Every finding on record at Mullican Care Center

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 Women's Secure Unit reviewed for a comfortable environment. The facility failed to ensure a comfortable environment was provided in the Women's Secure Unit dining room when the temperature was between 87-90.7 F on 07/21/2026. This failure could place residents at risk for heat-related illness, hospitalizations, and a decreased quality of life. Findings included: During an interview on 07/21/2026 at 8:21 AM, Resident # 5 said it had been hot in the Women's Secure Unit dining room lately. She was unable to provide a timeframe. During an observation and interview on 07/21/2026 at 3:21 PM, Resident #12 said it was hot in the Women's Secure Unit dining room. She appeared flushed but was not sweating. Resident #9 was flushed but not sweating, and she was unable to express how she felt due to her cognitive status. There were fans in the dining room, residents sitting in the dining area had water within reach, and the other residents in the dining room did not appear to be flushed or sweating. CNA G said it might have been about 2 weeks ago that the window unit in the Women's Secure Unit broke and it had been hot in the dining area. She said fans were placed in the dining room, but they were not helping. CNA G said the Maintenance Director was aware that the window unit was broken. She said none of the residents had complained to her about being too hot, and no residents had experienced any adverse effects related to the heat. During an interview on 07/21/2026 at 3:29 PM, a family member said it had been extremely hot in the dining room area for about 2 months, and she had reported it to administration and the ADON. The family member said the ADON told her it was being fixed and they had ordered parts for the window unit. During an observation of the dining room in the Women's Secure Unit with the Maintenance Director on 07/21/2026 at 3:45 PM, the temperature was 87-90.7 F. During an interview on 07/21/2026 at 3:54 PM, the Maintenance Director said one of the air conditioning units on the women's secure unit had not been working for about a month. He said he replaced the plug in it, but it still did not work, and he tried fixing it but it needed an electrician. He said he had been in contact with the electrician and was waiting for the electrician to go to the facility to fix the unit. He said he placed fans in the dining area to keep it cool, since the rest of the unit and resident rooms were cool. The Maintenance Director said he had been checking the temperature in the dining area of the Women's Secure Unit every other day, and it had been between 81-90 F at the peak of the day. The Maintenance Director said if the temperature in the Women's Secure Unit was too high the residents could get sick. During an observation and interview on 07/22/2026 at 2:49 PM, the Maintenance Director said the electrician had been to the facility, and the window unit on the women's secure unit was now functioning properly. An observation was made of the women's secure unit and the dining area was cool, and the window unit was functioning. During an interview on 07/23/2026 at 10:13 AM, LVN A said she was not aware of the dining room in the women's secure unit being hot. LVN A said she had not noticed any temperature issues, and none had been reported to her. LVN A said if there were any issues with the air conditioning units or with the temperature of the environment it should be reported to the Maintenance Director for him to address. LVN A said if the temperature was too high the residents could start feeling ill, their temperatures would go up, and they could dehydrate. LVN A said none of the residents in the women's secure unit had experienced any adverse events related to heat exposure. During an interview on 07/23/2026 at 10:16 AM, the ADON said one of the CNAs reported to her last week that it was hot in the dining room in the women's secure unit. The ADON said she went to the women's unit, and it was warm but not excessively hot. She said at the time it was 79. She said she notified the Maintenance Director, and he said he ordered a part for the air conditioning unit, and he placed fans in the area to cool it off. The ADON said she had not received any complaints from family members or residents about the dining room in the women's secure unit being hot. The ADON said the temperature being high was not good for the residents' health and they could get overheated. During the interview on 07/23/2026 at 10:21 AM, the DON said she was not aware it had been hot on the women's secure unit or that the air conditioning unit was not functioning. She said if it was hot or the air conditioning unit needed to be repaired, it would be reported to the Maintenance Director for him to address. The DON said if there were complaints regarding the temperature it should be checked. The DON said the temperature being too high could be uncomfortable for the residents, and it would not be good for them and the residents would need to be moved to a different area. During an interview on 07/23/2026 at 10:30 AM, the Administrator said she was not aware of any temperature issues on the women's secure unit. She said anything above 81 degrees would require evacuation of the residents to a different area of the facility. The Administrator said the Maintenance Director was responsible for ensuring safe temperatures were maintained. She said temperatures above 81 were dangerous and could cause heat strokes, heat exhaustion, and heat related illnesses. Record review of the facility's discharges for the past 6 months did not indicate any residents had been hospitalized related to heat exposure. During an interview on 07/23/2026 at 1:23 PM, the Administrator said they did not have a policy on temperature for the environment.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure:a pan with ground sausage was labeled and dateda container of turkey pot roast was discarded by the use by date of 07/16/2026. These failures could place residents at risk for food contamination and foodborne illness. Findings included: During an observation with the Dietary Manager on 07/20/2026 starting at 10:38 AM, there was a pan with ground sausage with no label or date and a container with turkey pot roast with a use by date of 07/16/2026 in the refrigerator in the kitchen. During an interview on 07/22/2026 at 2:42 PM, the Dietary Manager said all food in the refrigerator should be labeled and dated. He said expired food items were discarded on Mondays and Fridays. He said he was responsible for discarding expired food items and ensuring food was labeled and dated. He said he was not in the facility on Friday, so he did not discard expired food items. The Dietary Manager said he placed the pan of ground sausage in the refrigerator while preparing breakfast on 07/20/2026 and had not placed a label or date on the pan because he was in a hurry. The Dietary Manager said food should be labeled and dated and expired food items discarded because the residents could get sick. During an interview on 07/23/2026 at 10:37 AM, the Administrator said her expectations were all food items in the refrigerator were labeled, dated when opened, and dated with an expiration date. She expected expired food to be disposed of. The Administrator said the entire kitchen staff were responsible for ensuring food was properly labeled and disposed. The Administrator said she conducted random checks in the kitchen and if she noticed items needed to be labeled or discarded, she threw them away. The Administrator said not properly labeling/dating and not discarding expired food items could result in food borne illness. Record review of the facility's undated policy titled, Food Safety, indicated, Opened food shall be labeled, dated and stored properly. Record review of the facility's undated policy titled, Left-Over Foods, indicated, Food that is spoiled, contaminated, or suspect shall not be served and shall be discarded immediately.

Based on observation, interview, and record review the facility failed to ensure the emergency crash cart was equipped with a readily available oxygen supply when an empty oxygen cylinder was identified on the crash cart for 1 of 1 crash carts reviewed. The facility failed to ensure the facility's crash cart had an oxygen cylinder that was not empty and ready for use on 07/22/2026. This failure placed resident at risk of delay if administration of oxygen during a resident emergency placing resident at risk of delayed emergency treatment. Finding included: Observation on 07/22/2026 at 1:30 p.m., of the emergency crash cart revealed the oxygen cylinder attached to the crash cart registered at 0 psi, indicating the oxygen tank was empty. Interview on 07/23/2026 10:19 a.m., CNA C stated that staff would obtain oxygen from the crash cart during a resident emergency and that the nurse would turn the oxygen on. The CNA C stated it was their understanding that crash cart oxygen was checked by the night nurse and that oxygen should be readily available for emergency situations. Interview on 07/23/2026 at 10:32 a.m., CNA B stated Oxygen should be readily available for emergency situations. The CNA B stated staff should be able to turn the knob on the oxygen cylinder and have a full tank available not an empty tank because residents could require oxygen during an emergency. Interview on 07/23/2026 at 10:46 a.m., LVN A stated the Oxygen cylinder on the crash part should be full and not empty for emergency use the LVN A stated the nurse was responsible for checking the crash cart and all nursing would use the crash cart in an emergency situation. The LVN A stated the resident was at risk of delayed care in an emergency situation. Interview on 07/23/2026 at 10:54 a.m., The ADON stated the crash court was expected to be checked every night and that the oxygen cylinder should be full and readily available for emergency situations. The ADON stated Residents were at risk of not having oxygen available during an emergency. The ADON stated she expected all nursing to be able to check the oxygen cylinder and ensure it was full. Interview on 07/23/2026 at 11:39 a.m., The DON stated the oxygen tank on the crash cart should not be empty and should be available for resident emergencies. The DON stated the crash part was checked daily and that the night shift nurse was responsible for verifying the oxygen supply. The DON stated that she was unaware that oxygen tank was empty. The DON stated residents were at risk of not having oxygen during an emergency. Interview on 07/23/2026 at 12:32 p.m., the Administrator stated she expected nursing staff to ensure the crash cart had a full oxygen cylinder on the cart. The Administrator stated the residents were at risk of low oxygen level and delayed care. The Administrator stated that she expected the oxygen cylinder level to be checked daily. The Administrator was unaware of the empty oxygen cylinder on the crash cart. Record review of oxygen policy dated 02/2007 revealed the goal was for resident will maintain safe and effective prescribed oxygen delivery. Record review on 07/23/2026 revealed facility did not have a crash cart policy.

Based on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 4 residents (Resident #4 and Resident #3) reviewed for hospice services.1.The facility failed to maintain Resident #4's hospice binder containing information related to hospice services provided for the resident such as an updated care plan or the last IDG also known as Interdisciplinary Group meetings (a regular, collaborative team review of a patient's care meetings).2. The facility failed to obtain Resident #3's most up to date hospice medication list.These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Findings included: 1. Record review of Resident #4's face sheet, dated 07/22/26, reflected Resident #4 was an [AGE] year-old female, re-admitted to the facility on [DATE]with diagnoses which included dementia (a decline in mental ability that interferes with daily life), muscle weakness, anxiety (a feeling of unease, worry, or fear, often experienced as a normal reaction to stress), and depression (a common mental health condition characterized by persistent sadness and a loss of interest in activities, significantly impacting daily life). Record review of Resident #4's quarterly MDS assessment, dated 05/16/26, reflected Resident #4 rarely made herself understood, and was sometimes understood by others. Resident #4 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident #4 was on hospice services. Record review of Resident #4's comprehensive care plan revised 02/22/25 indicated Resident #4 had a terminal prognosis and was on hospice services. The intervention was to work with nursing staff to provide maximum comfort for the resident. Adjust provision of ADLs to compensate for resident's changing abilities and encourage participation to the extent the resident wishes. Record review of Resident #4's physician orders dated 09/29/25 indicated an order for {name} hospice with the diagnosis of dementia. Record review of Resident #4's hospice binder on 07/22/26 at 11:09 a.m., revealed it did not have last two IDG (Interdisciplinary Group) meetings or updated care plan. During an interview on 07/22/26 at 11:27 a.m., the hospice RN H said the binders at the facility should contain any supporting notes or documentation needed for Resident #4. She said the binder should at least have the face sheet, election form, code status, certification of terminal illness, plan of care, and medications. She said they meet every two weeks on Thursday for the IDG meetings and said the documentation should be updated at least the following week after the IDG meetings. She looked at Resident #4's hospice binder which contained the last IDG meeting which was held on 06/18/26 and last care plan was 02/22/26. She said she was at the facility and brought the meeting that was held on 07/16/26. She said she did not know why an updated care plan or IDG meeting which was held on 07/02/26 was not in the binder. She said she had just started working with Resident #4. She said it was important to have the binders at the facility to help the facility know the care and services they were providing. 2. Record review of Resident #3's face sheet dated 07/21/26 indicated she re-admitted to the facility on [DATE] with diagnosis which included stroke, anxiety (a feeling of unease, worry, or fear, often experienced as a normal reaction to stress), and depression (a common mental health condition characterized by persistent sadness and a loss of interest in activities, significantly impacting daily life). Record review of Resident #3's quarterly MDS dated [DATE] revealed she was rarely understood and sometimes understood others. The cognitive skills for daily decision making revealed she was severely impaired. The MDS indicated she was receiving hospice services. Record review of Resident #3's care plan initiated on 05/18/26 indicated resident was receiving hospice services from (unnamed) Hospice related to a stroke. The intervention was for staff to work cooperatively with hospice team to ensure the residents' spiritual, emotional, intellectual, physical, and social needs were met. Record review of Resident #3's physicians order dated 09/16/26 indicated: Admit to (unnamed) hospice services for diagnosis of stroke. Record review of Resident #3's physician order dated 06/06/24 indicated: Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 3 tablet via gastrostomy tube one time a day related to major depressive disorder. Record review of hospice medication list printed on 06/29/26 indicated, give Sertraline 50mg, daily for depression. During an interview on 07/23/26 at 10:30 a.m., the hospice nurse said the hospice binder should have the care plan, recertification, IDG meetings, doctors' orders, medication profile, face sheet, and out of hospital DNR. She said IDG meetings were held every 2 weeks, every other Wednesday and updated information was provided to the facility the next day. She said it was her responsibility to bring updated hospice documents to the facility. She said it was important for the hospice binder to be updated so everybody could be involved in the changes that were made in the plan of care, medications, as well as other stuff. During an interview on 07/23/26 at 11:06 a.m., LVN A said orders, the medication administration record, who to call, and the names of the aids should be in the binder. She said the hospice nurse was responsible for delivering updated documents. She said the hospice binder served as a reference. She said the expectation was for the information to be updated and current. During an interview on 07/23/26 at 11:26 a.m., the DON said there are forms like 3074, 3071, plan of care, notes, and do not resuscitate (DNR) form in the hospice binder. She said the hospice nurse was responsible for bringing up updated information. She said it was important to have updated information for continuity of care. She said the expectation was for the information from the hospice binder to match the facilities. During an interview on 07/23/26 at 11:44 a.m., the administrator said the hospice binders are specific to the residents and had their plan of care. She said the binders should be updated regularly. She said the hospice company was responsible for bringing up updated information. She said it was important to have updated information because that was the right way to properly care for the residents. Record review of the facilities policy titled Hospices Services, undated, indicated Goals: 12. The nursing facility and hospice provider must ensure that a coordinated plan of care reflects the participation of the hospice, nursing facility, the recipient, and legal representative to the extent possible.

Based on observation, interview, and record review, the facility failed to maintain 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 for 2 of 4 residents (Resident #20 and Resident#11) reviewed for infection control.1.The facility failed to ensure CNA B wore PPE which consisted of gown and gloves while in Resident #20's room on 07/21/26 who was on contact isolation for ESBL also known as extended-spectrum beta-lactamase, (infections are primarily transmitted through direct or indirect contact with the bacteria) and the facility failed to provide containers for the disposal of linen and trash.2. The facility failed to ensure LVN A wore PPE (gown) while performing wound care for Resident #11.These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included:1.Record review of Resident #20's face sheet, dated 07/22/22, indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (a decline in memory, thinking abilities, and behavior that interferes with daily life), stroke and muscle weakness.Record review of Resident #20's admission MDS assessment, dated 06/30/26, indicated Resident #20 usually understood and was usually understood by others. Resident #20's BIMS score was 03, indicating she was severely cognitively impaired. The MDS indicated Resident #20 required assistance with her ADLs and maximum assistance with toileting. The MDS indicated Resident #20 was always incontinent of bowel and bladder. The MDS did not indicate she was on isolation precautions.Record review of Resident #20's Physician order dated 07/20/26 indicated: Isolation precautions: Contact isolation for ESBL every shift. Record review of Resident #20's Physician order dated 07/20/26 indicated: Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day for UTI (urinary tract infection) for 10 Days.Record review of Resident #20's comprehensive care plan, last reviewed 07/20/26, indicated she was on contact isolation for ESBL. The intervention was for staff after providing resident care to remove gown and gloves in the resident's room and place in the container for soiled PPE.During an observation and interview on 07/21/26 at 9:03 a.m., Resident #20 was in her bed. Resident #20 had a sign by her doorway that said isolation, along with how to [NAME] (put on) and [NAME] (take off) PPE. The isolation cart was outside her door with gowns and gloves. There were no containers to dispose of her linen or trash. Resident #20 said she was not sure why she was in isolation.During an interview on 07/21/26 at 9:19 a.m., LVN A said Resident #20 was on contact isolation because she had ESBL. She said anyone who entered her room should wash their hands, apply a gown and gloves, and rewash before leaving the room to prevent the spread of infection. She said she was not sure about how to dispose of the gown and glove except in the regular trash.During an observation and interview on 07/21/26 at 9:30 a.m., CNA B walked out of Resident #20's room with linen in a normal trash bag and placed the bag in the linen barrel in the hallway. CNA B then walked back into Resident #20's room without applying a gown or gloves. CNA B said she was aware Resident #20 was on isolation for her urine but was told by the DON that she did not have to wear PPE just to go into the room. She said she was told by the DON that she did not have to dispose of the linen or trash in any special container.During an interview on 7/21/26 at 10:15 a.m., Laundry Aide K said she was aware Resident #20 was on isolation. She said she knew if Resident #20's clothes came to the laundry, she was supposed to wash them separately but if staff used towels or other linen for her, she would not know to wash them separately because there was no identifying markings for her to wash them separately.During an observation on 07/22/26 at 10:30 a.m., Resident #20 was in her bed. She had a box in her room with a red bag inside of it.During an interview on 07/22/26 at 11:00 a.m., CNA B said when she came to work this morning (07/22/26) the box with the red bag was in Resident #20's room. She said she asked the DON why the box was in her room and was told she needed to place her trash in the box related to Resident #20 being on contact and she was incontinent of urine. She said she could continue to put her linen in the regular barrel if it was in a regular trash bag. The surveyor asked how laundry staff would know if a resident was on contact isolation if she placed Resident #20's laundry in the regular linen barrel and she said she did not know. She said she could see how that might place other residents at risk for the spread of infection.2. Record review of Resident #11's face sheet dated 07/17/2026 indicated he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included stroke, diabetes (high blood sugar), and Peripheral vascular disease also known as PVD, (is a blood vessel disorder that includes peripheral artery disease (PAD) and venous problems).Record review of Resident #11's admission MDS assessment dated [DATE] indicated he sometimes made himself understood and usually understood others. The MDS also indicated he had a BIMS score of 08 which meant he was moderately cognitively impaired. The MDS indicated he required maximal assistance with toileting, transfers, dressing, bed mobility, and with eating. The MDS did not indicate a wound.Record review of Resident #11's comprehensive care plan last revised 06/02/26 indicated he had a wound The intervention was to keep foot offloaded and treatment as ordered.Record review of Resident #11's physician's order dated 07/09/26, indicated, paint right lateral ankle with betadine and leave open to air daily. The order did not indicate EBP.During an observation and attempted interview on 07/20/26 at 2:20 p.m., Resident #11 was in bed and had an EBP sign on his door and a cart inside his room. Resident #11 did not answer when asked about EBP.During an observation on 7/22/26 at 2:05 p.m., LVN A went into Resident #11's room to do wound care for his right outer ankle. She explained what she was going to do and applied gloves (she did not apply a gown). She performed wound care as ordered removed her gloves and performed hand hygiene.During an interview on 07/22/26 at 2:20 p.m., LVN A said Resident #11 was on EBP precautions. She said she was supposed to wear gown and gloves while performing wound care. She said she forgot to wear a gown while doing his wound care. She said it was important to wear a gown and gloves to protect the resident and herself. During an interview on 07/23/26 at 11:26 a.m., the DON said she expected all staff to follow the guidelines on the sign posted on the door. She said the staff were aware of Resident #20 being on contact precautions by the sign on the door and the setup outside the door. She said staff had to wear PPE (gown or gloves) when they entered Resident #20's room. She said she expected staff to put their trash in the red box in the room and hand deliver their linen which should be doubled bagged to the laundry. She said it was important for staff to wear PPE (gown and gloves), wash their hands before entering and exiting Resident #20's room to prevent infection control issues. She said residents who were on EBP and staff provided care, she expected staff to wear gowns and gloves and dispose of PPE in regular trash and wash their hands when they exit the room to protect the residents from any kind of germs. The DON said she was the overseer to monitor for infection control issues. During an interview on 07/23/26 at 11:43 a.m., the Administrator said staff should wear PPE (gown and gloves) when entering contact isolation rooms and when providing care for residents who were on EBP. She said for residents on contact isolation she expected for the linen to be placed in a water-soluble bag and then placed in a yellow bag and taken to the laundry and for trash to be placed in a red bag in the room and taken to the biohazard room as needed. She said the DON was the oversee of infection control. She said for isolated and EBP residents, staff should practice hand hygiene before and after leaving the room to prevent infection. She said they wanted to contain the infection to one area as much as possible.Record review of the facility's policy titled, Infection Control, dated 03/2024, indicated, The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility will isolate the resident. The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. The facility will require staff to Donn and Doff PPE before and after contact with residents who needs isolation to prevent the spread of infection to others in the facility. #7 Linens: 1. All soiled linen will be double bagged at the site that it was generated. All personnel will utilize appropriate personal protective equipment. 2. Soiled linen will be transported to the laundry site by cart. 3. The soiled linen will be processed as per linen protocol.Record review of the facility's policy titled, Enhanced Barrier Precautions, undated, indicated, Multidrug-resistant organism (MDRO) transmission is common in long term care (LTC) facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.

Based on observation, interview, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 3 medication carts (Secure Unit Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure MA F secured the Secure Unit Medication Cart, when it was not in use on 07/21/2026. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings included: During an observation on 07/21/2026 starting at 10:27 AM, there was an unlocked, unattended medication cart stationed in the hallway prior to entering the secured units. Multiple staff, visitors, and residents passed by the unlocked, unattended medication cart. At 11:50 AM, the State Surveyor notified the Administrator there was an unlocked, unattended medication cart. The Administrator said it should not be unlocked and locked it and said she would find the staff member responsible for the medication cart. During an interview on 07/21/2026 at 12:02 PM, MA F said she was responsible for the Secure Unit Medication Cart. She said she could have sworn that she had not left the medication cart unlocked. MA F said the medication cart should be locked at all times when not in use and out of sight. MA F said residents could open an unlocked, unattended medication cart and take the medications. During an interview on 07/23/2026 at 10:20 AM, the ADON said the person with the keys to the medication cart was responsible for making sure the medication cart was locked. The ADON said the medication carts should be locked anytime the staff walked away from the medication cart. The ADON said if the medication cart was unlocked the residents could get the medications. During an interview on 07/23/2026 at 10:21 AM, the DON said whoever was responsible for the medication cart at the time was responsible for ensuring it was locked. The DON said when she walked down the hall, she always checked the medication carts to ensure they were locked. The DON said she had not noticed any problems with the medication carts not being locked. The DON said if a medication cart was unlocked, a resident could have access to the medications. During an interview on 07/23/2026 at 10:28 AM, the Administrator said she expected the medication carts to be locked at all times unless the staff was in front of it administering medications. The Administrator said all the clinical staff and interdisciplinary team were responsible for ensuring the medication carts were locked. The Administrator said if a medication cart was unlocked, she feared a resident with a low BIMS score would have access to the medications or any other resident could get into the medication cart, and it was also a safety hazard. Record review of the facility's policy titled, Medication Storage in the Facility, dated 03/2025, indicated, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 out of 2 residents (Resident #25) reviewed for pressure ulcers. LVN A failed to provide wound care to Resident #25 according to physician orders for a state III pressure ulcer. This failure could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection. Findings included: Record review of face sheet dated 07/22/2026 revealed Resident #25 was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of Parkinson disease without dyskinesia (standard stiffness, shaking, and slowness, but no extra, uncontrolled writhing movements). Record review of care plan with the revision date 07/02/2026 revealed Resident #25 had a care plan for a pressure ulcer or potential for pressure ulcer development to the buttocks and right hip. Resident #25 care plan included intervention of to keep Resident #25 positioned off coccyx, report loose or missing dressings to the nurse, notify nurse of new skin breakdown, and provide wound care according to physician orders. Record review of quarterly MDS dated [DATE] revealed Resident #25 at risk of developing pressure ulcers. MDS revealed 0 unhealed pressure ulcers identified on MDS quarterly assessment. MDS assessment revealed Resident #25 had a BIMS of 07 indicating severe impairment. MDS assessment revealed Resident #25 was occasionally incontinent of bladder and frequently incontinent of bowel. Record review of order summary reported dated 07/22/2026 revealed Resident #25 had an order for wound care with the start date of 07/22/2026. Order stated clean right hip with normal saline, pat dry, apply anasep and collagen, then cover with dry dressing one time a day every Monday, Wednesday, Friday for wound healing. Order started on 07/22/2026 stated order to clean the wound to the coccyx with wound cleaner, apply methylene blue foam, and cover with dry dressing everyday and PRN if saturated, soiled, or dislodged. The order for the coccyx was ordered for one time a day for wound healing. Record review of weekly skin report dated 07/02/2026 revealed Resident #25 had 2 identified wounds which were located on his coccyx and right hip. Record review of weekly report dated 07/20/2026 revealed Resident #25 had a new identified stage I pressure wound located to the left hip. Record review of Wound Care Report date 07/22/2026 revealed Resident #25 had been seen by the wound care doctor and measurements for coccyx were 8.5cm X 3.5cm X 1.5cm for the. Observation 07/22/2026 at 1:35 p.m., revealed during the survey a previously unidentified pressure injury noted to be redden area unblanchable measuring 0.5cm X 0.7cm X 0.35cm was observed on Resident #25 left hip. Observation of wound care provided to Resident #25 LVN A did not follow physician orders when the LVN A sprayed the wound to the coccyx with wound cleaner and skipped the step of cleaning the wound and patting it dry. Interview on 07/23/2026 at 10:09 a.m., CNA C stated she was responsible for checking Resident #25 brief, changing Resident #25 brief during incontinent care, and rolling Resident #25 to perform care to Resident #25. CNA C stated Resident #25 was supposed to be offloading off his coccyx and right hip due to wounds. CNA C stated the DON incited yesterday turning every 2 hours and floating and using barrier cream. CNA C stated Resident #25 was at risk of pressure because he had been in more pain and staying in bed. CNA C stated that to her knowledge the nurses do wound care. CNA C stated the resident was at risk of wound worsening if he was not turned, changed, to prevent skin breakdown. CNA C stated elderly skin is thinner and breaks down faster. Interview on 07/23/2026 at 10:27 a.m., CNA B stated she knew Resident #25 had a pressure on his butt and right hip. CNA B stated she was responsible for floating his body with pillow. CNA B stated she was aware of the red spot to the left hip and it had been red for a couple of days. CNA B stated she reported it to her nurse. CNA B stated a new order for the CNAs to turn every 2 hours, and barrier cream was started yesterday 7/22/2026. CNA B stated Resident #25 was at risk for pressure ulcer CNA B stated that nursing was responsible for ensuring wound care was completed and prevented wounds from forming. Interview on 07/23/2026 at 10:40 a.m., LVN A stated she was supposed to follow physician orders when providing wound care. LVN A stated she was aware of the wound located on his right hip and coccyx, but the left hip wound was new and she was not notified. LVN A stated CNAs typically turned him on to the left hip to change his brief and off load his bottom. LVN A stated that she was not aware of Resident #25 needed to be on a turn schedule to reduce pressure to the left hip. LVN A stated Resident #25 was at risk of further skin breakdown with moisture from leaving the wound cleanser when she performed wound care to Resident #25. LVN A stated she expected the CNA to check and change every 2 hours. LVN A stated that she was nervous during observation of wound care and messed up. Interview on 07/23/2026 at 10:53 a.m., the ADON stated she expected wound care orders to be followed. ADON stated she was not aware until yesterday when the surveyor and DON identified the new pressure area located on the left hip. The ADON stated she was responsible for overseeing that the CNAs checked, changed, and repositioned Resident #25. The ADON stated Resident #25 should have been on a turn schedule, but it was not started until yesterday. The ADON stated he was high risk for skin breakdown due to his boney area located on his hips. The ADON stated she expected the nurse to be notified of new skin conditions. Interview on 07/23/2026 at 11:39 a.m., the DON stated that she observed the wound care. The DON stated she expected wound care orders to be followed. The DON stated she expected offloading with pillows to reduce pressure to the coccyx and right hip. The DON stated Resident #25 frequently layed on his right side which created a greater risk of skin breakdown. The DON stated she was unaware of the left hip pressure until surveyor identified it during observation of wound care to the coccyx and right hip. The DON stated she expected the CNA to notify the nurse of any skin changes. The DON stated Resident #25 was at risk of worsening wounds. Interview on 07/23/2026 at 12:14 p.m., the Administrator stated she expected wound care to be done according to physician order the nursing staff. The Administrator stated that his wound could have been prevented with interventions of turning every two hours. The Administrator stated that she was aware of the resident having the wound located on his coccyx and right hip. The Administrator stated she expected nursing to care for, treat, and prevent worsening of pressure ulcers. Record review of pressure injury: prevention, assessment and treatment policy revision dated 5/52025 revealed Nursing Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: NOTE: Add any interventions to care plan.1. Determine resident's skin tolerance to pressure and develop a turning schedule;residents should be turned every two (2) hours or more often if necessary andnotify the Treatment Nurse/designee of any potential problems.Assessment: 1. All residents should have a skin assessment on a weekly basis completed in PCC. 2. If the resident has any type of ulcer (pressure injury, arterial, venous, diabetic) an ulcerassessment should be completed at least weekly. Nursing Care Plan: 1. Identify the problem of pressure injuries on the Nursing Care Plan. 2. Under Nursing Intervention physician ordered treatments.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible in 1 of 6 shower rooms (located on the men's memory care unit) and in 1 of 8 Resident's room (Resident #40 in room [ROOM NUMBER]a) observed for safety hazards. 1.The facility failed to ensure the hygiene supply storage cupboard located on the men's memory care unit in the community shower room with supply items to include bottles of shampoo, body wash, shaving cream, and razors were secure and hygiene items were not accessible to cognitively impaired residents on 07/20/2026 at 12:27 p.m 2. The facility failed to ensure five disposable razors were secured and not left in room [ROOM NUMBER]a on Resident #40's over the bed table on 07/20/2026 at 11;57 a.m. These deficient practices could place residents at risk for harm or injury from sharp objects and liquids that are harmful if swallowed. The findings included: Observation of the men's memory care unit common shower room on 07/20/2026 at 12:27 p.m. revealed the bath hygiene storage cupboard was unsecured and contained a gallon of shampoo (opened with no lid) approximately 1/2 full, 5 cans of shaving cream, 4 disposable razors, 1 hairbrush and 6 bottles of body wash with varying levels of fullness. During an interview on 07/20/2026 at 11:12 a.m., CNA D stated that she was aware that the shower room supply cupboard was not secured and that she had not seen any residents taking items from the cupboard. CNA D stated that the residents could get sick if they drank from the shampoo or soap containers or they could cut themselves on the sharp razors. During an interview on 07/21/26 at 8:36 a.m., CNA E stated that the shower room is always unlocked and the residents on the memory care unit will often enter the restroom without assistance. CNA E stated that she would talk to the DON about getting a lock on the cupboard. During an interview on 07/22/2026 at 3;45 p.m. the ADON stated that it was important to keep hygiene supply items out of resident's reach, especially on the memory care unit and that she would notify the maintenance director to provide a lock for the storage cupboard. The ADON stated that Resident #40 should not have had disposable razors in his room and she would provide in-service for the staff on the memory care unit to ensure this does not happen again. Observation of room [ROOM NUMBER]a on 07/20/2026 at 11:57 a.m. revealed five disposable razors on the bedside table next to Resident #40's bed. Record review of Resident #40's face sheet dated 07/20/2026 revealed an [AGE] year-old male admitted [DATE] and readmitted [DATE]. Resident #40 resided on the men's secure memory care unit with diagnoses which included Alzheimer's dementia (loss of brain function that worsens over time), Major Depressive Disorder (persistent sadness or worry), Hypertension (high blood pressure), left eye blindness, and long-term use of anticoagulant (blood thinner). Record review of Resident #40's Quarterly MDS dated [DATE] revealed highly impaired hearing, resident was usually understood and was usually able to understand what was said to him with moderately impaired hearing and a BIMS score of 8 which indicated moderate cognitive impairment. Resident #40 required the use of a walker for mobility, was independent in eating, required supervision with bathing, dressing, transfers, and bed mobility. Record review of Resident #40's Care Plan with target date 09/27/2026 revealed impaired cognitive function or impaired thought processes, impaired visual function, and activities of daily living self-care performance deficit with intervention to assist with personal hygiene as required to include hair, shaving and oral care as needed. During an interview on 07/20/2026 at 11:12 a.m., CNA D stated that she had not given Resident #40 razors, had not noticed the razors in his room and was not sure if someone had given him the razors or if he took them from the restroom. CNA D stated she would remove the razors from his room for safety. During an interview on 07/21/2026 at 8:36 a.m., CNA E stated that she does not think it is safe for the residents to have disposable razors in their room because they could cut themselves. CNA E stated that the razors should have been in a locked area so Resident #40 could not get them on his own. During an interview on 07/23/2026 at 11:37 a.m., the DON stated that she expects the hygiene supply items and sharps like razors be kept out of reach of all residents, especially the residents who reside on the memory care wing. The DON stated that the risk was that residents could ingest dangerous liquids or cut themselves on the razor blades. During an interview on 07/23/2026 at 12:00 p.m., the Administrator stated that she was not aware the hygiene supply cupboard was not secured and items were accessible to the residents and put them at risk of becoming sick or injured. The Administrator stated that she expects the nursing staff to monitor the supplies and keep them out of reach from the residents. The Regional Nurse stated the facility did not have a policy regarding securing hygiene supply items and sharp items. Risks and Environmental hazards as identified in Appendix-PP of the State Operations Manual, Revised 08/08/2024, revealed in order to be considered hazardous, an element of the resident environment must be accessible to a vulnerable resident. Resident vulnerability is based on risk factors including the individual resident's functional status, medical condition, cognitive abilities, mood, and health treatments. Certain sharp items.may be.hazardous for others with cognitive impairments. Examples of such hazards might include.improper storage and access to toxic chemicals.

Based on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 1 of 3 residents (Resident #4) reviewed for hydration. The facility failed to ensure Resident #4 had water available in her room to drink on 7/20/26 and 07/21/26 . This failure could place residents at risk for dehydration (occurs when your body loses more fluid than you take in), electrolyte imbalance (occurs when certain mineral levels in your blood get too high or too low), and infections. Findings included: Record review of Resident #4's face sheet, dated 07/22/26, reflected Resident #4 was an [AGE] year-old female, re-admitted to the facility on [DATE]with diagnoses which included dementia (a decline in mental ability that interferes with daily life), muscle weakness, anxiety (a feeling of unease, worry, or fear, often experienced as a normal reaction to stress), and depression (a common mental health condition characterized by persistent sadness and a loss of interest in activities, significantly impacting daily life).Record review of Resident #4's quarterly MDS assessment, dated 05/16/26, reflected Resident #4 rarely made herself understood, and was sometimes understood by others. Resident #4 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident #4 was dependent on ADLs such as eating and personal hygiene. Record review of Resident #4's comprehensive care plan revised 05/16/25 indicated Resident #4 had a history of fall. The intervention was for staff to keep needed items, water, etc., in reach. During an observation on 07/20/23 at 1:43 p.m. Resident #4 did not have a water pitcher in the room.During an observation and attempted interview on 07/21/23 at 9:26 a.m. Resident #4's did not have a water pitcher in her room. Resident #4 did not answer when asked about her water pitcher due to her impaired cognition.During an interview on 07/21/26 at 9:30 a.m., CNA C came in the room and verified Resident #4 did not have a pitcher in her room. She said she was Resident #4's aide on yesterday (07/20/26) and today (07/21/26). She said she did not notice that Resident #4 did not have a water pitcher in her room. She said she was supposed to offer fluid any time she provided care but could not recall if she did. She said everyone should have a water pitcher in their room for hydration. She said she would get her a cup.During an observation on 07/21/26 at 2:30 p.m., Resident #4 was sitting up in her chair with water at her bedside.During an interview on 07/23/26 at 11:00 a.m., LVN A said she expected all residents to have some type of cup in their room to receive fluids. She said she was not aware Resident #4 did not have a water pitcher in her room. She said it was everyone's responsibility to ensure residents had some way of receiving fluids to prevent dehydration.During an interview on 07/23/26 at 11:26 a.m., the DON said she expected all residents to have water at their bedside and within reach. She said everyone should ensure staff had water at bedside. She said it was important to have water at bedside to maintain hydration and prevent dehydration. During an interview on 07/23/26 at 11:43 a.m., the Administrator said she expected all residents to have water at their bedside. She said she expected staff to change out water in the morning and in the evening. She said all staff were responsible for ensuring all residents had some way of receiving fluid to maintain proper hydration.Record review of the facility's policy titled, Hydration, dated 03/2024, indicated, Goals: #1. The residents will maintain adequate hydration. Procedure: #3. Fresh water will be maintained at bedside.

Based on observation, interview and record review, the facility failed to ensure that the medication error rate was not 5 percent or greater. The facility had a medication error rate of 8%, based on 2 errors out of 25 opportunities, which involved 2 of 5 residents (Resident #42 and Resident #10) reviewed for medication administration. 1. The facility failed to ensure Resident #10's was free from medication error when LVN A did not prime insulin pen Novolin R (medication used to treat high blood sugar) on 07/22/2025. 2. The facility failed to ensure Resident #42's was free from medication error when LVN A did not prime insulin pen Novolog (medication used to treat high blood sugar) on 07/22/2025. These failures could place residents at risk of not receiving the therapeutic effects of their medications, possible adverse reactions, and medication errors. Findings included:Record review of face sheet dated 07/22/2026 revealed Resident #10 was an [AGE] year-old male admitted to the facility on [DATE] with the diagnosis of dementia (severe memory loss) and type 2 diabetes (condition that effects blood sugar control). Record review of care plan dated 10/02/2025 revealed Resident #10 had a care plan for Diabetes Mellitus (condition that effects blood sugar control) with the intervention of diabetes medication as ordered by physician. Record review of Quarterly MDS dated [DATE] revealed Resident #10 had a BIMS of 14 indicating no cognitive impairment. The MDS assessment revealed an active diagnosis of Diabetes Mellitus. Record review of order summary report dated 07/22/2026 revealed Resident #10 had an order for NovoLog Flex Pen subcutaneous Pen-Injector 100UN/ML to inject per sliding scale: if 180 - 200 = 2U; 201 - 230 = 3U; 231 - 260= 4U; 261 - 290 = 5U; 291 - 320 = 6U; 321 - 350 = 7U; 351 - 400 = 8U and Greater than 400, give 10 units and notify the doctor. Record review of Nursing MAR dated 07/22/2026 revealed Resident #10 had a blood sugar of 336 and 7 units were administered according to documentation. Record review of face sheet dated 07/22/2026 revealed Resident #42 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis of type 2 diabetes mellitus (condition that effects blood sugar control). Record review of care plan dated revision date 01/10/2024 revealed Resident #42 had a care plan for Diabetes Mellitus with the intervention to receive diabetes medication as ordered by physician. Record review of Annual MDS assessment dated [DATE] revealed Resident #42 had a BIMS of 11 indicating moderate cognitive impairment. MDS assessment indicated resident had an active diagnosis of Diabetes Mellitus. Record review of order summary report dated 07/22/2026 revealed Resident #42 had an order for Novolin R solution 100 units/ML to inject per sliding scare: if blood sugar is 70 - 130 = 0U; 131 - 180 = 2U; 181 - 240 = 4U; 241 - 300 = 6U; 301 - 350 = 8U; 351 - 400 = 10U If greater than 400, 12 units and call doctor. Record review of Nursing MAR dated 07/22/2026 revealed Resident #42 had a blood sugar of 154 and 2 units were administered according to documentation. Observation on 07/22/2026 at 11:23 a.m., revealed LVN A failed to prime (remove air from the needle) Resident #10's insulin pen prior to administering 7 units of Novolog to Resident #10. Observation on 07/22/2026 at 11:30 a.m., revealed LVN A failed to prime (remove air from the needle) Resident #42's insulin pen prior to administering 2 units of Novolin R to Resident #42. Interview on 07/22/2026 at 11:32 a.m., LVN A stated that the DON showed her how to prime the insulin pen when she checked off her skills. LVN A stated at the time of check off she returned demonstrated. LVN A was unable to recall exact date of skills check off. Interview on 07/23/2026 at 10:47 a.m., LVN A stated she was unaware she did not prime the insulin pens for Resident #42 and Resident #10 when she administer insulin to both residents. LVN A stated she notified the DON of incorrectly performing priming of the insulin pen and she now knows how to properly turn and prime. LVN A stated she was supposed to prime the insulin and administer according to manufacture instructions. LVN A stated Resident #42 and Resident #10 was at risk of receiving less or more needed insulin than ordered when she did not properly prime the insulin pen to remove the air in the needle. LVN A stated Resident #42 and Resident #10 was at risk of adverse effects of insulin. Interview on 07/23/2026 at 10:54 a.m., the ADON stated she expected medications to be administered without error. ADON stated nursing staff who pass medications were checked off when hired. The ADON stated she expected insulin to be primed per manufacturer guidelines. The ADON stated Resident #42 and Resident #10 had the right to be free from medication error and received the physician ordered dose to treat the condition effectively. The ADON stated Resident #42 and #10 was at risk of high or low blood sugar. Interview on 07/23/2026 at 11:39 a.m., the DON stated she expected LVN A to prime the insulin pen according to the manufacturer guidelines when administering Resident #42 and Resident #10 insulin. The DON stated that Resident #42 and Resident #10 were at risk of high or low blood sugar. The DON stated Resident #42 and Resident #10 were at risk of adverse reactions of insulin. Interview on 07/23/2026 at 12:21 p.m., the Administrator stated she expected all medications including insulin pens to be administered according to manufacturer guidelines and physician orders. The Administrator stated Resident #42 and Resident #10 were at risk of adverse events due to inaccurate dosing. The Administrator stated insulin was for blood sugar control and it could have caused too high or too low blood sugar. Record review of Medication Administration and General Guidelines policy undated, revealed medications are administered in accordance with written orders of the attending physician. Record review of Insulin Pen Use policy revision date 04/01/2015 revealed always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by ensuring that pen and needle work properly and removing air bubbles. Policy revealed insulin pen should be primed by: A. Select a dose of 2 units by turning the dosage selector. B. Hold the pen with the needle pointing upwards. C. Tap the insulin reservoir so that any air bubbles rise up towards the needle. D. Press the injection button all the way in. Check if insulin comes out of the needle tip.

Based on observation, interview and record review, the facility failed to ensure that residents were free of significant medication errors for 2 of 5 residents (Resident #10 and Resident #42) reviewed for pharmacy services. 1. The facility failed to ensure LVN A primed Resident #10's insulin pen Novolin R (medication used to treat high blood sugar) on 07/22/2025 according to manufacture instructions. 2. The facility failed to ensure LVN A primed Resident #42's insulin pen Novolog (medication used to treat high blood sugar) on 07/22/2025 according to manufacture instructions. This failure could place residents at risk of medical complications and not receiving necessary medications. Findings included: 1.Record review of face sheet dated 07/22/2026 revealed Resident #10 was an [AGE] year-old male admitted to the facility on [DATE] with the diagnosis of dementia (severe memory loss) and type 2 diabetes (condition that effects blood sugar control). Record review of care plan dated 10/02/2025 revealed Resident #10 had a care plan for Diabetes Mellitus (condition that effects blood sugar control) with the intervention of diabetes medication as ordered by physician. Record review of Quarterly MDS dated [DATE] revealed Resident #10 had a BIMS of 14 indicating no cognitive impairment. MDS assessment revealed an active diagnosis of Diabetes Mellitus. Record review of order summary report dated 07/22/2026 revealed Resident #10 had an order for Novolog Flex Pen subcutaneous Pen-Injector 100UN/ML to inject per sliding scale: if 180 - 200 = 2U; 201 - 230 = 3U; 231 - 260 = 4U; 261 - 290 = 5U; 291 - 320 = 6U; 321 - 350 = 7U; 351 - 400 = 8U and Greater than 400, give 10 units and notify the doctor. Record review of Nursing MAR dated 07/22/2026 revealed Resident #10 had a blood sugar of 336 and 7 units were administered according to documentation. 2.Record review of face sheet dated 07/22/2026 revealed Resident #42 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis of type 2 diabetes mellitus (condition that effects blood sugar control). Record review of care plan dated revision date 01/10/2024 revealed Resident #42 had a care plan for Diabetes Mellitus with the intervention to receive diabetes medication as ordered by physician. Record review of Annual MDS assessment dated [DATE] revealed Resident #42 had a BIMS of 11 indicating moderate cognitive impairment. MDS assessment indicated resident had an active diagnosis of Diabetes Mellitus. Record review of order summary report dated 07/22/2026 revealed Resident #42 had an order for Novolin R solution 100 units/ML to inject per sliding scare: if blood sugar is 70 - 130 = 0U; 131 - 180 = 2U; 181 - 240 = 4U; 241 - 300 = 6U; 301 - 350 = 8U; 351 - 400 = 10U If greater than 400, 12 units and call doctor. Record review of Nursing MAR dated 07/22/2026 revealed Resident #42 had a blood sugar of 154 and 2 units were administered according to documentation. Observation on 07/22/2026 at 11:23 a.m., revealed LVN A failed to prime Resident #10 insulin pen when administering 7 units of Novolog. Observation on 07/22/2026 at 11:30 a.m., revealed LVN A failed to prime Resident #42 insulin pen when administering 2 units of Novolin R. Interview on 07/22/2026 at 11:32 a.m., LVN A stated she was unaware she did not prime the insulin pens for Resident #42 and Resident #10 when she administer insulin to both residents. LVN A stated she notified the DON of incorrectly performing priming of the insulin pen and she now knows how to properly turn and prime. LVN A stated she was supposed to prime the insulin and administer according to manufacture instructions. LVN A stated she was aware Resident #42 and Resident #10 were receiving insulin, which was a high-risk medication and was at risk of receiving less or more needed insulin than ordered when she did not properly prime the insulin pen to remove the air in the needle. LVN A stated Resident #42 and Resident #10 were at risk of adverse effects of insulin. Interview on 07/23/2026 at 10:54 a.m., the ADON stated she expected medications to be administered without error. ADON stated nursing staff who pass medications were checked off when hired. ADON stated she expected insulin to be primed per manufacturer guidelines. ADON stated Resident #42 and Resident #10 had the right to be free from medication error and received the physician ordered dose to treat the condition effectively. ADON stated Resident #42 and #10 was at risk of high or low blood sugar because it was a high-risk medication. Interview on 07/23/2026 at 11:39 a.m., the DON stated she expected LVN A to prime the insulin pen according to the manufacturer guidelines when administering Resident #42 and Resident #10 insulin which was a high-risk medication. DON stated that Resident #42 and Resident #10 were at risk of high or low blood sugar. DON stated Resident #42 and Resident #10 were at risk of adverse reactions of insulin. Interview on 07/23/2026 at 12:21 p.m., the Administrator stated she expected all medications including insulin pens to be administered according to manufacturer guidelines and physician orders. The Administrator stated Resident #42 and Resident #10 were at risk of adverse events due to inaccurate dosing. The Administrator stated insulin was a high-risk medication. Administrator stated insulin is for blood sugar control and could have caused too high or too low blood sugar. Record review of Medication Administration and General Guidelines policy undated revealed medications are administered in accordance with written orders of the attending physician. Record review of Insulin Pen Use policy revision date 04/01/2015 revealed always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly and removing air bubbles. Policy revealed insulin pen should be primed by:A. Select a dose of 2 units by turning the dosage selector.B. Hold the pen with the needle pointing upwards.C. Tap the insulin reservoir so that any air bubbles rise up towards the needle.D. Press the injection button all the way in. Check if insulin comes out of the needle tip.

Based on record reviews, interviews and observations, the facility failed to maintain medical records in accordance with the accepted professional standards and practices that are complete and accurately documented for1 of 6 (Resident #46) residents reviewed for documentation. Resident #46's electronic medical record did not contain complete and accurate documentation that reflected that a quarterly care plan conference was completed. This failure could result in the residents' records not accurately documenting completion of plan of care conference.The findings included: Record review of Resident #46's face sheet dated 07/23/2026 revealed an [AGE] year-old male admitted [DATE] with diagnoses which included [AGE] year-old female admitted [DATE] with diagnoses which included [NAME] Obstructive Pulmonary Disease (a progressive, irreversible lung disease that restricts airflow and makes breathing difficult), Diabetes mellitus Type II (a condition where the body does not make enough insulin or cannot use properly causing sugar to build up in the blood), Dementia (a group of symptoms that cause a loss of memory, thinking skills, and the ability to do daily tasks), and gout (a painful type of arthritis caused by high uric acid levels that form sharp crystals in the joint). Record review of Resident #46's Comprehensive MDS dated [DATE] revealed moderately impaired hearing, resident usually understood what was said to him and had a BIMS score of 9 which indicated moderate cognitive impairment. Resident #46 required the use of a walker for mobility, was independent in eating, required supervision in toileting bathing, dressing, bed mobility and transfers. Record review of Resident #46's Care Plan revealed the Care Plan was initiated 05/28/2026, and the next review date is 09/01/2026. Record review of the Care Plan Conference assessment for Resident #46 revealed only one assessment dated [DATE]. Record review of the EMR for Resident #46, revealed no evidence of an initial Care Plan Conference completed within 21 days of admission date of 05/28/2026. During an interview on 07/22/2026 at 2:28 p.m., the ADON stated that she does attend some care plan meetings and that the SW or the MDS Nurse will complete the Care Plan Conference for each meeting. The MDS Nurse stated that they used to sign in on a Care Plan Conference summary form, but they do not use that form any longer. During an interview on 07/22/2026 at 3:00 p.m., the SW stated that she had only been working at the facility for a few weeks, and that she would send an invitation to the responsible party. The SW stated that she believed she was responsible for completing the Care Plan Conference assessment but that anyone in the IDT meeting could complete the form. During an interview on 07/22/2026 at 3:39 p.m., the MDS Nurse stated she does attend some care plan meetings and did recall attending the initial plan of care meeting for Resident #46 with his daughter and son. The MDS Nurse was unable to locate any documentation which indicated the meeting took place, attendance at the meeting or content of the meeting. The MDS Nurse stated the SW was usually responsible for completing the Care Plan Conference for each meeting. During an interview on 07/22/2026 at 4:02 p.m., Resident #46's Responsible Party stated she had attended a care plan meeting with the facility staff, and other family members at the beginning of June 2026 but could not recall the date. The Responsible Party stated that she did not recall signing any document which indicated attendance at the review meeting. During an interview on 07/23/2026 at 11:37 a.m., the DON stated that she expects the meetings to be held quarterly and that someone from the IDT meeting should complete the Care Plan Conference assessment to reflect areas discussed during the meeting and attendance. The DON stated that the risks of not completing the required assessments is that there would be no proof that the required meeting took place. During an interview on 07/23/2026 at 12:00 p.m., the Administrator stated that she expects a member of the IDT meeting to complete the Care Plan Conference assessment and indicate all members in attendance to include the resident or the responsible party. The Administrator stated that she expected the assessment to reflect what was discussed at each initial, quarterly and as needed meeting and the results to be documented on the designated assessment form. The Administrator stated the risks of not completing the assessment would be that there would be no way to prove that the meeting was done. A request for facility policy on accuracy of documentation was requested on 07/23/2026 at 1:45 p.m. The DON stated they did not have a policy for documentation.

Based on interview and record review, the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood and sent a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 4 residents (Resident #1) reviewed for discharge. 1.The facility failed to notify the resident representative, (Office of the State Long-Term Care Ombudsman,) of the transfer or discharge with the reasons for the move in writing in a language and manner they understand. 2.The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State LTC Ombudsman involving Resident #1. 3.The facility failed to notify Resident #1's responsible party of his discharge prior to him being discharged from the facility. These failures could place residents at risk of not receiving an advocate who could inform them of their options, rights, and the added protection from being inappropriately transferred or discharged . Findings included:Record review of Resident #1's face sheet, dated 02/04/2026, indicated an [AGE] year-old male who was re-admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (a progressive decline in mental ability that interferes with daily life), diabetes mellitus (chronic disease in which the body is unable to produce or properly use insulin), high blood pressure, and depression (a mood disorder that cause a persistent feeling of sadness and loss of interest). Record review of the Resident #1's facility-initiated discharge protocol, dated 01/09/2026, indicated Resident #1 was to be discharged on 01/09/2026. The facility-initiated discharge protocol also indicated the ombudsman portion was not completed. Record review of Resident #1's discharge MDS assessment, dated 01/16/2026, indicated he was discharged on 01/16/26 to an inpatient psychiatric facility. The MDS also indicated he had a BIMS score of 2, which indicated he had severe cognitive impairment. Resident #1 required supervision for ADLs. Record review of Resident #1's eTransfer form, dated 01/16/2026 at 3:00 PM, completed by the ADON, indicated he was transferred on 01/16/2026 at 3:00 PM to an inpatient psychiatric hospital. The eTransfer form indicated the transfer was not an emergency transfer and the facility doctor and the resident representative were notified of the transfer on 01/16/26 at 9:00 AM. During an interview on 02/04/2026 at 1:27 PM, the local facility ombudsman said she was never notified of Resident #1 being discharged from the facility. The facility ombudsman said she found out Resident #1 was discharged on 01/21/2026. During an interview on 02/04/2026 at 2:31 PM, with Resident #1 revealed he was in the secure unit. Resident #1 said he went to the hospital the first time and did not respond to any further questions. During an interview on 02/04/2026 at 3:25 PM, the ADON said Resident #1 was sent to a behavioral health unit to try to ensure the residents of the facility were safe. The ADON said Resident #1 received a 30-day notice, but she did not know when because nursing was not involved with the 30-day discharge process. The ADON said she was not involved with Resident #1's discharge to the behavioral health unit. The ADON said she completed the discharge assessment to help RN A because he was swamped that day. The ADON said she did not verbally verify with RN A if he contacted Resident #1's family when he was discharged to the behavioral health unit. The ADON said when a resident went to the hospital the family should be contacted prior to the discharge. The ADON said she was not sure where the communication failed with Resident #1's family, but the family should always be notified when a resident was discharged from the facility. The ADON said if a family member was not notified of the residents discharge it could cause the family member to be concerned. The ADON said she was not sure how the resident could be affected. During the interview on 02/04/2026 at 3:58 PM, the Administrator said he was in contact with Resident #1's family member about not being able to fulfill Resident #1's needs at the facility around 01/13/2026. The Administrator said he spoke to Resident #1's family member about discharging him from the facility permanently. The Administrator said he provided a 30-day notice to Resident #1's family member, but he was unsure of the date when he provided it. The Administrator said Resident #1 had increased behaviors, and on 01/16/2026, they decided to send him to a behavioral hospital by obtaining an order from the county judge. The Administrator said when Resident #1 was discharged from the facility the doctor and his family should have been notified. The Administrator said to his knowledge they were not required to notify the ombudsman when a resident discharged to the hospital. The Administrator said he expected the nurses to ensure the doctor and family were notified when a resident was discharged from the facility. The Administrator said the Social Worker notified the doctor of Resident #1's discharge to the behavioral hospital on [DATE]. The Administrator said he was supposed to call Resident #1's family when he was sent to the behavioral hospital, but he forgot to notify them. The Administrator said it was important for the family to be notified of a resident's discharge, so they immediately knew what was happening with the resident. The Administrator said he was not sure how the family not being notified of a resident's discharge could affect the resident, but it could have an adverse effect. During an interview on 02/04/2026 at 3:44 PM, the DON said the facility had several behavior incidents with Resident #1 and she was not involved. She said she did not handle anything with the discharge or the transfer of the Resident #1. The DON said the resident did know the Administrator handed the 30-day discharge to Resident #1's responsible party for Resident #1 to be discharged . The DON said after the notice, the Social Worker stepped in to find placement for Resident #1. The DON said the discharge plan was set by the Social Worker. The DON said she expected the floor nurse to have notified the family and the doctor of Resident #1's discharge and ensured transportation was set up. The DON said she expected the ADON to ensure the family and the MD were notified prior to documenting the information on the eTransfer assessment. The DON said the failure placed a risk of the family not knowing Resident #1 was discharged and the family's rights to know any change in Resident #1's care. During an interview on 02/04/2026 at 4:20 PM, the Social Worker said Resident #1 had several behaviors. The Social Worker said she had been trying to get him into a behavior center, and she went to the local justice of peace and got a detention order from the courthouse in order for the behavior center to be able to take him. The Social Worker said the plan was for Resident #1 to go get treatment and return to the facility. The Social Worker said she heard the Administrator gave a 30-day notice to Resident #1's responsible party, but unsure if it was ever completed. The Social Worker said on 1/16/2026, she was not involved in notification of the family nor the doctor. The Social Worker said typically she handled discharges, but she never completed a discharge the way Resident #1 was discharged . The Social Worker said the Administrator said he was going to notify the responsible party of Resident #1's discharge but she was unsure if he did or not. The Social Worker said normally if she completed a discharge for a resident, she notified the family and the doctor. The Social Worker said importance of notifying the ombudsman was unknown and she was not aware if the ombudsman needed to be notified. The Social Worker said she did not know the risk associated with the family and doctor not being notified. During an interview on 02/04/2026 at 4:33 PM, the Administrator said it was an oversight that he did not complete the ombudsman notification portion on the Facility initiated Discharge Protocol, dated 01/09/2026. The Administrator said the notification to the ombudsman should have been completed when the form was completed and when Resident #1 was discharged from the facility. During an interview on 02/04/2026 at 4:37 PM, Resident #1's responsible party said the facility gave her a 30-day notice and the discharge date was the day of the notice on 1/9/26. The responsible party said Resident #1 was discharged on 1/16/26 and no one at the facility called to notify her of the discharge. The Responsible party said she spoke with the Administrator on January 16th, and he did not notify her of Resident #1 being discharged . Resident #1's responsible party said she did not know Resident #1 was discharged until the 21st of January when her and the local ombudsman came to visit. During an interview on 02/04/2026 at 4:41 PM, RN A said to the best of his knowledge Resident #1 was discharged prior to the start of his shift, and he was not involved in Resident #1's discharge from the facility to the behavioral health unit. RN A said the ADON and the DON told him the discharge process had been completed when he arrived for his shift. RN Asaid when a resident was discharged , the responsible party and doctor should be notified of the resident's discharge. RN A said the responsible party should be notified in case there were decisions that needed to be made, so they were aware of where the resident was being transported to and why the resident was discharged . Record review of the facility, undated, policy Facility Initiated Discharge indicated:The facility will permit each resident to remain in the facility and not transfer or discharge the resident from the facility. In the following limited circumstances, this facility may initiate transfers or discharges.This facility will ensure the discharge planning process addresses each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies, as appropriate, and involves the resident and if applicable, the resident representative and the interdisciplinary team in developing the discharge plan.Emergent Transfers to Acute CareResidents who are sent emergently to the hospital are considered facility-initiated transfers because the resident's return is generally expected. When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer and a notice of transfer will be provided to the resident and resident representative as soon as practicable. Copies of notices for emergency transfers will also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis.In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of discharge to the resident and resident representative, and will also send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. 1) The facility failed to dispose of expired food items. 2) The facility failed to label and date all food items in the refrigerator and freezer. 3) The facilty failed to main safe holding temps on the steam table. These failures could place residents at risk for food contamination and foodborne illness. The findings included: Record Review of in-services on labeling and dating was last completed by staff on 5/27/25. During observation in the kitchen refrigerator 1 of 2 on 5/27/25 at 9:25 a.m., the following was observed with the Dietary Manager: -2 quarts of BBQ Beef had an expiration date of 5/22/25. (Expired) -1/2 quart of container of Jelly had a preparation date of 5/19/25 and no expiration date. -2 quarts of ketchup in a container had a preparation date of 5/17/23 and no expiration date. -1 quart of diced tomatoes was not labeled, had no preparation date and no expiration date. During observation of freezer #1 of 2 on 5/27/25 at 9:35 a.m., the following was observed with the Dietary Manager: -(1) frozen roll of hamburger meat in a zip lock bag had a received date of 5/24/25 and no expiration date. During observation in the kitchen on 5/27/25 at 9: 52 a.m. the following was observed with the Dietary Manager: -(1) 16 ounces of celery seed seasoning had an open date of 12/4/23 and a expiration date of 10/21/24. (Expired) -(1) 16 ounces of Ground red pepper seasoning had a open date of 1/2/23 and a expiration date of 4/3/25. (Expired) -(1) 16 ounces of [NAME] sugar seasoning had a open date of 5/19/25 and expiration date of 5/4/25. (Expired) During an observation on 5/28/25 at 12:30 p.m., observations of food temperatures were made on the steam table by [NAME] B. The results were as followed, regular chicken parmesan was 87°F; the regular spaghetti noodles were 166.2°F; the green beans was 149.9°F; the spaghetti sauce was 100.4°F; the chocolate cake was 72.6°F; the puree chicken parmesan was 109°F; the puree spaghetti noodles was 106.1°F; the puree green beans was 115.5°; the puree garlic bread was 108.1°F and the puree chocolate cake was 54.3°F. During an interview on 5/29/25 at 8:28 a.m., the Dietary Manager stated he had been employed at the facility for 7 months. The Dietary Manager stated the Administrator oversaw him at the facility. The Dietary Manager stated all items in the refrigerator and freezer were to be labeled, dated with receive date, open date and expiration date. The Dietary Manager stated staff had completed in-services on labeling and dating all food items on Tuesday (5/27/25). The Dietary Manager said he conducted walk throughs in the kitchen every morning. The Dietary Manager stated he was not aware of the expired food items found in the kitchen. The Dietary Manager stated it was important to ensure staff were labeling and dating all food items so the staff knew when the food was bad so the food would not affect the residents or guests. During an interview on 5/29/25 at 8:44 a.m., the Administrator stated he had been employed at the facility since November of 2024. The Administrator stated all food items found in the kitchen were to be labeled, dated with receive date, open date and expiration date. The Administrator stated staff completed in-services on labeling and dating but he was not sure when the last in-service on labeling and dating was last completed. The Administrator stated he conducted walk throughs daily. The Administrator stated he was not aware of the expired food items found in the kitchen until yesterday on (5/28/25) when the Dietary Manager told him. The Administrator stated he was not made aware of staff not labeling and dating all food items until yesterday on (5/28/25) when the Dietary Manager told him. The Administrator stated he did expect the Dietary Manager to report to him of any issues noted in the kitchen. The Administrator stated, It was important to ensure staff were labeling, dating and discarding expired food items because staff have to know when the food was close to being discontinued because if the food went bad, we definitely don't want to serve bad foods. Record Review of the food and storage policy dated 2012 indicated, (6) When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes. Record Review of FDA dated 2022 indicated, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under ¶ (B) and in ¶ (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above for hot foods, except that roasts cooked to a temperature and for a time specified in ¶ 3-401.11(B) or reheated as specified in ¶ 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5°C (41°F) or less for cold food.

Based on observation, interview and record review, the facility failed to ensure that each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community, in that: The facility failed to serve meals, at the specific times posted, in the main dining room. This failure placed residents at risk of increased hunger, thirst, frustration, and decreased feelings of self-worth. Findings included: Record Review of in-services on time management was last completed by staff on 4/29/25. Record review of the facility's posted meal service reflected breakfast mealtime was 7:00 AM; lunch mealtime was 12:00 PM; and dinner mealtime was 5:00 PM. During an interview in the dining room on 5/28/25 at 9:00 a.m., Resident #38 stated that the breakfast and lunch meal was always served late. During observations on 05/28/25 at 12:42 PM, in the facility's main room, lunch meal service had not begun, and the residents had not begun to eat lunch. During an interview on 5/29/25 at 8:15 a.m., the Dietary manager stated he had been employed at the facility for 7 months. The Dietary Manager stated the meal serving times were 7am for breakfast, 12pm for lunch and 5pm for dinner. The Dietary Manager stated the reason why the lunch meal on 5/28/25 was late was because the cook folded under pressure and because the cook was in his own head. The Dietary Manager stated staff had been in serviced on serving the meals timely. The Dietary Manager stated it was important to serve the meals timely because the residents were in routine and the residents needed to be fed on time. During an interview on 5/29/25 at 8:37 a.m., the Administrator stated he had been the Administrator since November of 2024. The Administrator stated he was made aware of the lunch meal being served late on 5/28/25 (lunch meal) by the Dietary Manager. The Administrator stated staff had been in serviced on serving the meals timely. The Administrator stated in the past the Dietary staff had been 5 minutes late serving the meals and he in serviced staff on being on time to serve the meals timely. The Administrator stated, It was important to serve the meals timely because the residents needed to eat on time, for weight loss and for blood sugars; we have to keep the residents on their schedules.

Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 3 meals (lunch) reviewed for palatability and temperature. 1. The facility failed to provide food that was palatable and appetizing temperature for 1 of 3 meals observed on 5/28/25 (lunch) meal. 2. The facility failed to follow puree recipe for lunch meal served on 5/28/25. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: 1. Record Review of the facility week 1 menu dated on 5/28/25, indicated the lunch meal (A) items included Chicken Parmesan, Bowtie Pasta, Italian Blend vegetables, garlic bread, margarine, chocolate turtle poke cake, and iced tea. During an interview on 5/27/25 at 10:10 a.m., Resident #6 stated most of the times she liked the food. Resident #6 stated the hamburger meat made her stomach upset so she was always asking for alternative meal like a peanut butter and jelly sandwich. During an interview on 05/27/25 at 11:26 AM, Resident #17 said sometimes there was not enough food, and the meat was tough. Resident #17 said, I say you eat with your eyes and sometimes I look at it and say I don't want to eat it, it does not look appetizing. During an observation on 5/28/25 at 12:30 p.m., observations of food temperatures were made on the steam table by [NAME] B. The results were as followed, regular chicken parmesan was 87°F; the regular spaghetti noodles were 166.2°F; the green beans was 149.9°F; the spaghetti sauce was 100.4°F; the chocolate cake was 72.6°F; the puree chicken parmesan was 109°F; the puree spaghetti noodles was 106.1°F; the puree green beans was 115.5°; the puree garlic bread was 108.1°F and the puree chocolate cake was 54.3°F. During interview and food tasting on 5/28/25 at 1:12 p.m., the Dietary Manager stated the chicken parmesan was no hot but could have been a little warmer; the green beans was bland, needed more seasoning and was cool not warm; the chocolate cake was good; garlic bread was not sampled. During food tasting on 5/28/25 five surveyors stated the chicken parmesan was warm not hot; the green beans was bland; the chocolate cake was good; garlic bread was not sampled. During an interview on 5/29/25 at 8:24 a.m., the Dietary Manager stated he had been employed for 7 months. The Dietary Manager stated the Administrator oversaw him at the facility. The Dietary Manager stated he tasted the food served from the kitchen daily. The Dietary Manager stated he tasted the foods for the lunch meal on 5/28/25 prior to the test tray. The Dietary Manager stated he handled food complaints at the facility by having a one-on-one conversation with the resident along with another staff member and addressing the residents' needs face to face. The Dietary Manager stated he also address the complaints during resident council meetings when he was invited to attend. The Dietary Manager stated, It was important to ensure the food was palatable, attractive and appetizing because it was the only thing the residents looked forward to and it was the only thing the residents could control, it's a consistency 7 days a week. During an interview on 5/29/25 at 8:40 a.m., the Administrator stated he had been the Administrator since November of 2024. The Administrator stated he oversaw the Dietary Manager. The Administrator stated he tried getting test trays once a week. The Administrator stated in the past residents did not complain much about the foods served from the kitchen. The Administrator stated in the past he received a food complaint about the pork meat being too tough. The Administrator stated he told the dietary staff to make sure the meat was tender because some residents could not chew the meat. The Administrator stated he was not aware of any recent food complaints. The Administrator stated food complaints were handled at the facility by social worker. The Administrator stated the social worker would take the complaints to whatever department that needed to handle the complaint. The Administrator stated it was important that food was palatable, attractive, and appetizing to the residents because, He liked to see the people enjoy the food and because the residents looked forward to good food. 2. Record Review of the puree green beans indicated the following: (1) For Pureed Italian blend vegetables: add liquid, if needed (ex: reserved liquid broth, juice, milk, gravy, or sauce) to assist with pureeing. Puree with a blender or food processor until smooth NOTE: Water should not be used as a liquid to puree foods. Serve with a #10 scoop. Record Review of in-services on following the menu was last completed by staff on 4/1/25. During observation and interview of puree meal prepared by [NAME] B for the lunch meal served on 5/28/25 at 12:43 p.m., the following was noted: [NAME] B added 7 servings of regular green beans, 1 cup of water and 2 cups of food thickener. [NAME] B was observed not using the recipe book. [NAME] B stated he thought he had completed in-services on following the recipe book a few months ago. [NAME] B stated it was important to follow the recipe book for flavor and texture of the foods pureed. [NAME] B stated in the past of pureeing foods that he used water to mix with food thickener. [NAME] B stated he was the cook at the facility. [NAME] B stated he did not review the recipe book prior to pureeing foods for the lunch meal on 5/28/25. When asked why he did not review the recipe book prior to pureeing foods the cook stated, I do what I do, I been doing this since '93 and I get everything changes from 20 to 30 years ago. During an interview on 5/29/25 at 8:22 a.m., the Dietary Manager stated he had been the Dietary Manager for 7 months. The Dietary Manager stated the Administrator oversaw him at the facility. The Dietary Manager stated he was responsible for ensuring staff were following the recipe book. The Dietary manager stated he was not made aware of staff not following the recipe book. The Dietary Manger stated staff were last in serviced on following the recipe last month. The Dietary manager stated it was important for staff to follow the recipe book for consistency and proper nutrition. During an interview on 5/29/25 at 8:55 a.m., the Administrator stated he had been the Administrator since November of 2024. The Administrator stated he was not made aware of staff not following the recipe book. The Administrator stated he did expect the dietary staff to follow the recipe book. The Administrator stated he oversaw the Dietary Manager. The Administrator stated he was not sure if staff completed in-services on following the recipe. The Administrator stated he inspected the kitchen daily.

Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 6 residents (Resident #28) reviewed for pharmacy services. The facility failed to ensure RN A accurately reconciled Resident #28's narcotic medication log when she disposed Resident #28's clonazepam (controlled medication used for anxiety) tablet on 05/27/25. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: Record review of Resident #28's face sheet dated 05/28/25, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included anxiety and gastrostomy status (surgical opening into the stomach for nutritional support and medication administration). Record review of Resident # 28's quarterly MDS assessment dated [DATE], indicated she was rarely/never understood and usually understood others. Resident #28 had short/long term memory problems and her cognition was severely impaired. Resident #28 was dependent on staff on all ADLs and had a feeding tube. The MDS assessment indicated Resident #28 had received an antianxiety medication during the 7-day look back period. Record review of Resident #28's comprehensive care plan revised on 12/19/23, indicated she used antianxiety medications. The care plan interventions included to administer anti-anxiety medications as ordered by the physician. Record review of Resident #28's order summary report dated 05/28/25, indicated she had an order for clonazepam 0.5mg give one tablet via g-tube two times a day related to anxiety with a start date of 10/20/24. Record review of Resident #28's treatment administration record dated 05/01/25-05/31/25, indicated Resident #28 had received one tablet of clonazepam 0.5mg daily at 7:00 AM and 3:00 PM. During an observation and interview on 05/27/25 at 3:23 PM, RN A opened the narcotic box located on the nurse's medication cart and removed one tablet of Clonazepam 0.5mg from the medication card. RN A crushed the tablet and poured it in a medicine cup. RN A proceeded to apply PPE and administer Resident #28's clonazepam via her gastrostomy tube. RN A obtained the narcotic book from under the nurse's station and signed off the clonazepam tablet she administered. There was only 1 tablet of clonazepam 0.5mg left in the medication card. The narcotic record indicated Resident #28 should have had 2 tablets of Clonazepam 0.5mg tablets remaining. When asked how come the narcotic record indicated there should have been 2 tablets remaining, RN A said she was fixing to administer the tablet when she remembered the state surveyor wanted to observe the medication being administered so she disposed the tablet. RN A said she did not get a witness to the disposal of the medication because she had already disposed the medication and she had panicked. RN A said she had just started at the facility 3 days ago and did not know the policy on narcotic medication disposal. RN A said at previous facilities she was responsible for obtaining a witness when she disposed the clonazepam tablet and failure to do so was a discrepancy. During an interview on 05/29/25 at 09:13 AM, the DON said she expected a witness be obtained when narcotic medications were being disposed. She said the nurse was responsible to get a witness while they were wasting the medication and not after. She said failure to have a witness would lead to a drug diversion. During an interview on 05/29/25 at 09:20 AM, the Administrator said when narcotic medications were disposed, there should be a witness. He said the nurse and nursing administration were responsible for ensuring a witness was obtained when disposing a narcotic medication. He said failure to obtain a witness could lead to a drug diversion. Record review of the facility's undated policy Controlled Medications- Administration, indicated . Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. 6. When a controlled medication is administered, the license nurse administering the medication immediately enters all of the following information on the accountability record: date and time of administration, amount administered, signature of the nurses administering the dose, completed after the medication is actually administered. 7. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. If allowed by your state, they may be destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record on the line representing that dose .

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #39) reviewed for treatment and services related to indwelling catheters. The facility failed to ensure Resident #39's foley catheter was secured on 05/27/2025. This failure could place residents at risk for urinary tract infections and a decreased quality of life. Findings included: Record review of a face sheet dated 05/28/2025 indicated Resident #39 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of the prostate (prostate cancer) and benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of the prostate which results in difficulty urinating). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #39 understood others and was understood. The MDS assessment indicated Resident #39 had a BIMS score of 12, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #39 required supervision or touching assistance with toileting, showering/bathing, dressing, and personal hygiene. The MDS assessment indicated Resident #39 had an indwelling catheter (tube inserted into the bladder). Record review of Resident #39's Order Summary Report dated 05/28/2025 indicated an order to ensure catheter strap was in place and holding every shift change as needed with a start date of 03/05/2025. Record review of Resident #39's care plan last reviewed 05/27/2025 indicated he had an indwelling foley catheter. Resident #39's goal was for him to show no signs and symptoms of a urinary infection and remain free from catheter related trauma through the next review date. Resident #39's interventions included to ensure the tubing was anchored to his leg or linens so that the tubing was not pulling on the urethra (tube connects the urinary bladder to the external opening of the body). During an observation and interview on 05/27/2025 at 9:58 AM, Resident #39 was in his wheelchair in his room. Resident #39 showed surveyor his foley catheter was not secured to his leg. Resident #39 said it had been unsecured for days. Resident #39 said he had reported it to the staff, but they still had not fixed it. During an interview on 05/28/2025 at 8:39 AM, LVN C said she did not know why Resident #39's foley catheter was not secured. LVN C said the catheters are checked daily by the nurses to ensure they were secured. LVN C said if the catheter was not secured it could cause trauma to the urethra, the catheter could dislodge causing trauma, and the catheter could cause sores from it rubbing the penis. During an interview on 05/29/2025 at 10:08 AM, the DON said the nurses, CNAs, and anybody giving care to the residents should be checking to ensure the foley catheters were secured. The DON said she had not noticed any issues with the foley catheters not being secured, and the nurses should be doing rounds to ensure they had the catheters secured. The DON said it was important for the foley catheters to be secured because they did not want them to pull it out and hurt their urethra. During an interview on 05/29/2025 at 10:40 AM, the Administrator said Resident #39 should have an order for his foley catheter to be secured to his leg, and the nurse was responsible for ensuring it was secured. The Administrator said it was important for the foley catheter to be secured to keep it flowing correctly and where it needed to be, so it was not tugging. Record review of the facility's undated policy titled, Catheter Care, indicated, Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Keep tubing off floor and minimize friction or movement at insertion site. The policy did not further address securement of the foley catheter.

Based on interviews and record review the facility failed to coordinate assessments with the PASRR program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 5 residents (Resident #34) reviewed for PASRR. The facility failed to coordinate quarterly PASRR IDT meetings to discuss specialized services with the PASRR Coordinator for Resident #34. This failure could place residents with positive PASRR status at risk of not receiving specialized services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being. Findings included: Record review of Resident #34's face sheet dated 05/29/2025 indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included schizoaffective disorder (mood disorder that can include depression, delusions, hallucinations, disorganized thoughts, speech and behavior) and major depressive disorder, recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks). Record review of Resident #34's Comprehensive MDS assessment dated [DATE] indicated Resident #34 understood others and was understood. The MDS assessment indicated Resident #34 was considered by the state level II PASRR process to have serious mental illness. The MDS assessment indicated Resident #34 had a BIMS score of 14, which indicated his cognition was intact. Record review of Resident #34's care plan reviewed 05/27/2025 indicated, he had mental illness and was PASRR positive. Resident #34's goal indicated he would have the specialized services recommended by the local authority per PASRR specialized services program as needed. Resident #34's interventions indicated the local authority would be invited annually to the care plan meeting for review of specialized services. Record review of Resident #34's PASRR Level 1 Screening completed 05/17/2024 indicated there was evidence or an indicator that he had a mental illness. Record review of Resident #34's PASRR Evaluation dated 05/20/2024 indicated based on the Qualified Mental Health Professional Assessment Resident #34 met the PASRR definition of mental illness. The recommended services were not listed. Record review of Resident #34's PCSP Forms indicated the following meetings: On 06/10/2024, an initial IDT meeting was held. The PCSP Form indicated the following specialized services psychosocial rehabilitative services group and individual and routine case management. On 02/17/2025, a quarterly meeting was held. The PCSP Form indicated the following specialized services were ongoing psychosocial rehabilitative services group and individual and routine case management. This indicated the facility did not conduct IDT meetings quarterly. During an interview on 05/28/2025 at 2:07 PM, the MDS Coordinator said Resident #34's PASRR IDT meetings were not completed quarterly because his Medicaid had lapsed, and he did not qualify for services. During an interview on 05/28/2025 at 3:45 PM, PASRR Coordinator E said the MDS Coordinator had called her earlier today (05/28/2025) to schedule Resident #34's PASRR IDT meeting. PASRR Coordinator E said the MDS Coordinator told her some of his IDT meetings had been missed because there had been a gap in Resident #34's Medicaid. PASRR Coordinator E said when a resident lost Medicaid and then regained it an IDT meeting should be conducted when they regained their Medicaid. PASRR Coordinator E said IDT meetings should be conducted quarterly, and the facility reached out to coordinate them. During an interview on 05/29/2025 at 8:57 AM, the BOM said Resident #34 had a lapse in his Medicaid between 02/01/2024-07/31/2024, and his Medicaid had picked back up again on 08/01/2024. During an interview on 05/29/2025 at 9:06 AM, the MDS Coordinator said she was responsible for coordinating PASRR services and ensuring the quarterly IDT meetings with PASRR were conducted. The MDS Coordinator said Resident #34's IDT meetings with PASRR should be done quarterly. The MDS Coordinator said they were not scheduled quarterly because his Medicaid had lapsed, and if the residents did not have Medicaid the meetings could not be done. The MDS Coordinator said she was not aware Resident #34's PASRR IDT meetings were not completed quarterly. The MDS Coordinator said Resident #34 did not miss any of his specialized services. The MDS Coordinator said it was important PASRR IDT meetings to be conducted for the residents to have the best outcome they could have while they were at the facility. During an interview on 05/29/2025 at 10:44 AM, the Administrator said he expected for residents who qualified for PASRR services to have quarterly IDT meetings completed. The Administrator said the MDS Coordinator was responsible for coordinating with the PASRR coordinators. The Administrator said it was important for the residents to have quarterly PASRR IDT meetings to update their condition at the facility and ensure they qualified for services. Record review of the facility's policy titled, Preadmission Screening and Resident Review (PASRR) Survey Requirements 12/4/14 Provider Letter 14-21, did not address the frequency of the PASRR IDT meetings.

Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 16 residents (Resident #17) reviewed for grievances. The facility did not ensure a grievance was filed and Resident #17 was appropriately apprised of progress toward a resolution when Resident #17 reported to the Administrator that she was missing her $250 from her room on 1/31/25. This failure could place residents at risk for a decreased quality of life, and grievances not being addressed or resolved promptly. Findings included: Record review of Resident #17's face sheet dated 05/29/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with diagnoses of high blood pressure, chronic obstructive pulmonary disease (a disease in which the pulmonary system has limited airflow), anxiety, and congestive heart failure. Record review of Resident #17's quarterly MDS dated [DATE] indicated she made herself understood and was able to understand others. The MDS also indicated she had a BIMS score of 15 which meant she was cognitively intact. Record review of Resident #17's care plan dated 05/19/25 indicated she required supervision with ADLs. The care plan also indicated she made negative statements about staff and false allegations with interventions for the social worker and staff to listen to her concerns and encourage resident to attend activities to occupy her mind. Record review of the facility grievances dated 11/01/24-05/27/25 indicated there was not a grievance filed for Resident #17 on 01/31/25. During an interview on 05/28/25 at 10:10 AM Resident #17 said she told the facility Administrator she was missing the $250 and she did not feel the facility believed her. Resident #17 said someone had just taken it from her wallet in her room. Resident #17 said she usually kept a percentage of her money in her wallet and now the facility has given her a lock box to keep her money in for it to be safe. Resident #17 said she was keeping a percentage of the money she was getting from the facility and was saving it to get her some new clothes. Resident #17 said she had not had any more issues with her money coming up missing since the incident. She said the facility staff looked everywhere for the money, but it was not found . During an interview on 05/29/25 at 09:41 AM the Social Worker said she did not handle the missing money for Resident #17 because it was out of her scope with the amount of money. The Social Worker said grievance forms should have been filled out when the incident was reported in order for the staff to follow up with the issues noted. She said without the form others would not be aware of what had happened with Resident #17's missing money but it was not a grievance she completed. The Social Worker said the failure placed risk for staff not knowing if this was a reoccurring incident. She said Resident #17 has had issues with having false allegations. The Social Worker said Resident #17 gets money monthly, but she buys snacks and other things. During an interview on 05/29/25 at 09:51 AM the DON said all the Administrator did, related to Resident #17 was to let her know that Resident #17 was missing the money, and the administrator called the police. She said Resident #17 talked to the police and the officer asked her about pressing charges and Resident #17 said no. The DON said they normally would not fill out a grievance since it was reported to the state and the facility provided Resident #17 a lock box for the future since she carries her own money. During an interview on 05/29/25 at 10:20 AM Administrator said Resident #17 came to him and told him she was missing her money. The Administrator said she told him she was saving the money for clothing. He said he called the police, and Resident #17 did not want to press charges. The Administrator said he talked to the staff to see if any were aware of the missing money. He said he could not determine if she had that much money or not. The Administrator said after the incident the facility got her a lock box to place in her room. The Administrator said the facility did typically complete the grievance forms for the missing money and the importance was to ensure the resident needs were being met. He said the failure placed risk for others not knowing if an incident even occurred or resolved. Record review of the facility policy Resident Rights dated 11/28/2016 indicated: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy .Grievances. 1. The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination .4. The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding residents' rights contained in this paragraph. Upon request the provider must give a copy of the grievance policy to the resident .e. Ensuring that all written grievance decision include the date the grievance was received, a summary of thee statement of the resident's grievance, the steps taken to investigate the grievance and the summary of pertinent findings or conclusions .

Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine dental services to meet the needs of 3 of 17 (Resident #12, Resident #26, and Resident #47) residents reviewed for dental services. The facility did not assist Resident #12 with obtaining dental services when she had broken and missing teeth. The facility failed to ensure Resident #26 received dental services when she had severe cavities and oral pain. The facility failed to ensure Resident #47 received dental services when she had missing teeth, broken teeth, and oral pain. This failure could place residents at risk of not having their oral health care needs met and oral pain while chewing. Findings included: 1. Record review of the consolidated physician orders dated 02/16/23 indicated Resident #12 was a [AGE] year-old female that was admitted to the facility on [DATE] and had a diagnoses of Schizophrenia (disorder that affects a person's ability to think, feel and behave clearly), Asthma (inflamed airways that make it difficult to breath) and HTN (force of blood against the artery walls is too high). Record review of the Comprehensive MDS dated [DATE] indicated Resident #12 usually made herself understood and usually understands. Resident #12's BIMS score was a 7 indicating severe impairment. The MDS indicated Resident #12 was on a mechanically altered diet. The MDS indicated no issues with swallowing or dental status. The MDS indicated no weight loss of 5% over the last 6 months. Record review of Resident #12's order summary dated 07/28/22 indicated a regular diet with soft and bite-size food (Level 6 texture). The order summary indicated dental care as needed. The order summary indicated Tylenol #3 300-30mg q6h prn for arthopathy and Tylenol 325mg q4h PRN. Record review of Resident #12's care plan dated 07/03/22 indicated a potential nutritional problem related to new admit. Interventions included for the Dietary manager to discuss food preferences with the resident and family upon admission to meet dietary needs. Record review of Resident #12's oral and dental status assessment completed on 07/04/22 indicated Resident #12 did not have any upper teeth and broken teeth on the bottom. During an observation and interview on 2/15/23 at 3:00 p.m., Resident #12's teeth were broken, missing and discolored. Resident #12 stated her teeth hurt when she chewed and she, almost choked on broccoli the other day because she was not able to chew properly. Resident #12 stated she had reported her teeth hurting to staff but was unable to verbalize which staff members or when. During an interview on 02/14/23 at 10:01a.m., family member stated she had reported to facility staff when Resident #12 was admitted on [DATE] that resident had issues with dental. Family member stated she also notified the Administrator again in January 2023 that Resident #12 needed a dental evaluation. During an interview on 02/15/23 at 8:00 a.m., the Administrator stated, I was not aware of Resident #12 having any dental issues. The Administrator stated she did not remember Resident #12's family member had reported a dental issue to her. The Administrator stated all dental request were referred to Health drive and she was responsible for completing the referrals because the facility did not have a social worker. During an interview on 02/15/2023 at 8:38 a.m., the Customer Care Rep at Health drive denied having a dental referral for Resident #12. During an interview on 02/15/23 at 4:20 p.m., CNA F stated Resident #12's family member made weekly visits to the facility. CNA F stated she was aware that Resident #12 was complaining of tooth pain and needing a dental eval. CNA F stated she did not report it to the Administrator because the family member told her she had already reported the dental pain to the Administrator and the facility should be taking care of it. During an interview on 02/15/23 at 11:14 a.m., the MDS nurse stated she completed Resident #12's MDS and indicated on the MDS Resident #12 did not have any dental issues. The MDS nurse stated she was not aware of the oral and dental assessment found in Resident #12's chart that indicated dental issues and that was not where she looked when she filled out the MDS. The MDS nurse stated she only looked at the nursing assessment that was completed on admit to help with filling out the MDS. The MDS nurse reported she completed her own assessment on Resident #12 for the MDS and, she might have marked no dental issues on the MDS because Resident #12 would not let her look at her teeth. The MDS nurse stated she was responsible for filling out the MDS correctly and not indicating dental issues on the MDS, or tooth pain could result in distress to the patient. During an interview on 02/16/23 at 3:30 p.m., the DON stated all referrals for podiatry, dental and vision were sent to Health drive. The DON stated the Administrator was responsible for making Resident #12's dental referral and appointment. The DON stated she was not aware that Resident #12 needed a dental evaluation and Resident #12's family had never notified her of the dental issue. The DON stated Resident #12 should have been assessed upon admission for dental issues and staff should have been working as a team to monitor Resident #12 for dental issues. The DON stated the MDS nurse was responsible for making sure the MDS was filled out correctly. The DON stated she was responsible for looking over the MDS and making sure it was correct. The DON stated not getting dental care could make Resident #12 feel bad due to pain. During an interview on 02/16/23 at 3:44 p.m., the Administrator stated she had been at the facility since October 2022, and she was responsible for getting the physician order and completing dental referrals. The Administrator stated if residents do not have the right Medicaid and cannot afford dental, then she was responsible for looking for other pay alternatives. The Administrator stated she expected staff to report any dental issues to her. The Administrator reported she does not follow up on the dental referrals once she sends them to Health Drive and the only way she would know if it was not completed would be if someone complains again. The Administrator reported she expected the MDS to be accurate and the MDS nurse was responsible for making sure the MDS was correct. The Administrator stated the Corporate MDS team was responsible for making sure the MDS nurse filled out the MDS correctly. Record Review of the policy on Dental Services Revised on 12/2016 indicated routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Routine and 24-hour emergency dental services were provided to residents via contract agreement with a licensed dentist that came to the facility monthly. Social services representatives assisted residents with appointments, transportation arrangements and reimbursement of dental services under the state plan. 2. Record review of Resident #26's face sheet dated 02/16/2023 indicated, Resident #26 was readmitted on [DATE] with diagnoses of Parkinson's disease (brain disorder that causes unintended or uncontrollable movements), schizoaffective disorder, bipolar type (mood disorder characterized by abnormal thought processes and unstable mood), and type 2 diabetes mellitus with other diabetic neurological complication (high blood glucose levels with nerve damage). Record review of Resident #26's comprehensive MDS assessment with an assessment reference date of 11/27/2022 indicated, Resident #26 was usually understood and usually understood others. The MDS assessment indicated Resident #26 had a BIMS score of 13, indicating her cognition was intact. The MDS assessment indicated Resident #26 required limited assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and supervision for eating. Resident #26's MDS assessment indicated she did not have broken or loosely fitting full or partial denture, no natural teeth or tooth fragments, abnormal mouth tissue obvious or likely cavity or broken natural teeth, inflamed or bleeding gums or loose natural teeth, mouth or facial pain, discomfort, or difficulty with chewing. Record review of Resident #26's Order Summary Report dated 02/16/2023 indicated physician's orders for dental care PRN (as needed) with start date of 03/09/2020 and amoxicillin oral capsule 500 mg give 1 capsule by mouth every 8 hours for tooth abscess for 10 days until finished with start date of 02/11/2023. Record review of Resident #26's care plan with target date of 12/17/2022 did not reveal Resident #26's dental problems. During an observation and interview on 02/15/23 at 8:13 AM, Resident #26 stated in the past maybe the year before last she had her upper teeth in the back one on the right and one on the left side smoothed down because they were cavities. Resident #26 stated her other teeth were now being affected because she needs those 2 teeth pulled out and had not been able to see the dentist. Resident #26 stated her Medicaid did not pay for dental and she did not have money to pay the dentist. Resident #26 stated she had told the nurses her teeth were causing her pain and they needed to be taken out. Resident #26 stated one of the facility staff was supposed to refer her to a dentist that would take her Medicaid, but she had not heard back from them. Resident #26 was unable to recall who the staff member was. Resident #26 stated about a week ago she got an abscess on her left side related to her teeth and the facility physician order antibiotics for this. Observation of Resident #26's teeth indicated 2 upper teeth in the back one on the right and one on the left side were jagged and black with the left side having [NAME]/corrosion than the right. Resident #26 stated the pain was worse throughout the day and when she ate food. Resident #26 stated she had tramadol for chronic pain, and this helped with her teeth pain as well. Resident #26 stated sometimes she could not sleep related to the pain to her teeth, but that her pain had improved since starting the antibiotics. During the interview Resident #26 was calm and did not display any non-verbal signs and symptoms of severe pain. During an interview on 02/15/2023 at 8:38 AM, the customer service representative with Health Drive stated Resident #26 was referred in November of 2022, but her Medicaid did not cover dental services. During an interview on 02/15/2023 at 8:46 AM, the administrator stated she would have to ask the nurses what they do if a resident is having dental pain if they send to the ER or what. The administrator stated the social worker was responsible for referring the residents for dental services, but there was currently no social worker. The administrator stated currently she was making referrals for dental services. The administrator stated the nurses reported to her and she would fill out the form for Health Drive, then give it back to the nurses to get the doctors signature and then fax it back to Health Drive. The administrator stated if Health Drive would not see the residents because they had Medicaid, they would try to reach a dentist that does take their insurance. During an interview on 02/16/2023 at 6:24 PM, LVN A stated prior to last week on Wednesday (02/08/2023) or Thursday (02/09/2023), when Resident #26 asked her for pain medication for pain to her teeth, she was not aware of Resident #26 having dental issues. LVN A stated she was aware of Resident #26 having some swelling to the left side of her face and was started on antibiotics for an abscess on 02/11/2023, but she did not look at Resident #26's teeth to see what was going on. LVN A stated she should have looked at Resident #26's teeth. LVN A stated she did not know if Resident #26 had been referred to dental services. LVN A stated if a resident needed to be referred for dental services the nurses should notify the DON. LVN A stated she should have checked with the DON to see if any of the other nurses had notified her Resident #26 needed to be referred for dental services. LVN A stated she had not notified the DON of Resident #26 needing dental services because everybody knew about her teeth hurting. LVN A stated it was important for Resident #26 to be referred for dental services because of the tooth pain and she could have more infections. During an interview on 02/16/2023 at 7:12 PM, the ADON stated she did not know how a resident would be referred to the dentist. The ADON stated the social worker was responsible for making referrals for dental services, but the facility currently did not have social worker. The ADON stated, Right now we are all the social worker. The ADON stated in the past Resident #26 had asked to be referred for dental services, but she was not sure about this. The ADON stated Resident #26 should be referred for dental services, and it was important for her to receive dental services because she could get another infection. During an interview on 02/16/2023 at 8:05 PM, the DON stated if a resident needed to go to the dentist the facility had Health Drive that came to the facility. The DON stated she was not aware that Resident #26 needed to be referred for dental services. The DON stated the social worker was the one who did the referrals but with no social worker the facility staff tried to work as a team to make sure the resident received what they needed. The DON stated none of the nurses had told her Resident #26 was on antibiotics for a tooth abscess. The DON stated it was important for residents to be referred for dental services to help maintain their health. During an interview on 02/16/2023 at 8:59 PM, the administrator stated nobody had told her Resident #26 was having oral pain and needed to be referred for dental services. The administrator stated it was important for the residents to receive dental services for their quality of life and self-esteem. 3. Record review of Resident #47's face sheet, dated 02/16/2023, revealed Resident #47 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease, COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and acquired absence of left leg below knee (left leg amputation below the knee). Record review of Resident #47's order summary report, dated 02/16/2023, revealed an order which started on 09/19/2022, for dental care as needed. Record review of the comprehensive MDS assessment, dated 10/02/2022, revealed Resident #47 had clear speech and was understood by staff. The MDS revealed Resident #47 was able to understand others. The MDS revealed Resident #47 had a BIMS score of 15 which indicated no cognitive impairment. The MDS revealed Resident #47 had no obvious or likely cavity or broken natural teeth. The MDS revealed no significant weight loss. Record review of the medication administration record, dated February 2023, revealed no pain medications were given for complaints of dental pain. The MAR further revealed tramadol (pain medication) 50 mg was given several days for complaints of wrist pain, leg pain, or back pain. Record review of the comprehensive care plan, last revised on 9/24/2022, revealed no plan of care for oral or dental status. Record review of the admit or readmit screener assessment - section D, dated 09/20/2022 revealed Resident #47 had broken and carious teeth. Record review of the oral or dental status assessment, dated 09/19/2022, revealed Resident #47 had missing teeth. During an observation and interview on 02/15/2023 at 8:11 AM, Resident #47 stated she was having pain to her lower jaw in the back on the right side. Resident #47 stated the pain was 9 out of 10 on the pain scale during the last month. Resident #47 stated the pain was worse during meals when she was eating. Resident #47 was smiling with no facial grimacing observed. Resident #47 was working on her small gem puzzle during the interview. Resident #47 had missing teeth and inflamed gums. Resident #47's natural teeth were black with obvious cavities. Resident #47 had a split tooth to her lower jaw in the back on the right side that was rubbing on her tongue. Resident #47 stated she told the DON about her dental pain approximately 1 month ago. Resident #47 stated the DON told her she would see about the dentist. Resident #47 stated she had not been told anything else regarding a dental appointment. During an interview on 02/15/2023 at 8:24 AM, the DON stated the facility did not have a current social worker. The DON stated the facility used a mobile dental program for residents to receive dental services. The DON stated the administrator had been setting up the appointments through the mobile dental program. The DON stated when a referral was made, the mobile dental program had to run the residents funding. The DON stated if the resident was not eligible to receive services, then the facility looked for other dentists. The DON stated Resident #47 had not reported dental pain. During an interview on 2/15/2023 at 8:38 AM, a Customer Care Representative from the mobile dental program stated no referral had been made for Resident #47. During an interview on 02/16/2023 at 3:26 PM, CNA U stated Resident #47 had not complained of dental pain. CNA U stated Resident #47 did not ask for assistance with oral hygiene and was independent with ADLs. CNA U stated she was unaware of the oral status of Resident #47. CNA U stated broken teeth, missing teeth, and dental caries could have caused pain and illness to residents if not addressed. During an interview on 02/16/2023 at 5:20 PM, LVN T stated Resident #47 had not complained of dental pain. LVN T stated she was aware Resident #47 had broken and missing teeth and obvious dental caries. LVN T stated broken teeth, missing teeth, and dental caries could have caused pain to residents if not addressed. During an interview on 02/16/2023 at 6:14 PM, the DON stated she was not aware of Resident #47's dental pain. The DON stated she was unsure of Resident #47's dental status. The DON stated the MDS assessment should have accurately reflected Resident #47's oral or dental status so interventions could have been implemented to prevent Resident #47 from having oral or dental pain. During an interview on 02/16/2023 at 6:45 PM, the ADM stated she was unaware of Resident #47's dental pain. The ADM stated she expected nursing staff to adequately assess and monitor residents' oral or dental status. The ADM stated it was important to adequately assess and monitor residents' oral status to ensure a baseline is obtained and to prevent oral decline. Record review of the policy titled Dental Services, revised on 12/2016, indicated Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Routine and 24-hour emergency dental services are provided to our residents through a. A contract agreement with a licensed dentist that comes to the facility monthly; b. referral to the resident's personal dentist; c. Referral to community dentist; or d. Referral to other health care organizations that provide dental services . Social services representatives will assist residents with appointments, transportation arrangements and for reimbursement of dental services under the state plan, if eligible .

Based on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 3 of 7 residents (Resident #1, #2 & #6 reviewed for pharmacy services. The facility did not develop and implement medication administration procedures to prevent an adverse medication reaction. The facility had a 4-hour window of 6:00 p.m. to 10:00 p.m. for giving bedtime medication. MA A administered bedtime medication and other scheduled medication of [MEDICATION(S)] 0.5 mg, [MEDICATION(S)] Sprinkles 125 mg, [MEDICATION(S)] 10 mg, [MEDICATION(S)] 15 mg, [MEDICATION(S)] 1 mg, and Tylenol #4 with [MEDICATION(S)] 300/60 mg to Resident #1 at the same time causing him to become lethargic (state of having severe drowsiness or sleepy) and having to be admitted into the hospital. An Immediate Jeopardy was identified on 08/09/21. While the Immediate Jeopardy was removed on 08/10/21, the facility remained out of compliance at a scope of a isolation and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. The facility did not give Resident #s 2 and 6 medications as ordered at bedtime. The medications were given during a 4-hour window of 6:00 p.m. to 10:00 p.m. This failure could place residents requiring assistance with medication administration at risk for adverse effects, death, overdose and decline in health and for medications to not be administered as ordered. The findings included: 1. Review of Resident #1's Admission Record indicated an admitted [DATE] and an initial admitted [DATE].It also indicated he was discharged to the hospital on 7/15/2021 at 6:00 p.m. Resident #1 had not been readmitted back to the facility during the survey. Review of Resident #1's July 2021 physician order indicted he was [AGE] years old with diagnoses of [CONDITION(S)], anxiety disorder, paranoid [CONDITION(S)], acute kidney failure, [CONDITION(S)] disorder, current episodes of depression, moderate down syndrome, and cognitive communication deficit. The orders also indicated that he was to be administered [MEDICATION(S)](benzodiazepine used to treat anxiety) 0.5 mg at bedtime for anxiety disorder, [MEDICATION(S)] Sprinkles capsules delayed release sprinkle ([CONDITION(S)] medication) 125 mg at bedtime for [CONDITION(S)] disorder, and depression, [MEDICATION(S)] HCL 10 mg tablet twice a day for [CONDITION(S)] disorder, depression, anxiety and paranoid [CONDITION(S)], [MEDICATION(S)] ( benzodiazepine/sedative/hypnotic used to treat difficulty sleeping) 15 mg at bedtime for [CONDITION(S)] (difficulty sleeping), [MEDICATION(S)] (antipsychotic medication used to treat [CONDITION(S)], [CONDITION(S)] and depression) 1 mg at bedtime for paranoid [CONDITION(S)], and Tylenol with [MEDICATION(S)] #4 (Opioid) tablet 300/60 mg at bedtime for pain. Review of Resident #1's MDS dated [DATE] indicated his cognitive skills for daily decision making was severely impaired, no altered level of consciousness, and the only behavior exhibited was wandering. Review of Resident #1's care plan with a revision date of 6/23/2021 indicated medications were to be administered as ordered by the physician. Review of the MAR from 7/1/2021 - 7/31/2021 indicated Resident #1 received [MEDICATION(S)] Sprinkles 125 mg at bedtime, Tylenol [MEDICATION(S)] #4 tablet 300/60 mg at bedtime, and [MEDICATION(S)] 1 mg at bedtime and the administration time documented on the MAR was 8:00 p.m., and to administer [MEDICATION(S)] 0.5 mg at bedtime, and [MEDICATION(S)] 15 mg at bedtime and the administration time documented on the MAR was 6:00 p.m. - 10:00 p.m. MA A initialed on the MAR that she administered the medication to Resident #1 on 7/15/2021. The MAR also indicated the start date for [MEDICATION(S)] was 7/1/2021, [MEDICATION(S)]'s start date was 6/8/2021, [MEDICATION(S)]'s start date was 6/7/2021, [MEDICATION(S)]'s start date was 6/7/2021, and [MEDICATION(S)]'s start date was 6/8/2021. Review of Resident #1's Nurse's Note dated 7/15/2021 and timed 6:45 p.m. indicated at about 5:45 p.m. resident returned from dinner the nurse noted a change in condition blood pressure was 80/41 (blood pressure lower than 90/60 is considered low blood pressure), respirations was 9 (normal rate is 12-16), DON was notified and came to residents' room immediately with the crash cart. The nursing note indicated the resident was not responding to verbal stimuli, he was withdrawn from pain reflex and sternal rub and 911 was called. Nursing notes further indicated that 911 arrived at the facility at 6:15 p.m. to take the resident to the hospital. Review of Resident #1's Hospital admission orders indicated he was admitted into the hospital on 7/15/2021. Review of a hospital History and Physical report dated 7/16/2021 indicated Resident #1's admitting diagnoses was acute dehydration, [CONDITION(S)], medication reaction, and altered mental status. The report indicated he was sent from a nursing facility for evaluation of altered mental status and lethargy. He was administered 1 dose of [MEDICATION(S)] (medication used to reverse benzodiazepine overdose) and [MEDICATION(S)] (medicine that rapidly reverses an opioid overdose) and after he was administered the medication his mental status somewhat improved and patient was more alert. He was hypotensive (low blood pressure) and was placed on [MEDICATION(S)] (a medication used to raise blood pressure in adult patients with severe, acute [CONDITION(S)]). During an interview on 7/21/2021 at 1:21 p.m., MA A said on 7/15/2021 around 5:30 p.m. she administered Resident #1 his [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and Tylenol #4 with [MEDICATION(S)] while he was in the dining room eating dinner. She said shortly after she administered Resident #1 his medications, she observed the DON go down the hall with the crash cart for Resident #1. She said she had been a MA for about a month and was concerned she caused something to happen since she had administered Resident #1 his medications shortly before he became ill. During an interview on 7/21/2021 at 4:11 p.m., the DON said the medication times on the MAR need to be clarified for Resident #1. When asked if she thought the current medication times on Resident #1's MAR had the potential to cause him to be overdosed she said Yes. When the DON was asked if she has done anything to the MAR to correct the potential problem since the incident occurred with Resident #1 on 7/15/21, she said No. The DON said the physicians selected the frequency the medication was administered, but the facility selected the actual times on the MAR the medication was administered. She also stated that the facility has currently not done anything to correct the problem and she planned on discussing it with the pharmacy consultant on 7/23/2021. On 7/21/21 at 4:52 p.m. an attempt was made to contact Resident #1's physician. A message was left for the physician to call back. The investigator was not able to contact the physician during the surveyor. During an interview on 7/26/2021 at 2:13 p.m., the pharmacist reviewed Resident #1's medication in their computer system and said bedtime medication should be administered at 8:00 p.m. and not in the evening at 5:00 p.m. or 6:00 p.m. She also said Resident #1 should not have been administered the Tylenol #4 with [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] Sprinkles together at the same times because they all have the same side effects which are drowsiness, lethargy, and respiratory depression. Non-IJ 2. Review of Resident #2's July 2021 Order Summary Report indicated she was [AGE] year-old with diagnoses of [CONDITION(S)], unspecified [CONDITION(S)], [CONDITION(S)] Disorder, major depression, [CONDITION(S)], anxiety disorder, and dementia without disturbances disorder. It was also indicated she was ordered [MEDICATION(S)] 40 mg at bedtime. Review of Resident #2's MDS dated [DATE] indicated her cognitive skills for daily decision making was severely impaired. Review of Resident #2's care plan with revision date of 3/05/2021 indicated medications were to be administered as ordered. Review of Resident #2's MAR indicated [MEDICATION(S)] 40 mg was to be administered at bedtime and the administration time on the MAR was 6:00 p.m. - 10:00 p.m. 3. Review of Resident #6's July 2021 Order Summary Report indicated he was [AGE] years old with diagnoses of [CONDITION(S)], psychotic disorder with delusions due to unknown physiological condition, hypertension, [CONDITION(S)], major depression, [CONDITION(S)] disorder, [CONDITION(S)], anxiety disorder, and muscle weakness. The order also indicated to administer [MEDICATION(S)] 10 mg, [MEDICATION(S)] Sprinkles 125 mg, [MEDICATION(S)] HCL 50 mg, and [MEDICATION(S)] 75 mg at bedtime. Resident #6's MDS dated [DATE] indicated his cognitive skills for daily decision making was severely impaired, no behavioral symptoms were identified. Review of Resident #6's care plan with revision date of 4/16/2021 indicated a care plan to administer medications as ordered. Review of Resident #6's MAR indicated [MEDICATION(S)] 10, [MEDICATION(S)] Sprinkles 125 mg, [MEDICATION(S)] HCL 50 mg, and [MEDICATION(S)] 7.5 mg to be administered at bedtime and the administration time on MAR was 6:00 p.m. - 10:00 pm. During an interview on 7/21/2021 at 1:21 p.m., MA A said on 7/15/2021 around 5:30 p.m. she administered bedtime medications and other routine medications to Resident #2 and #6. During an interview on 7/21/2021 at 2:08 p.m. RN B stated that they have a 4-hour window for the medications on the MAR that is timed 6:00 p.m. - 10:00 p.m. She stated that if a medication was ordered for bedtime it should be administered at 8:00 p.m. - 9:00 p.m. and not before. During an interview with RN C on 7/21/2021 at 5:00 p.m. she stated the medication time ranges on the facilities MAR has the potential to cause medication errors because it gives ranges and not specific times for certain scheduled medications to be administered even if the physician has it ordered specifically for bedtime. She said that bedtime in the facility is between 8:00 pm. - 9:00 p.m. and not earlier and it should be reflected as such on the MAR. Record review of the facility policy titled, Medication Administration, dated 2/17/2020 indicated it is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. After administrative review, an Immediate Jeopardy was identified on 08/09/21 and the surveyor re-entered the facility. The Administrator was notified of the Immediate Jeopardy on 08/09/21 at 12:20 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 08/09/21 at 6:37 p.m. and reflected the following: 1. Resident's current medications were reviewed by the DON. 2. Medication Aide A educated regarding medication administration. DON began providing re-education to medication aides and licensed nurses about the Medication Administration Policy and Procedure. 3. An audit was conducted by the DON/designee to identify other residents who could potentially be affected by having their medications administered during the 6:00 p.m. - 10:00 p.m. timeframe. Facility changed to standard medication times avoiding concurrent use of anxiolytics, psychotropics, and sleep aides. Nursing staff in-serviced on new medication pass procedures. 4. Facility implemented a medication administration procedure to prevent an adverse medication reaction. Adding to every order, not to administer this medication simultaneously. 5. Facility reviewed resident's medications for the same drug classifications with common side effects that were given at the same time. MD notified. 6. On 07/28/21 the Administrator held an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting with the Performance Improvement Team to review the pharmacy services and the Performance Improvement Measures outlined in this document. The committee reviewed results of the audits and appropriate corrective measures were put in place. DON/designee will report findings of audits in the monthly QAPI meeting. Committee will continue with the performance improvement audits for monitoring of compliance and report on the next meeting monthly for three months or until compliance is achieved as determined by the committee. The plan will be updated, reviewed, and revised as needed monthly in the QAPI meeting. Monitoring of the facility's Plan of Removal included the following: Observations, interviews, and record reviews were conducted on 08/10/21 starting at 9:35 a.m. and continued through 08/10/21 at 4:30 p.m. with nine staff members from various shifts. The in-services included the removal of 4-hour time frames for medication administration, medication administration was changed to standard times, and in-services to ensure staff did not administer anti-anxiety, pain, sleep, and [CONDITION(S)] medications at the same time. Observations of medication administration revealed facility staff administered medications at the appropriate time without concurrent administration of medications for anxiety, pain, sleep, and psychotropics. Record reviews revealed residents no longer had orders to administer medications for anxiety, pain, sleep, and psychotropics at the same time. The medication times for residents were changed to standard medication times. The staff members were able to: Administer medications at the appropriate time and without concurrent administration of medications for anxiety, pain, sleep, and psychotropics. Verbalize their understanding of the in-services related to the plan of removal which included new medication administration times and orders not to administer medications for anxiety, pain, sleep, and psychotropics together. Interviewed staff members on 8/10/2021 at the following times: MA A was interviewed at 1:00 p.m. RN B was interviewed at 1:40 p.m. MA F was interviewed at 1:05 p.m. MA G was interviewed at 10:10 a.m. LVN H was interviewed at 10:35 a.m. MA I was interviewed at 11:25 a.m. MA K was interviewed at 2:50 p.m. LVN L was interviewed at 3:05 p.m. An interview with the DON on 08/10/21 at 2:10 p.m. revealed that going forward, she/designee would be responsible for ensuring medications were passed at the time they were ordered, and the monitoring would last for 3 months. The DON said she/designee would be responsible for the pharmacy review of medications to ensure anxiolytics, psychotropics, pain meds, and sleep aides were not ordered to be administered at the same time. The DON also said residents would not have 4-hour time windows for medication administration. An interview with the Administrator at 08/10/21 at 3:20 p.m. revealed that going forward, the DON/ADON would be responsible for ensuring medications were passed at the time they were ordered, and the monitoring would last for 3 months. The DON/ADON would be responsible for the pharmacy review of medications to ensure anxiolytics, psychotropics, pain meds, and sleep aides were not ordered to be administered at the same time. An interview with the ADON on 08/10/21 at 3:25 p.m. revealed that going forward, she/DON would be responsible for ensuring medications were passed at the time they were ordered, and the monitoring would last for 3 months. The ADON said she/DON would be responsible for the pharmacy review of medications to ensure anxiolytics, psychotropics, pain meds, and sleep aides were not ordered to be administered at the same time. An interview with the Corporate Nurse on 08/10/21 at 3:50 p.m. revealed that going forward the DON/ADON would be responsible for ensuring medications were passed at the time they were ordered, and the monitoring would last for 3 months. The Corporate Nurse said the DON/ADON would be responsible for the pharmacy review of medications to ensure anxiolytics, psychotropics, pain meds, and sleep aides were not ordered to be administered at the same time. The Corporate Nurse also said residents would not have 4-hour time windows for medication administration. An Immediate Jeopardy/Immediate Threat was identified on 08/09/21. While the Immediate Jeopardy was removed on 08/10/21, the facility remained out of compliance at a scope of a pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. The facility was provided the Immediate Jeopardy template on 08/09/21.

Based on interview and record review the facility failed to ensure residents were free from significant medication error for 1 of 7 residents (Resident #1) reviewed for medication administration. The facility did not administrator medications to Resident # 1 to prevent an adverse medication reaction. MA A administered bedtime medication and other scheduled medication of [MEDICATION(S)] 0.5 mg, [MEDICATION(S)] Sprinkles 125 mg, [MEDICATION(S)] 10 mg, [MEDICATION(S)] 15 mg, [MEDICATION(S)] 1 mg, and Tylenol #4 with [MEDICATION(S)] 300/60 mg to Resident #1 at the same time causing him to become lethargic (state of having severe drowsiness or sleepy) and having to be admitted into the hospital. An Immediate Jeopardy was identified on 08/09/21. While the Immediate Jeopardy was removed on 08/10/21, the facility remained out of compliance at a scope of a isolation and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. This failure could place residents requiring assistance with medication administration at risk for adverse effects, death, overdose and decline in health and for medications to not be administered as ordered. Findings included: Review of Resident #1's Admission Record indicated an admitted [DATE] and an initial admitted [DATE].It also indicated he was discharged to the hospital on 7/15/2021 at 6:00 p.m. Resident #1 had not been readmitted back to the facility during the survey. Review of Resident #1's July 2021 physician order indicted he was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders also indicated that he was to be administered [MEDICATION(S)](benzodiazepine used to treat anxiety) 0.5 mg at bedtime for anxiety disorder, [MEDICATION(S)] Sprinkles capsules delayed release sprinkle ([CONDITION(S)] medication) 125 mg at bedtime for [CONDITION(S)] disorder, and depression, [MEDICATION(S)] HCL 10 mg tablet twice a day for [CONDITION(S)] disorder, depression, anxiety and paranoid [CONDITION(S)], [MEDICATION(S)] ( benzodiazepine/sedative/hypnotic used to treat difficulty sleeping) 15 mg at bedtime for [CONDITION(S)] (difficulty sleeping), [MEDICATION(S)] (antipsychotic medication used to treat [CONDITION(S)], [CONDITION(S)] and depression) 1 mg at bedtime for paranoid [CONDITION(S)], and Tylenol with [MEDICATION(S)] #4 (Opioid) tablet 300/60 mg at bedtime for pain. Review of Resident #1's MDS dated [DATE] indicated his cognitive skills for daily decision making was severely impaired, no altered level of consciousness, and the only behavior exhibited was wandering. Review of Resident #1's care plan with a revision date of 6/23/2021 indicated medications were to be administered as ordered by the physician. Review of the MAR from 7/1/2021 - 7/31/2021 indicated Resident #1 received [MEDICATION(S)] Sprinkles 125 mg at bedtime, Tylenol [MEDICATION(S)] #4 tablet 300/60 mg at bedtime, and [MEDICATION(S)] 1 mg at bedtime and the administration time documented on the MAR was 8:00 p.m., and to administer [MEDICATION(S)] 0.5 mg at bedtime, and [MEDICATION(S)] 15 mg at bedtime and the administration time documented on the MAR was 6:00 p.m. - 10:00 p.m. MA A initialed on the MAR that she administered the medication to Resident #1 on 7/15/2021. The MAR also indicated the start date for [MEDICATION(S)] was 7/1/2021, [MEDICATION(S)]'s start date was 6/8/2021, [MEDICATION(S)]'s start date was 6/7/2021, [MEDICATION(S)]'s start date was 6/7/2021, and [MEDICATION(S)]'s start date was 6/8/2021. Review of Resident #1's Nurse's Note dated 7/15/2021 and timed 6:45 p.m. indicated at about 5:45 p.m. resident returned from dinner the nurse noted a change in condition blood pressure was 80/41 (blood pressure lower than 90/60 is considered low blood pressure), respirations was 9 (normal rate is 12-16), DON was notified and came to residents' room immediately with the crash cart. The nursing note indicated the resident was not responding to verbal stimuli, he was withdrawn from pain reflex and sternal rub and 911 was called. Nursing notes further indicated that 911 arrived at the facility at 6:15 p.m. to take the resident to the hospital. Review of Resident #1's Hospital admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a hospital History and Physical report dated 7/16/2021 indicated Resident #1's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The report indicated he was sent from a nursing facility for evaluation of altered mental status and lethargy. He was administered 1 dose of [MEDICATION(S)] (medication used to reverse benzodiazepine overdose) and [MEDICATION(S)] (medicine that rapidly reverses an opioid overdose) and after he was administered the medication his mental status somewhat improved and patient was more alert. He was hypotensive (low blood pressure) and was placed on [MEDICATION(S)] (a medication used to raise blood pressure in adult patients with severe, acute [CONDITION(S)]). During an interview on 7/21/2021 at 1:21 p.m., MA A said on 7/15/2021 around 5:30 p.m. she administered Resident #1 his [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and Tylenol #4 with [MEDICATION(S)] while he was in the dining room eating dinner. She said shortly after she administered Resident #1 his medications, she observed the DON go down the hall with the crash cart for Resident #1. She said she had been a MA for about a month and was concerned she caused something to happen since she had administered Resident #1 his medications shortly before he became ill. During an interview on 7/21/2021 at 4:11 p.m., the DON said the medication times on the MAR need to be clarified for Resident #1. When asked if she thought the current medication times on Resident #1's MAR had the potential to cause him to be overdosed she said Yes. When the DON was asked if she has done anything to the MAR to correct the potential problem since the incident occurred with Resident #1 on 7/15/21, she said No. The DON said the physicians selected the frequency the medication was administered, but the facility selected the actual times on the MAR the medication was administered. She also stated that the facility has currently not done anything to correct the problem and she planned on discussing it with the pharmacy consultant on 7/23/2021. On 7/21/21 at 4:52 p.m. an attempt was made to contact Resident #1's physician. A message was left for the physician to call back. The investigator was not able to contact the physician during the surveyor. During an interview on 7/26/2021 at 2:13 p.m., the pharmacist reviewed Resident #1's medication in their computer system and said bedtime medication should be administered at 8:00 p.m. and not in the evening at 5:00 p.m. or 6:00 p.m. She also said Resident #1 should not have been administered the Tylenol #4 with [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] Sprinkles together at the same times because they all have the same side effects which are drowsiness, lethargy, and respiratory depression. The website https://medlineplus.gov/druginfo/meds/a 5.html regarding Tylenol #4 assessed 07/26/2021 indicated taking certain medications during your treatment with acetaminophen and [MEDICATION(S)] such as [MEDICATION(S)], sedatives, sleeping pills or tranquilizers may increase the risk that you will experience breathing problems or other serious, life threatening breathing problems, sedation, or coma. According to online website https://www.ncbi.nlm.nih.gov/books/NBK 0/ assessed 7/26/2021 indicated the primary FDA-approved clinical uses for [MEDICATION(S)] include reversal agent for benzodiazepine overdose. Website https://www.drugabuse.gov/publications/drugfacts/[MEDICATION(S)] also assessed on 7/26/2021 indicated [MEDICATION(S)] is a medicine that rapidly reverses an opioid overdose. Record review of the facility policy titled, Medication Administration, dated 2/17/2020 indicated it is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. After administrative review, an Immediate Jeopardy was identified on 08/09/21 and the surveyor re-entered the facility. The Administrator was notified of the Immediate Jeopardy on 08/09/21 at 12:20 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 08/09/21 at 6:37 p.m. and reflected the following: 1. Resident's current medications were reviewed by the DON. 2. Medication Aide A educated regarding medication administration. DON began providing re-education to medication aides and licensed nurses about the Medication Administration Policy and Procedure. 3. An audit was conducted by the DON/designee to identify other residents who could potentially be affected by having their medications administered during the 6:00 p.m. - 10:00 p.m. timeframe. Facility changed to standard medication times avoiding concurrent use of anxiolytics, psychotropics, and sleep aides. Nursing staff in-serviced on new medication pass procedures. 4. Facility implemented a medication administration procedure to prevent an adverse medication reaction. Adding to every order, not to administer this medication simultaneously. 5. Facility reviewed resident's medications for the same drug classifications with common side effects that were given at the same time. MD notified. 6. On 07/28/21 the Administrator held an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting with the Performance Improvement Team to review the pharmacy services and the Performance Improvement Measures outlined in this document. The committee reviewed results of the audits and appropriate corrective measures were put in place. DON/designee will report findings of audits in the monthly QAPI meeting. Committee will continue with the performance improvement audits for monitoring of compliance and report on the next meeting monthly for three months or until compliance is achieved as determined by the committee. The plan will be updated, reviewed, and revised as needed monthly in the QAPI meeting. Monitoring of the facility's Plan of Removal included the following: Observations, interviews, and record reviews were conducted on 08/10/21 starting at 9:35 a.m. and continued through 08/10/21 at 4:30 p.m. with nine staff members from various shifts. The in-services included the removal of 4-hour time frames for medication administration, medication administration was changed to standard times, and in-services to ensure staff did not administer anti-anxiety, pain, sleep, and [CONDITION(S)] medications at the same time. Observations of medication administration revealed facility staff administered medications at the appropriate time without concurrent administration of medications for anxiety, pain, sleep, and psychotropics. Record reviews revealed residents no longer had orders to administer medications for anxiety, pain, sleep, and psychotropics at the same time. The medication times for residents were changed to standard medication times. The staff members were able to: Administer medications at the appropriate time and without concurrent administration of medications for anxiety, pain, sleep, and psychotropics. Verbalize their understanding of the in-services related to the plan of removal which included new medication administration times and orders not to administer medications for anxiety, pain, sleep, and psychotropics together. Interviewed staff members on 8/10/2021 at the following times: MA A was interviewed at 1:00 p.m. RN B was interviewed at 1:40 p.m. MA F was interviewed at 1:05 p.m. MA G was interviewed at 10:10 a.m. LVN H was interviewed at 10:35 a.m. MA I was interviewed at 11:25 a.m. MA K was interviewed at 2:50 p.m. LVN L was interviewed at 3:05 p.m. An interview with the DON on 08/10/21 at 2:10 p.m. revealed that going forward, she/designee would be responsible for ensuring medications were passed at the time they were ordered, and the monitoring would last for 3 months. The DON said she/designee would be responsible for the pharmacy review of medications to ensure anxiolytics, psychotropics, pain meds, and sleep aides were not ordered to be administered at the same time. The DON also said residents would not have 4-hour time windows for medication administration. An interview with the Administrator at 08/10/21 at 3:20 p.m. revealed that going forward, the DON/ADON would be responsible for ensuring medications were passed at the time they were ordered, and the monitoring would last for 3 months. The DON/ADON would be responsible for the pharmacy review of medications to ensure anxiolytics, psychotropics, pain meds, and sleep aides were not ordered to be administered at the same time. An interview with the ADON on 08/10/21 at 3:25 p.m. revealed that going forward, she/DON would be responsible for ensuring medications were passed at the time they were ordered, and the monitoring would last for 3 months. The ADON said she/DON would be responsible for the pharmacy review of medications to ensure anxiolytics, psychotropics, pain meds, and sleep aides were not ordered to be administered at the same time. An interview with the Corporate Nurse on 08/10/21 at 3:50 p.m. revealed that going forward the DON/ADON would be responsible for ensuring medications were passed at the time they were ordered, and the monitoring would last for 3 months. The Corporate Nurse said the DON/ADON would be responsible for the pharmacy review of medications to ensure anxiolytics, psychotropics, pain meds, and sleep aides were not ordered to be administered at the same time. The Corporate Nurse also said residents would not have 4-hour time windows for medication administration. An Immediate Jeopardy/Immediate Threat was identified on 08/09/21. While the Immediate Jeopardy was removed on 08/10/21, the facility remained out of compliance at a scope of a pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. The facility was provided the Immediate Jeopardy template on 08/09/21.

Based on interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 3 of 7 residents (Resident #1, #2 & #6) reviewed for pharmacy services. The facility did not develop and implement medication administration procedures to prevent an adverse medication reaction. The facility had a 4-hour window of 6:00 p.m. to 10:00 p.m. for giving bedtime medication. MA A administered bedtime medication and other scheduled medication of [MEDICATION(S)] 0.5 mg, [MEDICATION(S)] Sprinkles 125 mg, [MEDICATION(S)] 10 mg, [MEDICATION(S)] 15 mg, [MEDICATION(S)] 1 mg, and Tylenol #4 with [MEDICATION(S)] 300/60 mg to Resident #1 at the same time causing him to become lethargic (state of having severe drowsiness or sleepy) and having to be admitted into the hospital. The facility did not give Resident #s 2 and 3 medications as ordered at bedtime. The medications were given during a 4-hour window of 6:00 p.m. to 10:00 p.m. This failure could place residents requiring assistance with medication administration at risk for adverse effects and over sedation decline in health and for medications to not be administered as ordered. The findings included: 1. Review of Resident #1's July 2021 physician order indicted he was [AGE] years old with diagnoses of [CONDITION(S)], anxiety disorder, paranoid [CONDITION(S)], acute kidney failure, [CONDITION(S)] disorder, current episodes of depression, moderate down syndrome, and cognitive communication deficit. The orders also indicated that he was to be administered [MEDICATION(S)](benzodiazepine used to treat anxiety) 0.5 mg at bedtime for anxiety disorder, [MEDICATION(S)] Sprinkles capsules delayed release sprinkle ([CONDITION(S)] medication) 125 mg at bedtime for [CONDITION(S)] disorder, and depression, [MEDICATION(S)] HCL 10 mg tablet twice a day for [CONDITION(S)] disorder, depression, anxiety and paranoid [CONDITION(S)], [MEDICATION(S)] ( benzodiazepine/sedative/hypnotic used to treat difficulty sleeping) 15 mg at bedtime for [CONDITION(S)] (difficulty sleeping), [MEDICATION(S)] (antipsychotic medication used to treat [CONDITION(S)], [CONDITION(S)] and depression) 1 mg at bedtime for paranoid [CONDITION(S)], and Tylenol with [MEDICATION(S)] #4 (Opioid) tablet 300/60 mg at bedtime for pain. Review of Resident #1's MDS dated [DATE] indicated his cognitive skills for daily decision making was severely impaired, no altered level of consciousness, and the only behavior exhibited was wandering. Review of Resident #1's care plan with a revision date of 6/23/2021 indicated medications were to be administered as ordered by the physician. Review of the MAR from 7/1/2021 - 7/31/2021 indicated Resident #1 received [MEDICATION(S)] Sprinkles 125 mg at bedtime, Tylenol [MEDICATION(S)] #4 tablet 300/60 mg at bedtime, and [MEDICATION(S)] 1 mg at bedtime and the administration time documented on the MAR was 8:00 p.m., and to administer [MEDICATION(S)] 0.5 mg at bedtime, and [MEDICATION(S)] 15 mg at bedtime and the administration time documented on the MAR was 6:00 p.m. - 10:00 p.m. MA A initialed on the MAR that she administered the medication to Resident #1 on 7/15/2021. Review of Resident #1's Nurse's Note dated 7/15/2021 and timed 6:45 p.m. indicated at about 5:45 p.m. resident returned from dinner the nurse noted a change in condition blood pressure was 80/41 (blood pressure lower than 90/60 is considered low blood pressure), respirations was 9 (normal rate is 12-16), DON was notified and came to residents' room immediately with the crash cart. The nursing note indicated the resident was not responding to verbal stimuli, he was withdrawn from pain reflex and sternal rub and 911 was called. Nursing notes further indicated that 911 arrived at the facility at 6:15 p.m. to take the resident to the hospital. Review of Resident #1's Hospital admission orders indicated he was admitted into the hospital on 7/15/2021. Review of a hospital History and Physical report dated 7/16/2021 indicated Resident #1's admitting diagnoses was acute dehydration, UTI, medication reaction, and altered mental status. The report indicated he was sent from a nursing facility for evaluation of altered mental status and lethargy. He was administered 1 dose of [MEDICATION(S)] (medication used to reverse benzodiazepine overdose) and [MEDICATION(S)] (medicine that rapidly reverses an opioid overdose) and after he was administered the medication his mental status somewhat improved and patient was more alert. He was hypotensive (low blood pressure) and was placed on [MEDICATION(S)] (a medication used to raise blood pressure in adult patients with severe, acute hypotension). During an interview on 7/21/2021 at 1:21 p.m., MA A said on 7/15/2021 around 5:30 p.m. she administered Resident #1 his [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and Tylenol #4 with [MEDICATION(S)] while he was in the dining room eating dinner. She said shortly after she administered Resident #1 his medications, she observed the DON go down the hall with the crash cart for Resident #1. She said she had been a MA for about a month and was concerned she caused something to happen since she had administered Resident #1 his medications shortly before he became ill. During an interview on 7/21/2021 at 4:11 p.m., the DON said the medication times on the MAR need to be clarified for Resident #1. When asked if she thought the current medication times on Resident #1's MAR had the potential to cause him to be overdosed she said Yes. When the DON was asked if she has done anything to the MAR to correct the potential problem since the incident occurred with Resident #1 on 7/15/21, she said No. The DON said the physicians selected the frequency the medication was administered, but the facility selected the actual times on the MAR the medication was administered. She also stated that the facility has currently not done anything to correct the problem and she planned on discussing it with the pharmacy consultant on 7/23/2021. On 7/21/21 at 4:52 p.m. an attempt was made to contact Resident #1's physician. A message was left for the physician to call back. The investigator was not able to contact the physician during the surveyor. During an interview on 7/26/2021 at 2:13 p.m., the pharmacist reviewed Resident #1's medication in their computer system and said bedtime medication should be administered at 8:00 p.m. and not in the evening at 5:00 p.m. or 6:00 p.m. She also said Resident #1 should not have been administered the Tylenol #4 with [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] Sprinkles together at the same times because they all have the same side effects which are drowsiness, lethargy, and respiratory depression. 2. Review of Resident #2's July 2021 Order Summary Report indicated she was [AGE] year-old with diagnoses of [CONDITION(S)], unspecified [CONDITION(S)], [CONDITION(S)] Disorder, major depression, [CONDITION(S)], anxiety disorder, and dementia without disturbances disorder. It was also indicated she was ordered [MEDICATION(S)] 40 mg at bedtime. Review of Resident #2's MDS dated [DATE] indicated her cognitive skills for daily decision making was severely impaired. Review of Resident #2's care plan with revision date of 3/05/2021 indicated medications were to be administered as ordered. Review of Resident #2's MAR indicated [MEDICATION(S)] 40 mg was to be administered at bedtime and the administration time on the MAR was 6:00 p.m. - 10:00 p.m. 3. Review of Resident #6's July 2021 Order Summary Report indicated he was [AGE] years old with diagnoses of [CONDITION(S)], psychotic disorder with delusions due to unknown physiological condition, hypertension, [CONDITION(S)], major depression, [CONDITION(S)] disorder, [CONDITION(S)], anxiety disorder, and muscle weakness. The order also indicated to administer [MEDICATION(S)] 10 mg, [MEDICATION(S)] Sprinkles 125 mg, [MEDICATION(S)] HCL 50 mg, and [MEDICATION(S)] 75 mg at bedtime. Resident #6's MDS dated [DATE] indicated his cognitive skills for daily decision making was severely impaired, no behavioral symptoms were identified. Review of Resident #6's care plan with revision date of 4/16/2021 indicated a care plan to administer medications as ordered. Review of Resident #6's MAR indicated [MEDICATION(S)] 10, [MEDICATION(S)] Sprinkles 125 mg, [MEDICATION(S)] HCL 50 mg, and [MEDICATION(S)] 7.5 mg to be administered at bedtime and the administration time on MAR was 6:00 p.m. - 10:00 pm. During an interview on 7/21/2021 at 1:21 p.m., MA A said on 7/15/2021 around 5:30 p.m. she administered bedtime medications and other routine medications to Resident #2 and #6. During an interview on 7/21/2021 at 2:08 p.m. RN B stated that they have a 4-hour window for the medications on the MAR that is timed 6:00 p.m. - 10:00 p.m. She stated that if a medication was ordered for bedtime it should be administered at 8:00 p.m. - 9:00 p.m. and not before. During an interview with RN C on 7/21/2021 at 5:00 p.m. she stated the medication time ranges on the facilities MAR has the potential to cause medication errors because it gives ranges and not specific times for certain scheduled medications to be administered even if the physician has it ordered specifically for bedtime. She said that bedtime in the facility is between 8:00 pm. - 9:00 p.m. and not earlier and it should be reflected as such on the MAR. Record review of the facility policy titled, Medication Administration, dated 2/17/2020 indicated it is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. Based on interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 3 of 7 residents (Resident #1, #2 & #6) reviewed for pharmacy services. The facility did not develop and implement medication administration procedures to prevent an adverse medication reaction. The facility had a 4-hour window of 6:00 p.m. to 10:00 p.m. for giving bedtime medication. MA A administered bedtime medication and other scheduled medication of [MEDICATION(S)] 0.5 mg, [MEDICATION(S)] Sprinkles 125 mg, [MEDICATION(S)] 10 mg, [MEDICATION(S)] 15 mg, [MEDICATION(S)] 1 mg, and Tylenol #4 with [MEDICATION(S)] 300/60 mg to Resident #1 at the same time causing him to become lethargic (state of having severe drowsiness or sleepy) and having to be admitted into the hospital. The facility did not give Resident #s 2 and 3 medications as ordered at bedtime. The medications were given during a 4-hour window of 6:00 p.m. to 10:00 p.m. An Immediate Jeopardy/Immediate Threat was identified on 08/09/21. While the Immediate Jeopardy was removed on 08/10/21, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. The facility was provided the Immediate Jeopardy template on 08/09/21. This failure could place residents requiring assistance with medication administration at risk for adverse effects and over sedation decline in health and for medications to not be administered as ordered. The findings included: 1. Review of Resident #1's July 2021 physician order indicted he was [AGE] years old with diagnoses of [CONDITION(S)], anxiety disorder, paranoid [CONDITION(S)], acute kidney failure, [CONDITION(S)] disorder, current episodes of depression, moderate down syndrome, and cognitive communication deficit. The orders also indicated that he was to be administered [MEDICATION(S)](benzodiazepine used to treat anxiety) 0.5 mg at bedtime for anxiety disorder, [MEDICATION(S)] Sprinkles capsules delayed release sprinkle ([CONDITION(S)] medication) 125 mg at bedtime for [CONDITION(S)] disorder, and depression, [MEDICATION(S)] HCL 10 mg tablet twice a day for [CONDITION(S)] disorder, depression, anxiety and paranoid [CONDITION(S)], [MEDICATION(S)] ( benzodiazepine/sedative/hypnotic used to treat difficulty sleeping) 15 mg at bedtime for [CONDITION(S)] (difficulty sleeping), [MEDICATION(S)] (antipsychotic medication used to treat [CONDITION(S)], [CONDITION(S)] and depression) 1 mg at bedtime for paranoid [CONDITION(S)], and Tylenol with [MEDICATION(S)] #4 (Opioid) tablet 300/60 mg at bedtime for pain. Review of Resident #1's MDS dated [DATE] indicated his cognitive skills for daily decision making was severely impaired, no altered level of consciousness, and the only behavior exhibited was wandering. Review of Resident #1's care plan with a revision date of 6/23/2021 indicated medications were to be administered as ordered by the physician. Review of the MAR from 7/1/2021 - 7/31/2021 indicated Resident #1 received [MEDICATION(S)] Sprinkles 125 mg at bedtime, Tylenol [MEDICATION(S)] #4 tablet 300/60 mg at bedtime, and [MEDICATION(S)] 1 mg at bedtime and the administration time documented on the MAR was 8:00 p.m., and to administer [MEDICATION(S)] 0.5 mg at bedtime, and [MEDICATION(S)] 15 mg at bedtime and the administration time documented on the MAR was 6:00 p.m. - 10:00 p.m. MA A initialed on the MAR that she administered the medication to Resident #1 on 7/15/2021. Review of Resident #1's Nurse's Note dated 7/15/2021 and timed 6:45 p.m. indicated at about 5:45 p.m. resident returned from dinner the nurse noted a change in condition blood pressure was 80/41 (blood pressure lower than 90/60 is considered low blood pressure), respirations was 9 (normal rate is 12-16), DON was notified and came to residents' room immediately with the crash cart. The nursing note indicated the resident was not responding to verbal stimuli, he was withdrawn from pain reflex and sternal rub and 911 was called. Nursing notes further indicated that 911 arrived at the facility at 6:15 p.m. to take the resident to the hospital. Review of Resident #1's Hospital admission orders indicated he was admitted into the hospital on 7/15/2021. Review of a hospital History and Physical report dated 7/16/2021 indicated Resident #1's admitting diagnoses was acute dehydration, UTI, medication reaction, and altered mental status. The report indicated he was sent from a nursing facility for evaluation of altered mental status and lethargy. He was administered 1 dose of [MEDICATION(S)] (medication used to reverse benzodiazepine overdose) and [MEDICATION(S)] (medicine that rapidly reverses an opioid overdose) and after he was administered the medication his mental status somewhat improved and patient was more alert. He was hypotensive (low blood pressure) and was placed on [MEDICATION(S)] (a medication used to raise blood pressure in adult patients with severe, acute hypotension). During an interview on 7/21/2021 at 1:21 p.m., MA A said on 7/15/2021 around 5:30 p.m. she administered Resident #1 his [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and Tylenol #4 with [MEDICATION(S)] while he was in the dining room eating dinner. She said shortly after she administered Resident #1 his medications, she observed the DON go down the hall with the crash cart for Resident #1. She said she had been a MA for about a month and was concerned she caused something to happen since she had administered Resident #1 his medications shortly before he became ill. During an interview on 7/21/2021 at 4:11 p.m., the DON said the medication times on the MAR need to be clarified for Resident #1. When asked if she thought the current medication times on Resident #1's MAR had the potential to cause him to be overdosed she said Yes. When the DON was asked if she has done anything to the MAR to correct the potential problem since the incident occurred with Resident #1 on 7/15/21, she said No. The DON said the physicians selected the frequency the medication was administered, but the facility selected the actual times on the MAR the medication was administered. She also stated that the facility has currently not done anything to correct the problem and she planned on discussing it with the pharmacy consultant on 7/23/2021. On 7/21/21 at 4:52 p.m. an attempt was made to contact Resident #1's physician. A message was left for the physician to call back. The investigator was not able to contact the physician during the surveyor. During an interview on 7/26/2021 at 2:13 p.m., the pharmacist reviewed Resident #1's medication in their computer system and said bedtime medication should be administered at 8:00 p.m. and not in the evening at 5:00 p.m. or 6:00 p.m. She also said Resident #1 should not have been administered the Tylenol #4 with [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] Sprinkles together at the same times because they all have the same side effects which are drowsiness, lethargy, and respiratory depression. 2. Review of Resident #2's July 2021 Order Summary Report indicated she was [AGE] year-old with diagnoses of [CONDITION(S)], unspecified [CONDITION(S)], [CONDITION(S)] Disorder, major depression, [CONDITION(S)], anxiety disorder, and dementia without disturbances disorder. It was also indicated she was ordered [MEDICATION(S)] 40 mg at bedtime. Review of Resident #2's MDS dated [DATE] indicated her cognitive skills for daily decision making was severely impaired. Review of Resident #2's care plan with revision date of 3/05/2021 indicated medications were to be administered as ordered. Review of Resident #2's MAR indicated [MEDICATION(S)] 40 mg was to be administered at bedtime and the administration time on the MAR was 6:00 p.m. - 10:00 p.m. 3. Review of Resident #6's July 2021 Order Summary Report indicated he was [AGE] years old with diagnoses of [CONDITION(S)], psychotic disorder with delusions due to unknown physiological condition, hypertension, [CONDITION(S)], major depression, [CONDITION(S)] disorder, [CONDITION(S)], anxiety disorder, and muscle weakness. The order also indicated to administer [MEDICATION(S)] 10 mg, [MEDICATION(S)] Sprinkles 125 mg, [MEDICATION(S)] HCL 50 mg, and [MEDICATION(S)] 75 mg at bedtime. Resident #6's MDS dated [DATE] indicated his cognitive skills for daily decision making was severely impaired, no behavioral symptoms were identified. Review of Resident #6's care plan with revision date of 4/16/2021 indicated a care plan to administer medications as ordered. Review of Resident #6's MAR indicated [MEDICATION(S)] 10, [MEDICATION(S)] Sprinkles 125 mg, [MEDICATION(S)] HCL 50 mg, and [MEDICATION(S)] 7.5 mg to be administered at bedtime and the administration time on MAR was 6:00 p.m. - 10:00 pm. During an interview on 7/21/2021 at 1:21 p.m., MA A said on 7/15/2021 around 5:30 p.m. she administered bedtime medications and other routine medications to Resident #2 and #6. During an interview on 7/21/2021 at 2:08 p.m. RN B stated that they have a 4-hour window for the medications on the MAR that is timed 6:00 p.m. - 10:00 p.m. She stated that if a medication was ordered for bedtime it should be administered at 8:00 p.m. - 9:00 p.m. and not before. During an interview with RN C on 7/21/2021 at 5:00 p.m. she stated the medication time ranges on the facilities MAR has the potential to cause medication errors because it gives ranges and not specific times for certain scheduled medications to be administered even if the physician has it ordered specifically for bedtime. She said that bedtime in the facility is between 8:00 p.m. - 9:00 p.m. and not earlier and it should be reflected as such on the MAR. Record review of the facility policy titled, Medication Administration, dated 2/17/2020 indicated it is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. An Immediate Jeopardy/Immediate Threat was identified on 08/09/21. The Administrator was notified of the Immediate Jeopardy on 08/09/21 at 12:20 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 08/09/21 at 6:37 p.m. and reflected the following: 1. Resident's current medications were reviewed by the DON. 2. Medication Aide A educated regarding medication administration. DON began providing re-education to medication aides and licensed nurses about the Medication Administration Policy and Procedure. 3. An audit was conducted by the DON/designee to identify other residents who could potentially be affected by having their medications administered during the 6:00 p.m. - 10:00 p.m. timeframe. Facility changed to standard medication times avoiding concurrent use of anxiolytics, psychotropics, and sleep aides. Nursing staff in-serviced on new medication pass procedures. 4. Facility implemented a medication administration procedure to prevent an adverse medication reaction. Adding to every order, not to administer this medication simultaneously. 5. Facility reviewed resident's medications for the same drug classifications with common side effects that were given at the same time. MD notified. 6. On 07/28/21 the Administrator held an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting with the Performance Improvement Team to review the pharmacy services and the Performance Improvement Measures outlined in this document. The committee reviewed results of the audits and appropriate corrective measures were put in place. DON/designee will report findings of audits in the monthly QAPI meeting. Committee will continue with the performance improvement audits for monitoring of compliance and report on the next meeting monthly for three months or until compliance is achieved as determined by the committee. The plan will be updated, reviewed and revised as needed monthly in the QAPI meeting. Monitoring of the facility's Plan of Removal included the following: Observations, interviews, and record reviews were conducted on 08/10/21 starting at 9:35 a.m. and continued through 08/10/21 at 4:30 p.m. with nine staff members from various shifts. The in-services included the removal of 4-hour time frames for medication administration, medication administration was changed to standard times, and in-services to ensure staff did not administer anti-anxiety, pain, sleep, and [CONDITION(S)] medications at the same time. Observations of medication administration revealed facility staff administered medications at the appropriate time without concurrent administration of medications for anxiety, pain, sleep, and psychotropics. Record reviews revealed residents no longer had orders to administer medications for anxiety, pain, sleep, and psychotropics at the same time. The medication times for residents were changed to standard medication times. The staff members were able to: Administer medications at the appropriate time and without concurrent administration of medications for anxiety, pain, sleep, and psychotropics. Verbalize their understanding of the in-services related to the plan of removal which included new medication administration times and orders not to administer medications for anxiety, pain, sleep, and psychotropics together. Interviewed staff members and shifts were: MA A - worked day and evening shift RN B - worked day shift MA F - worked day shift MA G - worked day shift LVN H - worked day and evening shift MA I - worked day and evening shift RN J - worked day shift MA K - worked day and evening shift LVN L - worked evening shift An interview with the DON on 08/10/21 at 2:10 p.m. revealed that going forward, she/designee would be responsible for ensuring medications were passed at the time they were ordered, and the monitoring would last for 3 months. The DON said she/designee would be responsible for the pharmacy review of medications to ensure anxiolytics, psychotropics, pain meds, and sleep aides were not ordered to be administered at the same time. The DON also said residents would not have 4-hour time windows for medication administration. An interview with the Administrator at 08/10/21 at 3:20 p.m. revealed that going forward, the DON/ADON would be responsible for ensuring medications were passed at the time they were ordered, and the monitoring would last for 3 months. The DON/ADON would be responsible for the pharmacy review of medications to ensure anxiolytics, psychotropics, pain meds, and sleep aides were not ordered to be administered at the same time. An interview with the ADON on 08/10/21 at 3:25 p.m. revealed that going forward, she/DON would be responsible for ensuring medications were passed at the time they were ordered, and the monitoring would last for 3 months. The ADON said she/DON would be responsible for the pharmacy review of medications to ensure anxiolytics, psychotropics, pain meds, and sleep aides were not ordered to be administered at the same time. An interview with the Corporate Nurse on 08/10/21 at 3:50 p.m. revealed that going forward the DON/ADON would be responsible for ensuring medications were passed at the time they were ordered, and the monitoring would last for 3 months. The Corporate Nurse said the DON/ADON would be responsible for the pharmacy review of medications to ensure anxiolytics, psychotropics, pain meds, and sleep aides were not ordered to be administered at the same time. The Corporate Nurse also said residents would not have 4-hour time windows for medication administration. An Immediate Jeopardy/Immediate Threat was identified on 08/09/21. While the Immediate Jeopardy was removed on 08/10/21, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. The facility was provided the Immediate Jeopardy template on 08/09/21.

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries for 1 of 3 residents reviewed for pressure injuries. (Residents #44) The facility did not apply skin prep to Resident #44's great right toe as ordered by the physician, complete accurate weekly skin assessments, provide a foot cradle (a device that helps to keep sheets and blankets off of a resident's feet) or position the resident's feet to prevent pressure. Resident #44 developed an unstageable pressure injury to her right great toe and right pinky toe that was not identified until surveyor intervention. This failure could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: The physician order [REDACTED].#44 was [AGE] years old, readmitted [DATE] with [DIAGNOSES REDACTED]. The physician order [REDACTED].#44 was to skin prep (a liquid that forms a protective over skin) applied to the top of her right great toe every shift for preventative starting 1/2/20. The MDS dated [DATE] indicated Resident #44 understood and was able to make herself understood by others and had no cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident #44 was totally dependent on staff for transfers and bathing and was frequently incontinent of bowel and bladder. The MDS indicated Resident #44 was at risk for pressure injury development and had no unhealed pressure injuries. The care plan revised on 12/13/19 indicated Resident #44 had the potential for altered skin integrity due to her decreased mobility and incontinence. The care plan interventions included: assess Resident #44's skin on admission and weekly thereafter; assist with repositioning every two hours and as needed while in bed or in chair; follow treatment per physician orders; and notify physician of concerns. The care plan indicated Resident #44 was at risk for pressure injury development with interventions including: assess resident for risk; provide preventative treatments if indicated; skin assessment on admission and at a minimum weekly thereafter. The Braden Score skin assessment tool dated 12/18/2019, indicated Resident #44 was at risk for pressure injury development. A physician progress notes [REDACTED].#44 had no skin rashes or suspicious growths. The note did not indicate the physician evaluated the resident's feet or toes. The weekly skin assessment dated [DATE], completed by LVN A indicated Resident #44 had no skin impairments. The weekly skin assessment dated [DATE], completed by LVN A indicated Resident #44 had no skin impairments. The weekly skin assessment dated [DATE], completed by LVN A indicated Resident #44 had no skin impairments. The weekly skin assessment/observation tool dated 1/23/19 completed by LVN A indicated Resident #44 had no new skin issues. The observation tool listed no current wounds of any kind. During an interview on 1/24/20 at 2:40 p.m., LVN A said she thought she performed a skin assessment on Resident #44 yesterday (1/23/20). LVN A said Resident #44 had no pressure injuries or wounds. The nursing notes for the month of January 2020, did not indicate Resident #44 had any skin issues or the physician was notified of any skin issues. The January 2020 treatment administration record indicated skin prep was applied to the top of her right great toe every shift (day, evening and night) since 1/2/20 with the exception of the day shift on 1/13/20. The treatment administration record indicated Resident #44 did not have skin prep applied to her toe during the day shift on 1/13/20. During an observation and interview 1/21/20 at 3:24 p.m., Resident #44 was lying on her back in the bed with her feet resting on the bed. The resident was wearing socks and had her feet on top of the cover. The outer aspect of her right foot and pinky toe laid against the surface of the bed. Resident #44 said staff did not regularly float her feet off the bed. She said they would sometimes elevate them if she requested it. Resident #44 said she asked for a foot cradle in the past but never received a response from the staff. Resident #44 said she was not always repositioned in the bed when she requested. She said she felt she did not get repositioned as often as she needed because she required a mechanical lift and it took 2 staff members to assist her. She said she slid down in the bed and her toes pushed into the foot board on many occasions. During an observation on 1/22/20 at 8:30 a.m., Resident #44 was lying on her back in her bed with her feet resting on the bed. The outer aspect of her right foot and pinky toe laid against the surface of the bed. The bed covers were resting on top of the resident's toes. During an interview on 1/22/20 at 12:37 p.m., Resident #44 said about 2 weeks ago the ADON told a nurse to apply skin prep to Resident #44's great toe on the right foot until the doctor could look at it. She said the ADON applied the skin prep at that time. The resident said the ADON told her the skin prep would be applied every shift. Resident #44 said the skin prep was never applied again after that first time. She said when she asked staff about the skin prep, the nurse would say ok but never applied the skin prep or gave any explanation. Resident #44 said the doctor never came to look at her toes. During an observation on 1/23/20 at 7:30 a.m., Resident #44 was lying on her back in her bed with her feet resting on the bed. The outer aspect of her right foot and pinky toe laid against the surface of the bed. The bed covers were resting on the resident's toes. During an interview on 1/24/20 at 4:17 p.m., LVN C said Resident #44 did not have any wounds. During an interview and observation on 1/24/20 at 4:18 p.m., LVN C looked at Resident #44's right foot. On the great toe of the right foot there was a black area that appeared to be eschar (dead, dark crusty tissue) measuring approximately 2.5 mm in diameter, (surrounded by an area of redness approximately 1 centimeter in diameter. On the pinky toe of the right foot, just below the nail bed, there was a black area that appeared to be eschar, measuring approximately 0.5 centimeters in length and 1 centimeter in width. LVN C said it could have been a fungal infection, but she did not know. LVN C said she was an LVN and LVNs could not stage wounds. She said she had not seen either of the wounds before. She said she had not been applying the skin prep to Resident #44's great toe. She said she wasn't applying the skin prep because she missed it. LVN C said she did not perform the skin assessments for Resident #44. LVN C was documenting she applied the skin prep to the toe per the TAR. During an interview on 1/24/20 at 4:35 LVN C said the computer system generated a schedule for skin assessments to ensure each resident received a weekly skin assessment. She said the skin assessments were divided amongst different shifts. During an observation and interview on 1/24/20 at 4:30 p.m., the DON assessed Resident #44's right foot. On the great toe of the right foot there was a black area, appeared to be eschar approximately 2.5 mm in diameter surrounded by an area of blanchable redness approximately 1 centimeter in diameter. The DON said the wound was unstageable. On the pinky toe of Resident #44's the right foot, just below the nail bed, there was a black area which appeared to be eschar, measuring approximately 0.5 centimeters in length and 1 centimeter in width, depth could not be determined. The DON said the wound was unstageable. The DON said she would make sure the wound care physician saw Resident #44. During an interview on 1/24/20 at 4:47 p.m., the DON said she expected staff to perform accurate head to toe skin assessments weekly. The DON said the wounds on Resident #44's right foot should have been documented on the weekly skin assessment that was completed yesterday (1/23/20). The DON said she expected nursing staff to notify her if they found a skin issue they could not identify. The DON said Resident #44's heels should have been floated off the bed. She said staff should follow physician orders [REDACTED].#44's toe as ordered. During an interview on 1/24/20 at 6:30 p.m., administrator said she expected staff to perform weekly skin assessments accurately. She said she expected residents at risk for pressure injury to be repositioned per the policy and for preventative treatments to be applied as ordered by the physician. The administrator said she expected staff to notify the DON or physician if they could not identify a skin issue. The undated facility policy, titled Skin Management stated, It is the policy of this center to provide care based on each resident's comprehensive assessment to ensure that a resident who enters the facility without pressure injury does not develop pressure injury .Aggressive and appropriate preventive measures and care are provided to address a resident's unique risk factors. Based on each resident's comprehensive assessment, appropriate treatment and services are provided to prevent the formation of pressure injury. Residents having pressure injuries receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injury from developing. The facility policy revised July 2017 titled, Prevention of Pressure Ulcers/Injuries, stated Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment (1) Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon changes in condition .(4) Inspect the skin on a daily basis when performing or assisting with personal care or ADLs .Mobility/Repositioning (2) At least every 2 hours, reposition residents who are chair-bound or bed-bound with the head of the bed elevated 30 degrees or more. (3) At least every 2 hours, reposition residents who are reclining and dependent on staff for repositioning. (4) Reposition more frequently as needed, based on the condition of the skin and the resident's comfort .Monitoring (1) Evaluate, report and document potential changes in the skin. (2) Review the interventions and strategies for effectiveness on an ongoing basis. The website https://cdn.ymaws.com/npuap.siteym.com/resource/resmgr/npuap-pressure-injury-stages.pdf, accessed 1/28/20 indicated the following Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue .Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed .

Based on observation, interview and record review, it was determined the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment, and to prevent the development and transmission of disease and infection for two (Residents #1 and #23) of 23 residents observed for infection control. 1) Staff failed to isolate Resident #1, who had Clostridium difficile, from his roommate, Resident #23, who was at high risk of contracting Clostridium difficile due to his [DEVICE]. 2) CNA I, MA J, LVN A, and CNA F failed to wear gloves and/or gowns when entering Resident #1's room. 3) Housekeeping staff failed to clean Resident #1's room floor and the facility's floors with cleaners, which would kill Clostridium difficile. 4) Dietary staff failed to use cleaners in the kitchen, which killed Clostridium difficile. 5) Staff failed to Resident #2's bedpan in an appropriate place in her room. Staff failed to place a sign on the resident's door to alert visitors to check with nursing prior to entering her room. Staff failed to keep the isolation cart stocked with gowns. LVN A, CNA I, CNA H, and CNA G failed to wear gowns, gloves, and/or perform hand hygiene when entering or leaving Resident #2's room. CNA F removed Resident #2's contaminated food tray from her room and placed it the cart with the other residents' meal trays. Staff failed to keep the cardboard box in the resident's room appropriately lined with a biohazard bag. An Immediate Jeopardy (IJ) was identified on 05/25/12. While the IJ was removed on 05/26/12, the facility remained out of compliance at a scope of "widespread" and a severity level of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect all 109 residents, including Resident #23, by placing them at risk for being infected with Clostridium difficile, cross-contamination, and a decreased quality of life. Findings included: Clostridium difficile is a spore-forming, Gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD). Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridium difficile spores. Clostridium difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. The following measures can help prevent Clostridium difficile spread in long-term care settings: Use antibiotics judiciously; Use Contact Precautions: for patients with known or suspected Clostridium difficile infection: Place these patients in private rooms. Isolate patients immediately if[DIAGNOSES REDACTED]icile is suspected. If private rooms are not available, these patients can be placed in rooms (cohorted) with other patients with Clostridium difficile infection. Use gloves and gowns when entering patient rooms and during patient care, even for short visits. Perform Hand Hygiene after removing gloves. Because alcohol does not kill Clostridium difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs. Centers for Disease Control and Prevention. (March 6, 2012). Healthcare-associated Infections. (electronic version). Retrieved June 5, 2012, from Http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs. 1. Resident #1's Face Sheet dated 04/23/12 reflected he was a [AGE] year-old male, who was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident #1's MDS assessment dated [DATE] reflected his [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #1 needed supervision and set-up assistance with toileting and assistance with transfers. Resident #1's care plan dated 12/28/11 and reviewed on 03/20/12 reflected the resident had a history of [REDACTED]. The care plan of the same date also reflected Resident #1 was incontinent of urine and wore incontinent briefs. During rounds on 05/22/12 at 10:45AM, LVN A stated Resident #1 was occasionally incontinent of bowel and bladder. Resident #1's Care Plan with the last review date of 03/26/12 did not reflect a care plan for Clostridium difficile. Resident #1's hospital discharge physician's orders [REDACTED]. Resident #1's hospital discharge physician's orders [REDACTED]. Resident #1's Laboratory Report dated 05/15/12 reflected he was positive for both the Clostridium difficile [MEDICATION NAME] and Clostridium Difficile Toxin A/B. Resident #1's Physician's Telephone Order dated 05/25/12 reflected, "Check the stool for[DIAGNOSES REDACTED] toxin." An observation on 05/22/12 at 10:00 AM revealed no gowns were stocked in the isolation cart in front of Resident #1's room. Observation at 10:45 AM on 05/22/12 revealed Resident #1 was in contact isolation for Clostridium Difficile. Resident #23 was Resident #1's roommate. LVN A used alcohol gel hand sanitizer rather than soap and water for hand hygiene. There were gowns observed in the isolation cart. An observation on 05/23/12 at 9:00 AM revealed CNA F put gloves on, picked up Resident #1's contaminated breakfast tray, carried the tray to the meal cart, removed her gloves and without performing hand hygiene, she put the gloves in the trashcan in Resident #1's doorway. She then went down the hall, picked up residents' trays, and put them in the cart. An observation on 05/23/12 at 1:40 PM revealed CNA F picked up Resident #1's contaminated lunch tray and put it in the meal cart in the hallway. She did not wear gloves or wash her hands after handling Resident #1's tray. An observation on 05/24/12 at 2:45 PM revealed CNA I entered Resident #1's room wearing only gloves and closed the door behind him. The sign on the resident's door reflected, "See Nurse before entering room." There were no other signs on the door or on the medication cart indicating what type of personal protective equipment to use or what the type of isolation was. On 05/24/12 at 2:45 PM, MA J was queried about isolation precautions. The surveyor pointed at Resident #1's room and asked, "What do I need to put on to go into that room?" MA J replied, "Resident #1 is in isolation. He only needs gloves to go into the room. He's on contact isolation. The other resident is not on isolation, so you don't need anything to see him." An observation on 05/24/12 at 3:00 PM revealed MA J entered Resident #1's room wearing only gloves. She was carrying a handful of packaged graham crackers. She exited the room without gloves and put the graham crackers on top of the isolation cart in the hallway. MA J squirted some alcohol hand sanitizing gel onto her hands and rubbed it quickly into her hands. Then she picked up the wrapped packages of graham crackers and carried them to the common area where some residents were sitting. MA J unwrapped a package of graham crackers and handed them to Resident #25. MA J continued walking from the common area with the packaged graham crackers in her hands to the hallway. On 05/25/12 at 8:30 AM LVN K was interviewed. She was queried about contact isolation procedures. LVN K stated, "For contact isolation, the tag on the door indicates isolation. In dietary there is a tag on the tray that indicates the resident is on isolation and the kitchen staff are supposed to know to wear gloves to touch the tray. For staff that provide care and could be splashed with liquids like blood, urine, or stool, then they need to wear a full gown, gloves, but no mask. But, for only passing meal trays, or med (medication) pass they have to put on only gloves." An observation on 05/25/12 at 8:45 AM with LVN K of the central supply area revealed one and 1/2 cases of water-soluble laundry bags, three cases of red plastic bags, five boxes of surgical masks, one case of gloves with 1000 gloves per case, several cases of unpacked gloves on the shelf, one case of yellow laundry bags, one case of shoe covers. No gowns were observed stocked in the central supply area. On 05/25/12 at 8:45 AM LVN K was queried about the lack of gowns in the central supply area. LVN K stated there were more in another storage room that was outside the building. An interview on 05/25/12 at 8:55 AM with Laundry Aide L revealed she worked two days and two nights a week in the laundry and one day as a housekeeper. When Laundry Aide L was queried about handling potentially infectious laundry, she replied, "That laundry comes in a red bag. When the red bags come in I rip them open and inside them is a vinegar bag. A vinegar bag is one that goes right into the laundry machine and dissolves. I wash the laundry inside the vinegar bag three times on the hot cycle. The red bag goes into the trashcan. I always wear disposable gloves." Laundry Aide L pointed at the boxes of disposable gloves next to the laundry machine. She stated, "I don't wear a rubber apron or gown because the laundry is contained inside the water-soluble bags." Laundry aides were provided with a large plastic face shield, a plastic apron, a plastic raincoat like coat, box of disposable gloves and a pair of large thick plastic gloves for personal protective equipment. The personal protective equipment was observed hanging on a hook in the laundry room by the trash cans. The Dietary Manager was interviewed about infection control techniques in the kitchen on 05/25/12 at 9:15 AM. She stated staff wiped the meal tray carts after every meal with a K-Sani-Quat soaped cleaning cloth. She stated they changed the cloths often. The Dietary Manager also stated they used K-Sani-Quat cloths on the countertops in the kitchen. She stated all dishes and pans went through the dishmachine. The Dietary Manager stated, "Bleach water is used on the tables about once a month. We use it to take out stains. Sometimes we take the meal tray carts outside in the parking lots on weekends and wash them with a hose and running water." On 05/25/12 at 10:30 AM the surveyor contacted the chemical company who manufactured the K-Sani-Quat that was used in the kitchen. During the interview, the manufacturer's Representative stated, "K-Sani-Quat does not kill [DIAGNOSES REDACTED]icile." The Representative stated the only thing that killed [DIAGNOSES REDACTED]icile was bleach. On 05/25/12 at 10:35 AM Housekeeper N was interviewed about disinfection techniques in isolation rooms and housekeeping in the facility in general. Housekeeper N stated she cleaned rooms with a washcloth and Quat disinfectant. She stated she used a washcloth for each room for all the surfaces. Housekeeper N stated for[DIAGNOSES REDACTED]icile rooms she used Dispatch wipes cleaner on the surfaces but used the Quat disinfectant on the toilet bowls. She stated she wore gloves and used hand sanitizer to clean her hands. Housekeeper N stated she used Emerald cleaner on the floors in the isolation rooms and in the facility. When queried about Emerald cleaner, she stated she did not know what it was, but it was provided in the housekeeping room. Dispatch Hospital Cleaner Disinfectant Towels with Bleach contained a 1:10 dilution of bleach and a detergent, according to the bottle's label on 05/25/12. On 05/25/12 at 11:10 AM a copy of the label of Emerald floor cleaner #412 was obtained from the Housekeeping Supervisor. The phone number on the label was the supplier and distributor for Emerald floor cleaner. The surveyor called the Distributer of the floor cleaner about the cleaner's disinfection properties. The representative stated Emerald #412 was not a disinfectant of any kind. The Representative stated it was a floor cleaner. On 05/25/12 at 11:15 AM the Housekeeping Supervisor was interviewed regarding the chemicals used to clean and disinfect the facility. He stated, "We use Emerald on the floors to clean and disinfect. We also use 3M neutral cleaner three and one to clean the floors." 2. Resident #23 an [AGE] year-old male who was originally admitted to the facility on [DATE], according to his Face Sheet dated 03/09/12. Resident #23's MDS assessment dated [DATE] reflected he was totally dependent on staff for all ADLs, was incontinent of bowel and bladder, was unable to move or transfer himself, had severely impaired cognitive skills, was unable to understand verbal content, and utilized gastrostomy tube to receive food and water. The MDS assessment also reflected Resident #23's active [DIAGNOSES REDACTED]. Resident #23's MDS assessment reflected he received 51% or more of his calories through tube feeding. An observation on 05/23/12 at 7:55 AM revealed Resident #23 yelling and pulling on his gastrostomy tube. The surveyor called the Charge Nurse to the resident's room. LVN A put a glove on his right hand only. LVN A touched Resident #23's gastrostomy tube with his gloved hand. LVN A then reached into a box of gloves at the bedside table, donned a glove on the left hand without performing hand hygiene. LVN A straightened Resident #23's clothes and the gastrostomy tube. LVN A opened the bathroom door, removed Resident #1's wheelchair, entered the bathroom, and washed his hands. An observation on 05/25/12 at 10:00 AM revealed LVN K entered Resident #23's room to administer the resident's medications via [DEVICE]. When asked where he obtained the water to dilute Resident #23's [DEVICE] medications and feedings, LVN A pointed to the resident's bathroom and said, "From the sink or my medication cart." When asked where Resident #23's feeding syringe and graduated cylinder were rinsed after use, LVN A pointed to the sink in the bathroom and said, "In there." LVN A was wearing gloves, but not a gown. LVN A completed administering Resident #23's [DEVICE] medications, took off his gloves, put them in the trash can, went to the bathroom, rinsed the feeding syringe and graduate, washed his hands with soap and water, dried his hands, turned off the water without using a paper towel to touch the spigot handle, carried the syringe and graduate, and put them on Resident #23's bedside table. LVN A opened the door and left the room. An interview on 05/25/12 at 10:55 AM CNA F and CNA I were asked if Resident #23 was having a lot of bowel incontinent episodes and they stated the resident was having stools every time they changed him. CNA F stated it was not diarrhea, but it was not solid. She stated he had been having it for days, but she did not tell the Charge Nurse. 3. Resident #2 was originally admitted on [DATE]. Resident #2 was readmitted on [DATE], according to the Face Sheet dated 05/24/12. Resident #2's MDS assessment dated [DATE] reflected the resident was an [AGE] year-old female, who required extensive assistance for transfers, dressing, and eating. The assessment also reflected the resident required physical help in part of bathing activity and she was unable to walk in the corridor. Further review of Resident #2's MDS assessment revealed she was frequently incontinent of bowel and bladder. The assessment reflected her [DIAGNOSES REDACTED]. Resident #2's May 2012 physician's orders [REDACTED]. A handwritten note on Resident #2's Physicians Orders reflected Clostridium difficile toxin 05/10/12. Resident #2's Care Plan reflected the last review date was 02/17/12 and there was not a care plan for Clostridium difficile. During initial rounds on 05/22/12 at 9:35 AM, LVN A stated, "(Resident #2) has Clostridium difficile and is on isolation." An observation at that time revealed there was not a sign on the resident's door reflecting isolation or to see the nurse prior to entering. An isolation cart was outside the door in the hall way. The isolation cart had one box of size small gloves and shoe covers. The cart did not contain isolation gowns, biohazard bags (red bags) or yellow bags (used to denote contaminated linen). LVN A and the surveyor entered Resident #2's room. The biohazard bag had slipped down inside the cardboard box and the contaminated contents were touching the inside of the cardboard box. (Note: the red plastic bag should be completely lining the cardboard box to prevent any leakage of contaminated substances through the cardboard.) The cardboard box was located in the resident's bathroom. A bedpan was on top of an opened bedside commode and there was an odor of feces. LVN A was queried about the bedpan on the bedside commode. LVN A stated, "I don't know why this is here." LVN A used a gloved hand to remove the bedpan from the opened bedside commode which was full of feces. LVN A put the bedpan in the bathroom and closed the lid on the bedside commode. LVN A's pants were sagging and slipping down, and he pulled them up using the same contaminated gloved hand. LVN A did not his wash hands with soap and water after touching the commode and removing his gloves. LVN A exited the room and used alcohol gel hand sanitizer. An observation at 8:03 AM on 05/23/12 revealed CNA I entered Resident #2's room with a pastry and chocolate milk. She placed it on Resident #2's bedside table. CNA I then exited the room. CNA I was not wearing gloves or a gown when she entered or exited the resident's room. CNA I did not use hand hygiene before or after entering the isolation room. An observation at 8:15 AM on 05/23/12 revealed CNA H and CNA I entered Resident #2's room wearing gloves, but not gowns. They pulled Resident #2 up in bed and repositioned her. Their uniforms were pressed against the bed during the repositioning. They wore dirty gloves, when they raised the head of the resident's bed. Then the CNAs repositioned the resident's bedside commode and touched the resident's headboard. They went to the resident's bathroom, pulled off their gloves, put them in the red biohazard box and left the room. They both used hand sanitizer in the hallway. Observation of the isolation cart in front of #2's room at 8:30 AM on 05/23/12 revealed no gowns were in the isolation cart for Resident #2. Observation at 8:45 AM on 05/23/12 revealed CNA H entered Resident #2's room without a gown, gloves, or performing hand hygiene. She went to the sink in the resident's bathroom, wet a washcloth and gave Resident #2 the wet washcloth. Resident #2 wiped her face with the washcloth. CNA H then went back outside the room and put on a pair of gloves. CNA H went back in the room and took the washcloth from the Resident #2. CNA H put the wet washcloth in the biohazard red bag, removed her gloves and washed her hands in the resident's bathroom. An observation on 05/23/12 at 10:00 AM revealed gowns were being stocked in Resident #2's isolation cart in the hallway. Observation at 1:50 PM on 05/23/12 revealed CNA G entered Resident #2's room without performing hand hygiene. She did not put on gloves or a gown. CNA G went outside the resident's room without performing hand hygiene. CNA G removed several packages of Sweet and Low from the meal cart and took the packages into Resident #2's room. CNA G open and stirred the package of Sweet and Low into Resident #2's tea. She was not wearing gloves or a gown. CNA G did not perform hand hygiene after leaving the room. An observation on 05/23/12 at 1:55 PM revealed CNA F entered Resident #2's room and took the resident's tray from her bedside table. He placed the resident's contaminated meal tray in the meal cart with the other residents's meal trays, which were sent back to the kitchen. CNA F did perform hand hygiene, but did not glove, and did not put on a gown when he entered her room or after putting the contaminated meal tray on the cart. 4. The facility's policy "Clostridium Difficile," revised August 2009 was part of the Infection Control Policy and Procedure Manual. The DON provided the surveyors with a copy of the policy and stated it was the current policy. The policy reflected, "Policy Statement Preventive Measures will be taken to prevent the occurrence of Clostridium difficile infections among residents and precautions will be taken while caring for residents with Clostridium Difficile (to prevent transmission of Clostridium difficile to others)...1. The facility has adopted Standard Precautions, and all residents' blood, body fluids, excretions, and secretions are considered potentially infectious...3. Residents with diarrhea associated with Clostridium difficile...will be placed on Contact Precautions for the duration of the illness...4. Residents considered high at risk of developing symptoms associated with Clostridium difficile include those with advancing age, gastrointestinal manipulation (especially nasogastric tube insertion), previous gastrointestinal illness caused by Clostridium difficile...6. When caring for residents with diarrhea or fecal incontinence, staff will maintain vigilant hand washing with soap and water, rather than alcohol-based hand rubs...7. Due to the persistence of Clostridium difficile spores for prolonged periods of time all fecally-contaminated articles must be considered potentially infectious and disinfected with disinfecting agent recommended for Clostridium difficile (household bleach and water solution). 8. At a 1:10 dilution of bleach and water will be used for routine environmental disinfection of rooms for residents with [DIAGNOSES REDACTED]icile...." The facility's policy "General Control Practices" revised August 2009 reflected, "Contact Precautions Contact Precautions In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. a. Examples of infections requiring Contact Precautions include, but are not limited to: ...(2) Diarrhea associated with Clostridium diffile...Resident Placement During Contact Precautions b. Resident Placement (1) Place the individual in a private room if it is not feasible to contain drainage, excretions, blood or body fluids...(2) If a private room is not available, the Infection Control Coordinator will assess various risks associated with other resident placement options(e.g., cohorting). Gloves and Handwashing During Contact Precautions c...(3) Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. (4) After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room. Gowns During Contact Precautions d. Gown (1) In addition to wearing a gown as outlined under Standard Precautions, wear a gown (clean, nonsterile) for all interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. (2) After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces...." The facility's policy "Handwashing/Hand Hygiene" revised August 2009 reflected, "...5. All employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non- antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents; b. When hands are dirty visibly soiled with blood or other body fluids; ...d. After removing gloves; e. After handling items potentially contaminated with blood, body fluids, or secretions...g. When there is likely exposure to spores (i.e., [DIAGNOSES REDACTED]icile and Bacillus anthracis). (Note: Alcohol-based hand rubs are inactive against spores. For effective mechanical removal of spores, wash hands for 30 to 60 seconds with soap and water.)" 5. On 05/25/12 at 1:05 PM an IJ was identified. During an interview with the Administrator and the DON on 05/25/12 at 1:05 PM, they were informed of the IJ and Plan of Removal was requested at that time. The DON was asked what training was provided to staff on isolation techniques and Clostridium difficile. The DON replied the facility used a computer program for in-services. She also stated she had given other in-services on Infection Control in the past. She stated, "A nurse from (county name) County Health Department came out and gave an in-service last week." The DON was asked how she ensured staff were competent in their skills. The DON replied, "There are no specific proficiencies for Infection Control. I used the (computer program) in-services. We have no specific proficiency for hand washing or using gloves and gowns." The DON and the Administrator were asked if they had addressed Clostridium difficile in their QA meetings. The administrator replied, "Not as a specific topic of its own. The QA goes through all of the infections but not Clostridium difficile as a specific topic." The DON and Administrator were asked about management of residents with Clostridium Difficile infections. The DON replied, "We do what the policy and procedure says. But what (corporate nurse) told me was to wear gloves only. If you feel you may come in contact with body fluids then you wear a gown." When asked how CNAs determined what type of personal protective equipment they should use for particular infections, the DON replied, "They put on what they are told to put on by the nurses." During this same interview on 05/25/12 at 1:05 PM, the DON was asked what her job responsibilities were. She replied, "My responsibilities are to educate staff, make sure the staff know how to use the proper equipment, enforce policies and procedures." The DON and Administrator were asked how they thought the IJ occurred. The DON replied, "It occurred when you (surveyor) were concerned that we were not wearing gowns. I think it's a mis-communication. We may need to change our policy. I think the staff are handwashing in serviced (were taught to wash their hands) but people are just not thinking they're in a hurry and they may need to be re-educated to see if they have an understanding of handwashing. (Corporate RN) told us that the gowns were really not necessary unless they came in contact with stool. My interpretation of the policy is based on what (Corporate RN) said. She said that to deliver food to a resident you don't need a gown you only have to wear a gown if you anticipate getting splashed. I have read the policies myself but I just can't quote them." The DON also stated whenever she was in doubt, she called the Corporate RN. She stated the Corporate RN told her what to do. The Administrator was asked if the Medical Director was informed there were residents with [DIAGNOSES REDACTED]icile in the facility. The DON replied, "They are his patients. I think he would know but I don't know." The Administrator was asked what the Medical Director's role was in assisting with the management of residents with Clostridium difficile. She replied, "He attends all the QA meetings here and we discuss infections during QA meetings." 6. The Plan of Removal accepted on 05/26/12 reflected the following: 1. Resident #23 was assessed from head to toe with vital signs on 05/05/12 at 4:15 PM and not problems were found. His attending physician was notified on 05/25/12 at 10:45 AM and gave a telephone order to culture the resident's stool to rule out[DIAGNOSES REDACTED]. Resident #23 was transferred to a private room and was placed on contact isolation as a precaution until the results of the stool culture were received. If stool culture comes back positive for[DIAGNOSES REDACTED], the resident will be treated according to his physician's orders [REDACTED]. If stool culture comes back negative for[DIAGNOSES REDACTED], contact isolation will be discontinued. 2. Nurses were informed at every shift of residents on isolation through the 24-hour report as well as nurse to nurse verbal report. All other nursing staff were informed at every shift of residents on isolation through the Accu-nurse electronic documentation system. 3. Charge Nurses assessed each resident on their assigned halls for signs and symptoms of diarrhea on 05/25/12. No residents had diarrhea or reported having any diarrhea that day. 4. An in-service will be held on 05/26/12 at 2:00 PM by the DON to re-educate all staff (nursing, housekeeping, dietary, etc.) regarding Clostridium difficile including signs and symptoms of infection and on immediate reporting to a resident's Charge Nurse. They will re-educate nursing staff regarding strict adherence to contact isolation practices including applications of personal protective equipment when caring for residents with[DIAGNOSES REDACTED], proper handwashing techniques, using disinfectant wipes that contain bleach to wipe out any spills from contaminated stools. A competency-based test will be given to each nursing staff member to validate comprehension and compliance. This re-education and competency-based testing will be completed on 05/25/12 at 6:00 PM by the DON and ADONs. Nursing staff, including weekend nursing staff, will not be allowed to return to work without completing this re-education and competency-based tests. New hire nursing staff will not be allowed to work without completing the education competency-based test. The DON, ADONs and/or other designee will monitor new hires to ensure completion and compliance. Staff members that fail competencies will be re-educated until successful skills are achieved. 5. All staff (nursing, housekeeping, dietary, etc.) will be validated by a proficiency check-off as well as a return demonstration on proper handwashing technique and proper application of personal protective equipment. These proficiency check-offs will be completed by the DON, ADONs and/or designee on 05/25/12 at 6:00 PM. Any nursing staff, including the weekend nursing staff, who has not completed the proficiency check-off will not be allowed to return to work. The DON, ADONs, and/or designee will monitor new hires to ensure completion and compliance. Staff members who fail competencies will be re-educated until successful skills are achieved. 6. All housekeeping staff will be re-educated on using Quat Disinfectant Cleaner Concentrate to clean and disinfect floors in rooms that are not used as an isolation room. All housekeeping staff will be re-educated on utilizing Dispatch with bleach to clean and disinfect floors in rooms that are used as an isolation room. All other floor cleaners in the facility were disposed of by the Housekeeping Supervisor and will not be used. This re-education will be completed by the Housekeeping Supervisor on 05/25/12 at 6:00 PM. Any housekeeping staff, including weekend housekeeping staff, who have not completed this re-education, will not be allowed to work. The Housekeeping Supervisor will monitor new hires to ensure completion and compliance. 7. All dietary staff will be re-educated on cleaning each food tray cart with soap and water and wiping them with a solution that contains bleach. This re-education will be completed by the Dietary Supervisor on 05/25/12 at 6:00 PM. Any dietary staff, including weekend dietary staff, who have not completed this re-education, will not be allowed to work. The Dietary Supervisor will monitor new hires to ensure completion and compliance. 8. All telephone orders, new admissions/re-admissions and 24-hour reports will be reviewed and discussed in the daily morning meeting, during the week to ensure new cases of infections that require contact isolation are appropriately addressed. Any identified issues will be addressed immediately by the DON/ADON/or nurse designee. This meeting will be attended by the DON, ADON, and the MDS nurses. All telephone orders, new admissions/re-admissions and 24-hour reports will be reviewed on the weekend by the Weekend Supervisor for completion and compl

Based on observation, interview, and record review, it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three (Residents #1, #2, and #23) of 23 residents reviewed for infection control. 1) The DON failed to ensure the facility's Infection Control policies and procedures were implemented by all facility staff, including nursing, housekeeping and dietary staff. a. Staff failed to isolate Resident #1, who had [MEDICAL CONDITION], from his roommate, Resident #23, who was at high risk of contracting [MEDICAL CONDITION] due to his [DEVICE]. b. CNA I, MA J, LVN A, and CNA F failed to wear gloves and/or gowns when entering Resident #1's room. c. Housekeeping staff failed to clean Resident #1's room floor and the facility's floors with cleaners, which would kill [MEDICAL CONDITION]. d. Dietary staff failed to use cleaners in the kitchen, which killed [MEDICAL CONDITION]. e. Staff failed to Resident #2's bedpan in an appropriate place in her room. Staff failed to place a sign on the resident's door to alert visitors to check with nursing prior to entering her room. Staff failed to keep the isolation cart stocked with gowns. LVN A, CNA I, CNA H, and CNA G failed to wear gowns, gloves, and/or perform hand hygiene when entering or leaving Resident #2's room. CNA F removed Resident #2's contaminated food tray from her room and placed it the cart with the other residents' meal trays. Staff failed to keep the cardboard box in the resident's room appropriately lined with a biohazard bag. On 05/25/12, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 05/26/12, the facility remained out of compliance at a scope of "widespread" and a severity level of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect all 109 residents by placing them at risk for cross-contamination, infections, and a decreased quality of life. Findings included: [MEDICAL CONDITION] is a spore-forming, Gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD). Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the [MEDICAL CONDITION] spores. [MEDICAL CONDITION] spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. The following measures can help prevent [MEDICAL CONDITION] spread in long-term care settings: Use antibiotics judiciously; Use Contact Precautions: for patients with known or suspected [MEDICAL CONDITION] infection: Place these patients in private rooms. Isolate patients immediately if [MEDICAL CONDITION] is suspected. If private rooms are not available, these patients can be placed in rooms (cohorted) with other patients with [MEDICAL CONDITION] infection. Use gloves and gowns when entering patient rooms and during patient care, even for short visits. Perform Hand Hygiene after removing gloves. Because alcohol does not kill [MEDICAL CONDITION] spores, use of soap and water is more efficacious than alcohol-based hand rubs. Centers for Disease Control and Prevention. (March 6, 2012). Healthcare-associated Infections. (electronic version). Retrieved June 5, 2012, from Http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs. 1. During an interview on 05/25/12 at 1:05 PM with the Administrator and the DON, the DON stated, "My responsibilities are to educate staff, make sure the staff know how to use the proper equipment, enforce policies and procedures." 2. The facility's policy "[MEDICAL CONDITION]," revised August 2009 was part of the Infection Control Policy and Procedure Manual. The DON provided the surveyors with a copy of the policy and stated it was the current policy. The policy reflected, "Policy Statement Preventive Measures will be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents and precautions will be taken while caring for residents with [MEDICAL CONDITION] (to prevent transmission of [MEDICAL CONDITION] to others)...1. The facility has adopted Standard Precautions, and all residents' blood, body fluids, excretions, and secretions are considered potentially infectious...3. Residents with diarrhea associated with [MEDICAL CONDITION] be placed on Contact Precautions for the duration of the illness...4. Residents considered high at risk of developing symptoms associated with [MEDICAL CONDITION] include those with advancing age, gastrointestinal manipulation (especially [MEDICAL CONDITION] tube insertion), previous gastrointestinal illness caused by [MEDICAL CONDITION]...6. When caring for residents with diarrhea or fecal incontinence, staff will maintain vigilant hand washing with soap and water, rather than alcohol-based hand rubs...7. Due to the persistence of [MEDICAL CONDITION] spores for prolonged periods of time all fecally-contaminated articles must be considered potentially infectious and disinfected with disinfecting agent recommended for [MEDICAL CONDITION] (household bleach and water solution). 8. At a 1:10 dilution of bleach and water will be used for routine environmental disinfection of rooms for residents with [DIAGNOSES REDACTED]icile...." The facility's policy "General Control Practices" revised August 2009 reflected, "Contact Precautions Contact Precautions In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. a. Examples of infections requiring Contact Precautions include, but are not limited to: ...(2) Diarrhea associated with ,[MEDICAL CONDITION]. diffile...Resident Placement During Contact Precautions b. Resident Placement (1) Place the individual in a private room if it is not feasible to contain drainage, excretions, blood or body fluids...(2) If a private room is not available, the Infection Control Coordinator will assess various risks associated with other resident placement options(e.g., cohorting). Gloves and Handwashing During Contact Precautions c...(3) Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. (4) After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room. Gowns During Contact Precautions d. Gown (1) In addition to wearing a gown as outlined under Standard Precautions, wear a gown (clean, nonsterile) for all interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. (2) After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces...." The facility's policy "Handwashing/Hand Hygiene" revised August 2009 reflected, "...5. All employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non- antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents; b. When hands are dirty visibly soiled with blood or other body fluids; ...d. After removing gloves; e. After handling items potentially contaminated with blood, body fluids, or secretions...g. When there is likely exposure to spores (i.e., [DIAGNOSES REDACTED]icile and Bacillus anthracis). (Note: Alcohol-based hand rubs are inactive against spores. For effective mechanical removal of spores, wash hands for 30 to 60 seconds with soap and water.)" 3. Resident #1's Face Sheet dated 04/23/12 reflected he was a [AGE] year-old male, who was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident #1's hospital discharge physician's orders [REDACTED]. Resident #1's Laboratory Report dated 05/15/12 reflected he was positive for both the [MEDICAL CONDITION] and [MEDICAL CONDITION] Toxin A/B. An observation on 05/22/12 at 10:00 AM revealed no gowns were stocked in the isolation cart in front of Resident #1's room. Observation at 10:45 AM on 05/22/12 revealed Resident #1 was in contact isolation for [MEDICAL CONDITION]. Resident #23 was Resident #1's roommate. LVN A used alcohol gel hand sanitizer rather than soap and running water for hand hygiene. There were gowns observed in the isolation cart. An observation on 05/23/12 at 9:00 AM revealed CNA F put gloves on, picked up Resident #1's contaminated breakfast tray, carried the tray to the meal cart, removed her gloves and without performing hand hygiene, she put the gloves in the trashcan in Resident #1's doorway. She then went down the hall, picked up residents' trays, and put them in the cart. An observation on 05/23/12 at 1:40 PM revealed CNA F picked up Resident #1's contaminated lunch tray and put it in the meal cart in the hallway. She did not wear gloves or wash her hands after handling Resident #1's tray. An observation on 05/24/12 at 2:45 PM revealed CNA I entered Resident #1's room wearing only gloves and closed the door behind him. The sign on the resident's door reflected, "See Nurse before entering room." There were no other signs on the door or on the medication cart indicating what type of personal protective equipment to use or what the type of isolation was. On 05/24/12 at 2:45 PM, MA J was queried about isolation precautions. The surveyor pointed at Resident #1's room and asked, "What do I need to put on to go into that room?" MA J replied, "Resident #1 is in isolation. He only needs gloves to go into the room. He's on contact isolation. The other resident is not on isolation, so you don't need anything to see him." An observation on 05/24/12 at 3:00 PM revealed MA J entered Resident #1's room wearing only gloves. She was carrying a handful of packaged graham crackers. She exited the room without gloves and put the graham crackers on top of the isolation cart in the hallway. MA J squirted some alcohol hand sanitizing gel onto her hands and rubbed it quickly into her hands. Then she picked up the wrapped packages of graham crackers and carried them to the common area where some residents were sitting. MA J unwrapped a package of graham crackers and handed them to Resident #25. MA J continued walking from the common area with the packaged graham crackers in her hands to the hallway. On 05/25/12 at 8:30 AM LVN K was interviewed. She was queried about contact isolation procedures. LVN K stated, "For contact isolation, the tag on the door indicates isolation. In dietary there is a tag on the tray that indicates the resident is on isolation and the kitchen staff are supposed to know to wear gloves to touch the tray. For staff that provide care and could be splashed with liquids like blood, urine, or stool, then they need to wear a full gown, gloves, but no mask. But, for only passing meal trays, or med (medication) pass they have to put on only gloves." An observation on 05/25/12 at 8:45 AM with LVN K of the central supply area revealed one and 1/2 cases of water-soluble laundry bags, three cases of red plastic bags, five boxes of surgical masks, one case of gloves with 1000 gloves per case, several cases of unpacked gloves on the shelf, one case of yellow laundry bags, one case of shoe covers. No gowns were observed stocked in the central supply area. On 05/25/12 at 8:45 AM LVN K was queried about the lack of gowns in the central supply area. LVN K stated there were more in another storage room that was outside the building. An interview on 05/25/12 at 8:55 AM with Laundry Aide L revealed she worked two days and two nights a week in the laundry and one day as a housekeeper. When Laundry Aide L was queried about handling potentially infectious laundry, she replied, "That laundry comes in a red bag. When the red bags come in I rip them open and inside them is a vinegar bag. A vinegar bag is one that goes right into the laundry machine and dissolves. I wash the laundry inside the vinegar bag three times on the hot cycle. The red bag goes into the trashcan. I always wear disposable gloves." Laundry Aide L pointed at the boxes of disposable gloves next to the laundry machine. She stated, "I don't wear a rubber apron or gown because the laundry is contained inside the water-soluble bags." Laundry aides were provided with a large plastic face shield, a plastic apron, a plastic raincoat like coat, box of disposable gloves and a pair of large thick plastic gloves for personal protective equipment. The personal protective equipment was observed hanging on a hook in the laundry room by the trash cans. The Dietary Manager was interviewed about infection control techniques in the kitchen on 05/25/12 at 9:15 AM. She stated staff wiped the meal tray carts after every meal with a K-Sani-Quat soaped cleaning cloth. She stated they changed the cloths often. The Dietary Manager also stated they used K-Sani-Quat cloths on the countertops in the kitchen. She stated all dishes and pans went through the dishmachine. The Dietary Manager stated, "Bleach water is used on the tables about once a month. We use it to take out stains. Sometimes we take the meal tray carts outside in the parking lots on weekends and wash them with a hose and running water." On 05/25/12 at 10:30 AM the surveyor contacted the chemical company who manufactured the K-Sani-Quat that was used in the kitchen. During the interview, the manufacturer's Representative stated, "K-Sani-Quat does not kill [DIAGNOSES REDACTED]icile." The Representative stated the only thing that killed [DIAGNOSES REDACTED]icile was bleach. On 05/25/12 at 10:35 AM Housekeeper N was interviewed about disinfection techniques in isolation rooms and housekeeping in the facility in general. Housekeeper N stated she cleaned rooms with a washcloth and Quat disinfectant. She stated she used a washcloth for each room for all the surfaces. Housekeeper N stated for[DIAGNOSES REDACTED]icile rooms she used Dispatch wipes cleaner on the surfaces but used the Quat disinfectant on the toilet bowls. She stated she wore gloves and used hand sanitizer to clean her hands. Housekeeper N stated she used Emerald cleaner on the floors in the isolation rooms and in the facility. When queried about Emerald cleaner, she stated she did not know what it was, but it was provided in the housekeeping room. Dispatch Hospital Cleaner Disinfectant Towels with Bleach contained a 1:10 dilution of bleach and a detergent, according to the bottle's label on 05/25/12. On 05/25/12 at 11:10 AM a copy of the label of Emerald floor cleaner #412 was obtained from the Housekeeping Supervisor. The phone number on the label was the supplier and distributor for Emerald floor cleaner. The surveyor called the Distributer of the floor cleaner about the cleaner's disinfection properties. The representative stated Emerald #412 was not a disinfectant of any kind. The Representative stated it was a floor cleaner. On 05/25/12 at 11:15 AM the Housekeeping Supervisor was interviewed regarding the chemicals used to clean and disinfect the facility. He stated, "We use Emerald on the floors to clean and disinfect. We also use 3M neutral cleaner three and one to clean the floors." 3. Resident #23 an [AGE] year-old male who was originally admitted to the facility on [DATE], according to his Face Sheet dated 03/09/12. Resident #23's MDS assessment dated [DATE] reflected he was totally dependent on staff for all ADLs, was incontinent of bowel and bladder, and he had a gastrostomy tube to receive food and water. An observation on 05/23/12 at 7:55 AM revealed Resident #23 yelling and pulling on his gastrostomy tube. The surveyor called the Charge Nurse to the resident's room. LVN A put a glove on his right hand only. LVN A touched Resident #23's gastrostomy tube with his gloved hand. LVN A then reached into a box of gloves at the bedside table, donned a glove on the left hand without performing hand hygiene. LVN A straightened Resident #23's clothes and the gastrostomy tube. LVN A opened the bathroom door, removed Resident #1's wheelchair, entered the bathroom, and washed his hands. An observation on 05/25/12 at 10:00 AM revealed LVN K entered Resident #23's room to administer the resident's medications via [DEVICE]. When asked where he obtained the water to dilute Resident #23's [DEVICE] medications and feedings, LVN A pointed to the resident's bathroom and said, "From the sink or my medication cart." When asked where Resident #23's feeding syringe and graduated cylinder were rinsed after use, LVN A pointed to the sink in the bathroom and said, "In there." LVN A was wearing gloves, but not a gown. LVN A completed administering Resident #23's [DEVICE] medications, took off his gloves, put them in the trash can, went to the bathroom, rinsed the feeding syringe and graduate, washed his hands with soap and water, dried his hands, turned off the water without using a paper towel to touch the spigot handle, carried the syringe and graduate, and put them on Resident #23's bedside table. LVN A opened the door and left the room. An interview on 05/25/12 at 10:55 AM CNA F and CNA I were asked if Resident #23 was having a lot of bowel incontinent episodes and they stated the resident was having stools every time they changed him. CNA F stated it was not diarrhea, but it was not solid. She stated he had been having it for days, but she did not tell the Charge Nurse. 4. Resident #2 was originally admitted on [DATE]. Resident #2 was readmitted on [DATE], according to the Face Sheet dated 05/24/12. Resident #2's MDS assessment dated [DATE] reflected the resident was an [AGE] year-old female. Resident #2's May 2012 physician's orders [REDACTED]. A handwritten note on Resident #2's Physicians Orders reflected [MEDICAL CONDITION] toxin 05/10/12. During initial rounds on 05/22/12 at 9:35 AM, LVN A stated, "(Resident #2) has [MEDICAL CONDITION] and is on isolation." An observation at that time revealed there was not a sign on the resident's door reflecting isolation or to see the nurse prior to entering. An isolation cart was outside the door in the hall way. The isolation cart had one box of size small gloves and shoe covers. The cart did not contain isolation gowns, biohazard bags (red bags) or yellow bags (used to denote contaminated linen). LVN A and the surveyor entered Resident #2's room. The biohazard bag had slipped down inside the cardboard box and the contaminated contents were touching the inside of the cardboard box. (Note: the red plastic bag should be completely lining the cardboard box to prevent any leakage of contaminated substances through the cardboard.) The cardboard box was located in the resident's bathroom. A bedpan was on top of an opened bedside commode and there was an odor of feces. LVN A was queried about the bedpan on the bedside commode. LVN A stated, "I don't know why this is here." LVN A used a gloved hand to remove the bedpan from the opened bedside commode which was full of feces. LVN A put the bedpan in the bathroom and closed the lid on the bedside commode. LVN A's pants were sagging and slipping down, and he pulled them up using the same contaminated gloved hand. LVN A did not his wash hands with soap and water after touching the commode and removing his gloves. LVN A exited the room and used alcohol gel hand sanitizer. An observation at 8:03 AM on 05/23/12 revealed CNA I entered Resident #2's room with a pastry and chocolate milk. She placed it on Resident #2's bedside table. CNA I then exited the room. CNA I was not wearing gloves or a gown when she entered or exited the resident's room. CNA I did not use hand hygiene before or after entering the isolation room. An observation at 8:15 AM on 05/23/12 revealed CNA H and CNA I entered Resident #2's room wearing gloves, but not gowns. They pulled Resident #2 up in bed and repositioned her. Their uniforms were pressed against the bed during the repositioning. They wore dirty gloves, when they raised the head of the resident's bed. Then the CNAs repositioned the resident's bedside commode and touched the resident's headboard. They went to the resident's bathroom, pulled off their gloves, put them in the red biohazard box and left the room. They both used hand sanitizer in the hallway. Observation of the isolation cart in front of #2's room at 8:30 AM on 05/23/12 revealed no gowns were in the isolation cart for Resident #2. Observation at 8:45 AM on 05/23/12 revealed CNA H entered Resident #2's room without a gown, gloves, or performing hand hygiene. She went to the sink in the resident's bathroom, wet a washcloth and gave Resident #2 the wet washcloth. Resident #2 wiped her face with the washcloth. CNA H then went back outside the room and put on a pair of gloves. CNA H went back in the room and took the washcloth from the Resident #2. CNA H put the wet washcloth in the biohazard red bag, removed her gloves and washed her hands in the resident's bathroom. An observation on 05/23/12 at 10:00 AM revealed gowns were being stocked in Resident #2's isolation cart in the hallway. Observation at 1:50 PM on 05/23/12 revealed CNA G entered Resident #2's room without performing hand hygiene. She did not put on gloves or a gown. CNA G went outside the resident's room without performing hand hygiene. CNA G removed several packages of Sweet and Low from the meal cart and took the packages into Resident #2's room. CNA G open and stirred the package of Sweet and Low into Resident #2's tea. She was not wearing gloves or a gown. CNA G did not perform hand hygiene after leaving the room. An observation on 05/23/12 at 1:55 PM revealed CNA F entered Resident #2's room and took the resident's tray from her bedside table. He placed the resident's contaminated meal tray in the meal cart with the other residents's meal trays, which were sent back to the kitchen. CNA F did perform hand hygiene, but did not glove, and did not put on a gown when he entered her room or after putting the contaminated meal tray on the cart. 5. On 05/25/12 at 1:05 PM an IJ was identified. During an interview with the Administrator and the DON on 05/25/12 at 1:05 PM, they were informed of the IJ and Plan of Removal was requested at that time. The DON and the Administrator were asked if they had addressed [MEDICAL CONDITION] in their QA meetings. The administrator replied, "Not as a specific topic of its own. The QA goes through all of the infections but not [MEDICAL CONDITION] as a specific topic." The DON and Administrator were asked about management of residents with [MEDICAL CONDITION] infections. The DON replied, "We do what the policy and procedure says. But what (corporate nurse) told me was to wear gloves only. If you feel you may come in contact with body fluids then you wear a gown." When asked how CNAs determined what type of personal protective equipment they should use for particular infections, the DON replied, "They put on what they are told to put on by the nurses." During this same interview on 05/25/12 at 1:05 PM, the DON and Administrator were asked how they thought the IJ occurred. The DON replied, "It occurred when you (surveyor) were concerned that we were not wearing gowns. I think it's a mis-communication. We may need to change our policy. I think the staff are handwashing in serviced (were taught to wash their hands) but people are just not thinking they're in a hurry and they may need to be re-educated to see if they have an understanding of handwashing. (Corporate RN) told us that the gowns were really not necessary unless they came in contact with stool. My interpretation of the policy is based on what (Corporate RN) said. She said that to deliver food to a resident you don't need a gown you only have to wear a gown if you anticipate getting splashed. I have read the policies myself but I just can't quote them." The DON also stated whenever she was in doubt, she called the Corporate RN. She stated the Corporate RN told her what to do. The Administrator was asked if the Medical Director was informed there were residents with [DIAGNOSES REDACTED]icile in the facility. The DON replied, "They are his patients. I think he would know but I don't know." The Administrator was asked what the Medical Director's role was in assisting with the management of residents with [MEDICAL CONDITION]. She replied, "He attends all the QA meetings here and we discuss infections during QA meetings." 6. The Plan of Removal accepted on 05/26/12 reflected the following: 1. Resident #23 was assessed from head to toe with vital signs on 05/05/12 at 4:15 PM and not problems were found. His attending physician was notified on 05/25/12 at 10:45 AM and gave a telephone order to culture the resident's stool to rule out [MEDICAL CONDITION]. Resident #23 was transferred to a private room and was placed on contact isolation as a precaution until the results of the stool culture were received. If stool culture comes back positive for [MEDICAL CONDITION], the resident will be treated according to his physician's orders [REDACTED]. If stool culture comes back negative for [MEDICAL CONDITION], contact isolation will be discontinued. 2. Nurses were informed at every shift of residents on isolation through the 24-hour report as well as nurse to nurse verbal report. All other nursing staff were informed at every shift of residents on isolation through the Accu-nurse electronic documentation system. 3. Charge Nurses assessed each resident on their assigned halls for signs and symptoms of diarrhea on 05/25/12. No residents had diarrhea or reported having any diarrhea that day. 4. An in-service will be held on 05/26/12 at 2:00 PM by the DON to re-educate all staff (nursing, housekeeping, dietary, etc.) regarding [MEDICAL CONDITION] including signs and symptoms of infection and on immediate reporting to a resident's Charge Nurse. They will re-educate nursing staff regarding strict adherence to contact isolation practices including applications of personal protective equipment when caring for residents with [MEDICAL CONDITION], proper handwashing techniques, using disinfectant wipes that contain bleach to wipe out any spills from contaminated stools. A competency-based test will be given to each nursing staff member to validate comprehension and compliance. This re-education and competency-based testing will be completed on 05/25/12 at 6:00 PM by the DON and ADONs. Nursing staff, including weekend nursing staff, will not be allowed to return to work without completing this re-education and competency-based tests. New hire nursing staff will not be allowed to work without completing the education competency-based test. The DON, ADONs and/or other designee will monitor new hires to ensure completion and compliance. Staff members that fail competencies will be re-educated until successful skills are achieved. 5. All staff (nursing, housekeeping, dietary, etc.) will be validated by a proficiency check-off as well as a return demonstration on proper handwashing technique and proper application of personal protective equipment. These proficiency check-offs will be completed by the DON, ADONs and/or designee on 05/25/12 at 6:00 PM. Any nursing staff, including the weekend nursing staff, who has not completed the proficiency check-off will not be allowed to return to work. The DON, ADONs, and/or designee will monitor new hires to ensure completion and compliance. Staff members who fail competencies will be re-educated until successful skills are achieved. 6. All housekeeping staff will be re-educated on using Quat Disinfectant Cleaner Concentrate to clean and disinfect floors in rooms that are not used as an isolation room. All housekeeping staff will be re-educated on utilizing Dispatch with bleach to clean and disinfect floors in rooms that are used as an isolation room. All other floor cleaners in the facility were disposed of by the Housekeeping Supervisor and will not be used. This re-education will be completed by the Housekeeping Supervisor on 05/25/12 at 6:00 PM. Any housekeeping staff, including weekend housekeeping staff, who have not completed this re-education, will not be allowed to work. The Housekeeping Supervisor will monitor new hires to ensure completion and compliance. 7. All dietary staff will be re-educated on cleaning each food tray cart with soap and water and wiping them with a solution that contains bleach. This re-education will be completed by the Dietary Supervisor on 05/25/12 at 6:00 PM. Any dietary staff, including weekend dietary staff, who have not completed this re-education, will not be allowed to work. The Dietary Supervisor will monitor new hires to ensure completion and compliance. 8. All telephone orders, new admissions/re-admissions and 24-hour reports will be reviewed and discussed in the daily morning meeting, during the week to ensure new cases of infections that require contact isolation are appropriately addressed. Any identified issues will be addressed immediately by the DON/ADON/or nurse designee. This meeting will be attended by the DON, ADON, and the MDS nurses. All telephone orders, new admissions/re-admissions and 24-hour reports will be reviewed on the weekend by the Weekend Supervisor for completion and compliance. Any identified issues will be addressed immediately by the Weekend Supervisor. 9. QA meeting is scheduled for 05/25/12 at 6:00 PM to be attended by the Administrator, DON, and ADONs to discuss the current IJ situation and Plan of Removal. The Medical Director will attend the QA meeting via telephone conference. The DON, ADONs and Administrator will monitor the re-education and training program to ensure effectiveness and compliance. Any identified issues will be reviewed during the monthly QA meeting every three months and randomly thereafter. If at any time, the Medical Director is unable to attend a scheduled QA meeting, then he will be informed of all issues and or/concerns via telephone conference. If the QA committee determines any changes are needed to the policy and/or procedure, all staff will be re-educated by the DON/ADON/or nurse designee and will provide return demonstration. 10. The facility's two Medical Co-Directors were notified by the DON of the I J on 05/25/12 at approximately 2:30 PM and 3:00 PM. 7. From 1:20 PM through 2:30 PM on 05/26/12 demonstrations and interviews were conducted with staff regarding the training they had received about personal protective equipment, how to know residents are in isolation, which PPE (personal protective equipment) equipment should be worn, and hand washing techniques. RN D, LVN O, CNA F, CNA I, Housekeeper P, the Housekeeping Supervisor, and the Dietary Manager, were all able to successfully demonstrate proper hand washing, proper donning and removal of shoe covers, gowns, gloves, and masks; were able to identify which cleaners killed [MEDICAL CONDITION], and were able to relate what sign should be on doors indicating isolation. Housekeeper P and the Housekeeping Supervisor were also able to demonstrate appropriate disinfection of isolation rooms using a disposable mop, dispatch cleaner, and dispatch wipes for surfaces. 8. The Administrator and the DON were notified on 05/26/12 at 2:49 PM that the IJ was removed. While the IJ was removed, the facility remained out of compliance a scope of "widespread" and a severity level of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy." 9. Complications that result from [MEDICAL CONDITION] include pseudomembranous [MEDICAL CONDITION], (PMC), toxic mega colon, perforations of the colon,[MEDICAL CONDITION], death. The risk for disease increases in patients with antibiotic exposure, proton pump inhibitors, gastrointestinal surgery/manipulation such as a gastrostomy feeding tube, long length of stay in healthcare settings, a serious underlying illness, immune compromising conditions, advanced age. However, early experimental data suggest that, even using soap and water, the removal of