEDICATION NAME] was given to Resident 5 in error and without a physician's order. During a review of facility's policy and procedure titled, Medication Administration dated as revised October 2004, page 12-8, procedure #17, indicated PRN (medication given as needed) medication was charted with initials, and time is given in the corner of the box. On page 12-12, in the same policy and dated as revised February 2013, indicated A physician order is required for administration of controlled drugs. Under the section titled Procedure when the Resident is readmitted from Outside Inpatient Setting indicated: 1. Upon readmission from a setting outside the nursing home, the nursing home receives physician orders that list medications the resident is to take upon readmission to the nursing home. 2. The admitting charge nurse reviews all available information as well as medications the resident was taking at the nursing home prior to admission to the hospital or other setting and reconciles the medication regime. 7 a. Clinical record review for Resident 12 was initiated on March 10, 2016. Resident 12 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a physician's order for Resident 12, dated February 15, 2016, indicated [MEDICATION NAME](r) XR (extended release) 7 mg (milligram) q day (everyday) x 1 week, then [MEDICATION NAME](r) XR 14 mg q day x1 week, then [MEDICATION NAME] (r) XR 21 mg q day x 1 week, then [MEDICATION NAME](r) XR 28 mg x 1 week. Review of the February 2016, Medication Administration Record (MAR) was conducted with the Director of Nursing (DON) on March 13, 2016, at 11:00 AM. The DON stated signed initials on the MAR showed the dose was administered. The DON stated Resident 12 was ordered to receive seven doses of [MEDICATION NAME](r) XR 7 mg but was administered five doses. The DON stated Resident 12 was ordered to receive seven doses of [MEDICATION NAME](r) XR 14 mg but was administered four doses. Review of the March 2016, Medication Administration Record (MAR) was conducted with the DON on March 13, 2016, at 11:00 AM. She acknowledged again that the signed initials on the MAR showed the dose was administered. The DON stated Resident 12 was ordered to receive seven doses of [MEDICATION NAME](r) XR 21 mg but was administered six doses. The DON stated Resident 12 was ordered to receive six doses. The DON stated Resident 12 was ordered to receive seven doses of [MEDICATION NAME] XR 28 mg but was administered five doses so far. Review of the pharmacy delivery invoices on March 13, 2016 at 11:52 AM, for the medication [MEDICATION NAME](r) XR with the doses of 7 mg, 14 mg, 21 mg, and 28 mg, showed the facility was delivered a quantity of seven capsules for each of the dosage strengths prior to the discovery of the medication error. During a concurrent observation, the DON acknowledged that only two doses of the [MEDICATION NAME](r) XR 28 mg was removed from Resident 12's medication card compared to the MAR which showed five doses of the [MEDICATION NAME](r) XR 28 mg was administered. The DON acknowledged the discrepancy of [MEDICATION NAME](r) XR 28 mg capsules found in the medication cart compared with the signed initials on the MAR which showed the [MEDICATION NAME](r) XR 28 mg dose was administered. The facility was unable to provide additional pharmacy delivery invoices for the medication [MEDICATION NAME](r) XR. Review of the facility policy, Policies for Medication Administration, revised April 2, 2013, indicated, 13. Initial each medication in the correct box on the MAR after the medication is given. 7 b. Clinical record review for Resident 12 was initiated on March 10, 2016. Resident 12 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the facility's Medication Administration Record (MAR) for March 2016 indicated, [MEDICATION NAME] 10 mg one tab by mouth BID (twice a day) hold if SBP (systolic blood pressure) less than 100 accompanied by a handwritten date of 3-7-16. The MAR indicated eight handwritten initials with blood pressure readings written on the MAR. During an observation and concurrent interview on March 12, 2016 at 11:00 AM, the Director of Nursing (DON) stated she was unable to locate the physician's order in the medical chart for [MEDICATION NAME] for Resident 12. During an interview on March 13, 2016, at 10:00 AM, accompanied by the the DON, five doses of [MEDICATION NAME] were punched out from the resident's morning and evening [MEDICATION NAME] medication cards. During a concurrent interview, the DON stated five doses of the medication [MEDICATION NAME] were administered to Resident 12. Review of the physician's orders dated March 7, 2016 at 9:30 AM, indicated orders for [MEDICATION NAME](r) SL 0.4 mg prn (as needed) for chest pain x 3 and Isodil 10 mg po (by mouth) BID (twice a day) and hold if SBP (systolic blood pressure) less than 100. Review of the nursing notes, dated March 7, 2016, at 9:40 AM, showed: 9:20 AM .resident stated he was having chest pain . 9:28 AM - (The Physician) made aware and received new orders. Give [MEDICATION NAME](r) (medication used to relieve chest pain) SL (sublingual - under then tongue) 0.4 mg Tab. Give SL PRN Q5 mins for chest pain. [MEDICATION NAME](r) (medication to treat and prevent chest pain) 10 mg po (by mouth) BID (twice a day). Hold if SBP less than 100. Order faxed to pharmacy. During an interview on March 12, 2016 at 12:00 PM, the DON stated she could not locate the medication Isodil in the medication cart for Resident 12. During an interview on March 13, 2016 at 11:25 AM, the Medical Director stated that a mistake was made that led to Resident 12 receiving the medication [MEDICATION NAME] instead of the medication Isodil. Review of the pharmacy delivery invoices on March 13, 2016, at 11:52 AM, indicated the medication [MEDICATION NAME] 10 mg for Resident 12 was filled by the Pharmacy on March 7, 2016. During a concurrent interview, the DON acknowledged that there was no pharmacy delivery invoice for the medication Isodil prior to the discovery of the medication error. Review of the facility policy, Policies for Medication Administration, revised April 2, 2013, indicated A physician order that includes the dosage, route, frequency, duration, and other required considerations is required for the administration of medications. 8. During monitoring of the facility on March 13, 2016, due to the immediate jeopardy not being removed before exiting on March 11, 2016, a medication pass observation was conducted. During the observation of the medication pass process on March 13, 2016 at 9:40 AM, LVN 5 was observed preparing medications to administer to Resident H. LVN 5 prepared and administered the medications to Resident H. During a review of Resident H's clinical record, the facesheet (demographics) indicated Resident H was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A clinical record review of the recapitulation (physician order summary) dated March 2016, indicated Eliquis (a medication to prevent blood clots) 5 MG 9 AM and 9 PM PO (by mouth) every 12 hours. A concurrent record review of the physician telephone orders dated March, 10 2016 at 7:30 PM, indicated Hold Eliquis 5 MG PO at HS (bedtime) for seven (7) days. During a concurrent review for Resident H, the Medication Administration Record (MAR) dated March 2016, indicated that Eliquis was not given as ordered on March 11 and 12, 2016 at 9:00 AM. During an interview with LVN 5 on March 13, 2016 at 10:29 AM, LVN 5 stated the physician orders indicated to hold Eliquis at bedtime. LVN 5 stated according to the MAR the morning dose of Eliquis was held on March 11, and 12, 2016, in addition to the bedtime dose being held. LVN 5 stated the Eliquis morning dose should have been given on March 11, and 12, 2016. During a telephone interview with the Physician (Physician 1) on March 13, 2016 at 1:13 PM, Physician 1 stated that he only ordered Eliquis to be held at bedtime. Physician 1 stated it was important for Resident H to receive the Eliquis. Physician 1 stated the Eliquis should not be held for too long because Resident H has a history of irregular heart beat and developing blood clots. A clinical record review of Resident H's Care plan Risk for bleeding dated January 27, 2016 indicated Administer medications .as currently prescribed by the resident's physician. The facility policy and procedure titled Medication Administration dated last revised April 2, 2013, indicated under Standard: All medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help in diagnosis . A physician order that includes dosage, route, frequency, duration, and other required considerations is required for administration of medication. 9. During monitoring of the facility on March 13, 2016, due to the immediate jeopardy not being removed before exiting on March 11, 2016, a medication pass observation was conducted. During the observation of the medication pass process on March 13, 2016 at 11:25 AM, LVN 3 was observed preparing medications to administer to Resident 9. LVN 3 prepared and administered the medications to Resident 9. During a concurrent review of the [MEDICATION NAME] (an antidepre