Every finding on record at North Mountain Medical and Rehabilitation Center

Number of residents sampled: 154Number of residents cited: 26Based on observation, interview, review of clinical record, and review of facility policy and procedure, facility failed to ensure that residents with an atypical rash received appropriate treatment, isolation, and infection control measures for 24 residents (#155, #36, #50, #185, #186, #41, #51, #53, #54, #55, #85, #188, #99, #180, #189, #106, #9, #123, #190, #150, #153, #14, #31, and #176); failed to ensure staff performed hand hygiene when providing care for one resident (#143); and, failed to ensure enhanced barrier precautions were followed for one resident (#115). The deficient practice could lead to spread of infection.Findings include: Regarding atypical rash -Resident #155 was admitted on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia, critical illness myopathy, and encounter for attention to tracheostomy. The clinical census lists revealed that Resident #36 and Resident #155 were roommates in September 2025.An NP progress note dated August 12, 2025 revealed Resident #155 had no rash. A change in condition note dated August 18, 2025 included the resident had rashes on arms, hands, back, and abdomen, with raised red bumps. The note also included the provider was notified and new orders for triamcinolone cream for 10 days were received. An NP progress note dated August 18, 2025 indicated that the resident had rash to arms, hands, back, and abdomen, and was started on triamcinolone cream. A physician order dated August 18, 2025 included for COC monitoring due to rashes on abdomen, arms, hands, and back, every shift for 3 days. A medication administration note dated August 19, 2025 revealed Resident #155 had rash that was still visible to abdomen, arms, and back. A medication administration note dated August 20, 2025 included the resident had rashes on arms, hands, back, and abdomen. An annual MDS assessment dated [DATE], revealed a BIMS assessment that was not completed due to the resident being rarely or never understood. The assessment coded no open lesions other than ulcers, rashes, or cuts. An NP progress note dated September 3, 2025 included the resident was seen by the provider; and that, the resident had a rash. The plan was to continue triamcinolone cream as ordered and to monitor the rash. A weekly skin evaluation dated September 4, 2025 revealed no new skin issues; however, the documentation did not indicate whether the resident's rash was still present or has resolved. A weekly skin evaluation dated September 6, 2025 included Resident #155 had an open area to the left buttock. The documentation did not include whether the resident's rash was still present or has resolved. A weekly skin evaluation dated September 11, 2025 revealed no new skin issues noted; however, the documentation did not indicate whether the resident's rash was still present or has resolved. A change in condition note dated September 13, 2025 included rash on the resident's body; and, a new order was received to treat Resident #155 for atypical rash. The documentation included that the resident would be administered with Permethrin cream treatment on September 14, 2025, at bedtime. The physician order dated September 13, 2025 revealed the following:COC monitoring related to body rash, every shift for atypical rash for 3 days; and,Permethrin External Cream 5%, to apply to neck to toes topically at bedtime every Sunday for atypical rash, for 1 administration, and to start on September 14, 2025. A medication administration note dated September 14, 2025 revealed Resident #155 had rashes on hands, arms, and back. A medication administration note dated September 15, 2025 included the resident had rashes on abdomen, back, arms, and legs. An NP progress note dated September 17, 2025 revealed the resident had a rash, and continued with Permethrin cream as ordered for atypical rash. The weekly skin evaluations dated September 18 and 25, 2025 included had no new skin issues. The documentation did not indicate whether the resident continued to have a rash or the rash has resolved. A physician order dated September 29, 2025 included for Permethrin External Cream 5%, to apply to neck to toes topically at bedtime every Monday, for 1 administration. Review of the MAR for September 2025, revealed the Permethrin cream treatment was completed on September 14, 21 and 29. The clinical record revealed no documentation of any orders for contact isolation precautions since August 18, 2025. Despite documentation the resident received Permethrin for a rash, there was no evidence found that facility implemented steps in controlling the spread of scabies such as washing of all clothing and bedding used during the days before treatment began; and, items that cannot be washed or dry cleaned were sealed in plastic bag for several days to a week. During an interview and clinical record review conducted with the Nurse Practitioner (NP/Staff #401) on November 24, 2025, at 10:01 a.m., the NP stated that in September 2025 she identified that Resident #155 had an atypical rash and suspected scabies. She stated that she ordered Permethrin cream on September 13, 2025, and expected staff to follow the facility protocol for a suspected scabies infection. An interview was conducted with a charge nurse (Staff #323) on November 25, 2025, at 10:20 a.m. The LPN stated that when a resident develops a new skin condition, nursing staff contact the provider, and any treatment orders are implemented. She stated that if a resident has an atypical rash and was prescribed Permethrin cream, physician order should be in place for contact isolation precautions. The charge nurse said that she knows Permethrin cream is used to treat scabies; and that, residents treated with Permethrin cream should be placed on contact isolation both to prevent staff exposure to the strong medication and to prevent the infection from spreading. A review of the clinical record for Resident #155 was conducted with the charge nurse who stated that she found no physician orders or other evidence that contact isolation precautions were implemented for Resident #155 when the atypical rash was identified on September 13, 2025. In an interview conducted with the Assistant Director of Nursing (ADON/Staff #87) on November 25, 2025, at 10:44 a.m. the ADON stated when isolation precautions are ordered along with Permethrin cream treatment, staff understand that the resident's rash could be contagious. She said that facility providers expect staff to follow a protocol in which residents treated with Permethrin cream are placed on isolation precautions, the cream is applied and left on for 8-12 hours, and the resident's room is deep cleaned. A review of the clinical record was conducted with the ADON who stated that she found no physician orders or other evidence that contact isolation precautions were implemented for the resident from September 13, 2025, when the atypical rash was identified, through September 15, 2025, when the Permethrin cream would have been washed off. Staff #87 also stated that she did not know whether there was any written policy or protocol for staff to follow regarding Permethrin cream treatment. -Resident #36 was re-admitted on [DATE], with diagnoses of anoxic brain damage. The clinical census lists revealed that Resident #36 and Resident #155 were roommates in September 2025. The care plan dated June 4, 2025 revealed the resident had the potential to develop infection related to medical condition due to multiple co-morbidities. Interventions included in-house infectious disease consult and use standard precautions to prevent infection. A weekly skin evaluation dated September 4, 2025 included the resident had no new skin issues. An NP progress note dated September 12, 2025 revealed Resident #36 had no rashes. A change in condition note dated September 13, 2025 included a new order was received to treat Resident #36 preventatively for atypical rash; and that, the resident would receive Permethrin cream treatment on September 14, 2025, at bedtime. The documentation also included that there were no rash was noted at the time. The physician order dated September 13, 2025 included for the following:COC monitoring due to atypical rash prophylaxis, every shift for 3 days; and,Permethrin External Cream 5%, to apply to neck to toes topically at bedtime for atypical rash prophylaxis, for 1 administration. Review of the MAR for September 2025 revealed the Permethrin cream was documented as administered on September 14, 2025. A medication administration note dated September 15, 2025 revealed Resident #36 was s/p Permethrin cream treatment from September 14, 2025; and, was showered in the morning. However, despite documentation the resident received Permethrin, there was no evidence found that the resident's clothing, towels and beddings were washed; and, items that cannot be washed or dry cleaned were sealed in plastic bag for several days to a week. There was no documentation found in the clinical record that the resident was placed on any contact isolation precautions. A facility deep cleaning log for September 2025 revealed that the room shared by Resident #36 and Resident #155 was not deep cleaned until September 16, 2025 (approximately 2 days after permethrin was administered on September 14, 2025). The documentation also included that the room was due to a recurring schedule, and not specified due to the room coming off of isolation. -Resident #50 was admitted to the facility on [DATE], and re-admitted to the facility on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, end stage renal disease, and cognitive communication deficit. A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #50 had a brief interview for mental status (BIMS) assessment score of 12, indicating moderate cognitive impairment. Section M revealed no open lesions other than ulcers, rashes, or cuts coded. A daily skilled note dated July 3, 2025 included that Resident #50 had no active symptoms effecting the integumentary system observed, and no active skin condition(s) or treatments observed. A physician progress note dated July 14, 2025, revealed Resident #50 complained of itching, and the plan included to consult dermatology to evaluate. A physician order dated July 14, 2025, included for a dermatology appointment as soon as possible. A Physician Progress Note dated July 16, 2025, revealed Resident #50 still continued to have a rash and will be started on Permethrin cream awaiting dermatology appointment. A Change in Condition Note dated July 16, 2025, revealed Resident #50 was monitored for atypical rash, was showered this shift, and to be treated tonight with Permethrin cream. Also, the note revealed isolation precautions were in place.The physician order dated July 16, 2025, included for:Change of condition (COC) monitoring due to atypical rash, every shift for three days; and,Permethrin External Cream 5% (anti-parasitic medication) to apply to entire body neck down at bedtime, to leave on for 8-12 hours, and then to wash off, every Wednesday for atypical rash, for 3 weeks. The order was discontinued on August 6, 2025. A medication administration note dated July 17, 2025, revealed the Permethrin cream treatment was administered to the resident. A medication administration note dated July 18, 2025, revealed Resident #50 went to the hospital for a hernia repair on July 17, 2025. The admission note dated July 22, 2025 revealed the resident was re-admitted to the facility and had a rash on upper back and neck. The care plan dated July 22, 2025 revealed the resident had the potential to develop infection related to complex medical condition/diagnoses; and, had the potential for skin breakdown. Interventions included to administer medications/treatment as ordered, to follow facility policy and procedure for line listing, summarizing and reporting infections, to follow facility policy and procedures for transmissible infection screening/precautions, contact/droplet isolation as necessary or as ordered by the physician and maintain standard precautions when providing resident care. A daily skilled note dated July 23, 2025, revealed Resident #50 had no active symptoms effecting the integumentary system observed, and no active skin condition(s) or treatments observed. A physician order dated July 27, 2025 included an order to schedule dermatology consult due to skin itching. A Change in Condition Note dated July 28, 2025, revealed Resident #50 had no skin issues prior to transportation to gastrointestinal follow-up appointment, and no new skin issues noted upon transport back to the facility. A nurse practitioner (NP) progress note dated August 1, 2025 revealed Resident #50 had a rash and pruritus; and, had a pending dermatology consult. The documentation did not include any treatment order for the rash and pruritus. The weekly skin evaluation dated August 6, 2025, and signed August 12, 2025, revealed the resident had no new skin issues. However, the assessment did not indicate of whether the rash that was identified on August 1 was still present or not. However, a late entry NP progress note dated August 12, 2025, revealed the resident had a rash/pruritis and a pending dermatology consult. A physician order dated August 13, 2025, included to schedule dermatology appointment with a specified provider on August 27, 2025 at 4:00 P.M. The appointment/procedure note dated August 13, 2025, revealed Resident #50 had a dermatology consult, had a rash noted to upper back, abdomen, and neck, and rash to body, returned with new orders for triamcinolone cream (corticosteroid cream) to be applied to affected areas as needed for itching, and to schedule follow-up appointment to dermatology on August 27, 2025. A weekly skin evaluation dated August 13, 2025, revealed the resident had no new skin issues noted. The assessment did not indicate any rash present. The physician orders dated August 18, 2025, included for the following:COC monitoring for atypical rash, every shift for three days;Permethrin External Cream 5%, to apply neck to toes topically in the evening for atypical rash for one day on August 18, 2025 and on August 25, 2025; and,Ivermectin Oral Tablet (anti-parasitic medication) to give 21 mg by mouth one time a day for Atypical rash for 2 Days, on August 19 and 26, 2025. Review of the Medication Administration Record (MAR) for August 2025 revealed that Resident #50 was administered with Permethrin cream treatment on August 18; and, Ivermectin oral tablets on August 19, 2025. The NP progress note dated August 19, 2025 included atypical rash; and that, the resident had followed up with dermatology who recommended Ivermectin and Permethrin cream treatment. The note did not document what the resident was diagnosed with or treated for. A nursing note dated August 19, 2025 revealed Resident #50 was found with blood from self-inflicted scratches to left forearm and to right chest; and that, the wound nurse provided treatment. According to the documentation, the resident was alert and oriented and reported that he scratched himself because he was itching. The weekly skin evaluation dated August 19, 2025 included that the resident had self-inflicted to right upper chest and left forearm area. The assessment did not include details on what the resident self-inflicted; and, did not indicate whether the resident had a rash or not. However, the medication administration note dated August 19, 2025 revealed Resident #50 had rash over his complete body. A weekly skin evaluation dated August 20, 2025 revealed the resident had a skin problem on the right rear right shoulder and, had self-inflicted to right upper chest and left forearm. However, the documentation did not include description of the skin problem, what was self-inflicted, and, whether or not the resident's rash over his body has resolved or not. The medication administration note dated August 20, 2025 included that Resident #50 had rash over his complete body, with spot areas on the neck/face. Per the documentation, the resident reported that he had he had less itchiness after cream treatment and shower; and that, he was started on antibiotic for his rash on this date. A medication administration note dated August 21, 2025, revealed the resident's rash was resolving slowly. Review of the Medication Administration Record (MAR) for August 2025 revealed that Resident #50 was administered with Permethrin cream treatment on August 25; and, Ivermectin oral tablets on August 26, 27, and 29, 2025. The weekly skin evaluation dated August 27, 2025 revealed the resident had no new skin issues. The assessment did not include whether the resident had the rash or that the rash previously identified had resolved. A nursing note dated August 28, 2025 revealed Resident #50 had a rash on the back and complained of itching. The NP progress note dated August 29, 2025 revealed that Resident #50 reported pain of 2/10 and itching from previous scabies infection; and that, the provider notified the nurse of the resident's itching. A physician order dated August 31, 2025 indicated for Permethrin External Cream 5%, to apply neck to toes topically one time only for atypical rash for one day, and to shower 8-10 hours post treatment. Despite documentation the resident received Permethrin and Ivermectin for a rash, there was no evidence found that facility implemented steps in controlling the spread of scabies such as washing of all clothing and bedding used during the days before treatment began; and, items that cannot be washed or dry cleaned were sealed in plastic bag for several days to a week. A physician order dated September 1, 2025, included for a dermatologist consult for a rash. Continued review of the MAR for September 2025 revealed Permethrin cream treatment was administered September 1, 2025; and, revealed Ivermectin was administered to the resident on September 2, 2025. A weekly skin evaluation dated September 3, 2025 revealed the resident had no new skin issues. The assessment did not include documentation of a rash. The dermatology visit note dated September 9, 2025 revealed that the visit was a follow-up for scabies, evaluated during a visit on August 27, 2025. The documentation included that the resident had scaly pink patches located on the left pretibial region, negative scrapings; and that, resident still had significant itchiness which was common post scabies infection. Impression included Sequelae of other specified infectious and parasitic disease and an associated diagnosis was Post-Scabetic Dermatitis. The note revealed that the resident had additional counseling that scabies was an infestation of mites that is very contagious; and that, household contacts should be treated, contaminated clothing should be isolated x 72 hours and washed and dried on high heat, and to contact the office if scabies fails to resolve after two weeks of treatment. The weekly skin evaluation dated September 10, 2025 revealed the resident had no new skin issues noted; and, did not include whether the resident's rash was still present or not. A physician order dated September 10, 2025 included for triamcinolone acetonide external cream 0.1 % apply to torso, bilateral upper extremities topically every 12 hours for atypical rash for 2 weeks. Despite documentation of a diagnosis of scabies or post-scabetic infection, the late entry NP progress note dated September 20, 2025 included an assessment of atypical rash, pruritus and chronic itching. Plan included to continue triamcinolone cream as ordered, and atarax (anti-itching medication) as needed, and that, dermatology consult was pending. The documentation included that the resident was followed up with dermatology and recommendation included Ivermectin and Permethrin cream. A late entry NP progress note dated September 25, 2025 revealed the resident's atypical rash was resolved. Despite a diagnosis of scabies or post-scabetic infection, and treatment, the clinical record no evidence that the resident was placed on any isolation precautions.-Resident #185 was admitted on [DATE] with diagnoses of rheumatoid arthritis, cognitive communication deficit, and critical illness myopathy. The care plan dated May 12, 2025 included the resident had a potential for skin breakdown. Interventions included to administer medications/treatment as ordered and to follow facility policies/protocols for the prevention/treatment of skin breakdown. A quarterly MDS assessment dated [DATE], revealed the resident had a BIMS score of 11 indicating resident had moderate cognitive impairment. Section M revealed resident had no open lesions other than ulcers, rashes, or cuts. A daily skilled note dated June 30, 2025 included there were no active symptoms effecting the integumentary system observed, and no active skin condition(s) or treatments observed for Resident #185. A medication administration note dated July 1, 2025 revealed a change of condition for a rash that was discovered during resident's bath today; and that, the rash was on left breast, upper back, and upper chest area. The documentation also included that the rash was reported to the provider who ordered nystatin treatment, and Benadryl for itching. However, the NP progress note dated July 2, 2025 revealed that the resident had no rashes on the skin. The medication administration note dated July 2, 2025 included that the resident continued on change of condition related to rash to the left breast, upper back and upper chest. The nursing note dated July 3, 2025 revealed that resident continued to be on change of condition related to rash to the left breast, upper back and upper chest; and that, the rash were still visible. A medication administration note dated July 3, 2025 revealed the resident's rash was still present, there were bumps scattered in initially reported areas, and red. The documentation included that nystatin (antifungal) was applied 3x on shift to affected extremities and itching medication was provided for comfort. The NP progress notes dated July 4 and 9, 2025 revealed that the resident had no rashes on the skin. The daily skilled note dated July 10, 2025 included that the resident had an active symptom of a recurring rash which was located on the arms, back and chest; and that, the skin condition was not a new onset condition. The medication administration notes dated July 19, 2025 included that resident complained of itching, and were administered with medications for itching, and the physician was notified. The NP progress notes dated July 19 and 22, 2025 revealed that the resident had no rashes on the skin.The daily skilled note dated July 26, 2025 included no active symptoms and active skin condition or treatment observed. The clinical record revealed documentation that the resident continued to complain of itching and continued to receive PRN (as needed) medications for itching. A Daily Skilled Note dated August 1, 2025, revealed there were no active symptoms effecting the integumentary system observed, and no active skin condition(s) or treatments observed for Resident #185. A nursing note dated August 2, 2025, revealed resident complained of itching at times, was on change in condition related to atypical prophylaxis (preventative treatment) and would receive Permethrin cream treatment tonight. A physician order dated August 2, 2025, included for Permethrin External Cream 5%, to apply to head to toes topically for atypical rash prophylaxis for 1 day, and to shower 8-10 hours post-treatment. A medication administration note dated August 5, 2025 resident continued on change in condition related to atypical rash prophylaxis; and that, the resident was scheduled for Permethrin cream. Another medication administration note dated August 5, 2025 revealed Resident #185 refused the Permethrin cream treatment, the provider was notified and there were no further orders. The NP progress note dated August 5, 2025 included that skin was warm and dry; and that itching was stable. The documentation did not include whether the resident had a rash or not. Despite the documentation of resident's continued complain of itching, continued administration of PRN medications for itching, and resident's refusal of the Permethrin cream, the clinical record revealed no documentation that the resident was placed on any contact isolation precautions from August 2 through 10, 2025. A late entry physician progress note dated August 9, 2025 included that skin was warm and dry; and that, itching was stable. The documentation did not include whether the resident had a rash or not. The medication administration notes dated August 11, 2025 included that the resident had itchiness, had red bumps; and that, the physician was notified. A Change in Condition Note dated August 11, 2025, revealed Resident #185 had red blotchy rash on bilateral arms and chest with no open areas at this time. Per the documentation, the provider was notified, and new orders for hydrocortisone cream (steroid cream) to help with the itching was received. A physician order dated August 11, 2025, included for COC monitoring for a rash to upper body and itching for 3 days.The medication administration note dated August 12, 2025 revealed resident continued on change of condition monitoring related rash to the chest and upper body. The documentation included that hydrocortisone was applied and had a positive effect. A Late Entry NP Progress Note dated August 12, 2025 revealed that the resident complained of a rash and itching on the upper extremity and was started on hydrocortisone ointment. A Late Entry NP Progress Note dated August 14, 2025 included skin was warm and dry; and that, itching was stable. The documentation did not include whether the resident had a rash or not. A Medication Administration Note dated August 14, 2025, revealed Resident #185 remained on Change of condition related to rash upper body and itching; and that, the resident was given hydrocortisone cream which was effective. Further, the documentation included that the rash remained present. A Medication Administration Note dated August 15, 2025, revealed the resident had a rash on chest and arms and received hydrocortisone medication for itchiness. The skin/wound note dated August 20, 2025 included that the resident went for an appointment and that there were no new skin issues noted. A late entry NP progress notes dated August 24 and 27, 2025 included skin was warm and dry; and that, itching was stable. The documentation did not include whether the resident had a rash or not. The clinical record revealed documentation that the resident continued to complain of itching and continued to receive PRN (as needed) medications for itching. A physician order dated August 31, 2025 included for a dermatology consult for pruritis. The late entry physician progress note dated September 4, 2025 revealed skin was warm and dry. Plan was for regular skin assessment and preventative care as per facility protocol.A weekly skin evaluation dated September 5, 2025, revealed Resident #185 had no new skin issues noted. The assessment revealed no evidence of whether the rash was still present or not. The appointment/procedure note dated September 11, 2025 revealed skin assessment included generalized rash; and that, Resident #185 went to a dermatology appointment and returned at 10:16 a.m. with new orders from the dermatologist. Per the documentation, it was okay to initiate Permethrin cream and triamcinolone cream related to atypical rash and according to the orders of the primary physician. It also included that the resident was to be creamed tonight and PPE (personal protective equipment) in place. The physician orders dated September 11, 2025 included the following:COC monitoring for atypical rash, for three days;Contact and droplet isolation for atypical rash, every shift until September 12, 2025; and,Permethrin External Cream 5%, to apply to neck to toes topically at bedtime every Thursday for atypical rash, for 3 administrations. The weekly skin evaluations dated September 12 and 19, 2025, revealed Resident #185 had no new skin issues; and, documentation whether the rash was still present or not. The MAR for September 2025 revealed Resident #185 was administered Permethrin cream treatment on September 11, 18, and 25, 2025. The weekly skin evaluations dated September 26, 2025, revealed Resident #185 had no new skin issues; and, documentation whether the rash was still present or not. Despite documentation the resident received Permethrin for a rash, there was no evidence found that facility implemented steps in controlling the spread of scabies such as washing of all clothing and bedding used during the days before treatment began; and, items that cannot be washed or dry cleaned were sealed in plastic bag for several days to a week. -Resident #186 was admitted to the facility on [DATE] with diagnoses of acute infarction of the large intestine, heart failure, and cognitive communication deficit. The admission note dated August 19, 2025 included that resident #186 was alert and oriented and skin assessment was completed by 2 nurses. Per the documentation, the resident had a surgical incision to the abdomen with staples and had generalized bruising. The documentation did not include any rash. The care plan dated August 19, 2025 included the resident had a potential for skin breakdown. Interventions included to administer medications/treatments as ordered and to follow facility policies/protocols for the prevention/treatment of skin breakdown. The NP progress note dated August 20, 2025 revealed skin was warm and dry. The care plan dated August 20, 2025 included the resident had a potential to develop infection related to complex medical conditions/diagnoses. Interventions included to follow facility policy and procedures for transmissible infection screening/precautions, contact/droplet isolation as necessary or as ordered by the physician and maintain standard precautions when providing resident care. An admission MDS assessment dated [DATE], revealed the resident had a BIMS score of 13 indicating resident had intact cognition. The assessment also coded that the resident had no open lesions other than ulcers, rashes, or cuts. The NP progress note dated August 29, 2025 revealed skin was warm and dry; and that, skin had no rash, pruritus, abrasions or ulcerations. The daily skilled noted dated August 31, 2025 included the skin was warm, had no active symptoms affecting the integumentary system observed. Active symptom was a surgical wound located at the mid-abdomen. The documentation did not include any rash. The daily skilled noted dated September 1, 2025 included the skin was warm, had no active symptoms affecting the integumentary system observed; and, the documentation did not include any rash. The weekly skin evaluation dated September 2, 2025 included the resident had no new skin issues noted. A Daily Skilled Note dated September 5, 2025 revealed the resident had no active symptoms effecting the integumentary system observed and no active skin condition(s) or treatments observed. A late entry NP progress note dated September 5, 2025 revealed that Resident #186 had no rash, pruritus, or abrasions. However, the physician orders dated September 5, 2025, included for:COC monitoring for atypical rash prophylaxis (a preventative treatment to prevent infection):Contact and droplet isolation, every shift for 1 day, starting September 5, 2025; and,Permethrin External Cream 5%, to apply to neck to toes topically at bedtime for prophylactic treatment for 1 day. A medication administration note dated September 5, 2025 revealed Resident #186 was on COC (change of condition) monitoring for atypical rash every shift for three days; and that, the resident had been showered to prepare for the cream procedure that night, and was awaiting the dose to arrive from the pharmacy. Review of the MAR for September 5, 2025 revealed that Permethrin was documented as administered on September 5, 2025. The medication administration note dated September 6, 2025 included the resident was continued on COC monitoring related to atypical rash prophylaxis, Permethrin cream was applied, and the resident was to be scheduled for a shower. Another medication administration note dated Septembe

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that medications were administered within ordered parameters and in accordance with accepted standards of practice for one of five sampled residents (Resident #10) who were found to have unnecessary medications. The deficient practice had the potential to cause adverse drug effects and place residents at risk for harm from unnecessary medication that was not clinically indicated at the time of administration.Findings include:Resident #10 was admitted to the facility on [DATE], with the diagnosis that included nontraumatic intracerebral hemorrhage, unspecified; type 2 diabetes mellitus with hyperglycemia; and metabolic encephalopathy.A physician's order dated July 22, 2025, for an injection of Lantus subcutaneous solution 100 units/ML (insulin glargine), 20 units subcutaneously at bedtime for diabetes mellitus, and to hold if blood glucose is under a reading of 120. The order was discontinued on November 9, 2025.A quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed that a staff assessment for mental status was completed because Resident #10 had exhibited memory problems and severely impaired cognitive skills. The MDS assessment also revealed that the resident received an injection daily for the 7 days preceding the assessment.A review of the November 2025 MAR (Medication Administration Record), revealed that Lantus Subcutaneous Solution 100 UNIT/ML (insulin glargine), 20 units subcutaneously at bedtime for diabetes mellitus, and to hold if blood glucose is under a reading of 120, had been administered out of ordered parameters on:November 4, 2025, with a blood glucose reading of 117November 5, 2025, with a blood glucose reading of 118A physician's order dated November 9, 2025, was written for injection of Lantus subcutaneous solution 100 units/ML (insulin glargine), 15 units subcutaneously at bedtime for diabetes mellitus, and to hold if blood glucose is under a reading of 120.A review of the November 2025 MAR (Medication Administration Record), revealed that Lantus Subcutaneous Solution 100 UNIT/ML (insulin glargine), 15 units subcutaneously at bedtime for diabetes mellitus, and to hold if blood glucose is under a reading of 120, had been administered out of ordered parameters on:November 16, 2025, with a blood glucose reading of 113November 19, 2025, with a blood glucose reading of 90November 20, 2025, with a blood glucose reading of 98November 22, 2025, with a blood glucose reading of 88November 23, 2025, with a blood glucose reading of 86Further review of the clinical record revealed no evidence that the provider had been notified regarding the resident's blood sugar status or that Lantus had been administered outside of parameters on November 4, 2025, November 5, 2025, November 16, 2025, November 19, 2025, November 20, 2025, November 22, 2025 or November 23, 2025.An interview was conducted on November 25, 2025, at 1:47 PM, with a Registered Nurse (RN/Staff #323), who stated that medications, such as insulin, are to be administered within the ordered parameters set by the provider. The RN also stated that administering insulin outside of orders could cause hypoglycemia, and identified hypoglycemia as low blood sugar, which can exhibit signs and symptoms such as clamminess and a feeling of being cold, and may also lead to a resident being unable to wake up. The RN also stated that the only exception to administering medications out-of-parameter would have been if the provider had ordered it. Staff #323 stated that administering medications outside of the ordered parameters does not meet the facility's expectations.An interview was conducted on November 25, 2025, at 1:58 PM, with the Director of Nursing (DON/Staff #210), who stated when administering medications, staff are expected to complete adequate hand hygiene, to confirm the resident that will be taking the drug, to confirm the route of the medication administration, and to confirm the order of the medication that would be administered. The DON also stated, medications must be administered within the provider ordered parameters which included blood pressure or blood glucose. The DON reviewed the electronic health record for the resident and stated that Lantus Subcutaneous Solution 100 UNIT/ML (insulin glargine), 20 units subcutaneously at bedtime for diabetes mellitus, and to hold if blood glucose is under a reading of 120, had been administered out of ordered parameters on November 4, 2025, with a blood glucose reading of 117 and November 5, 2025, with a blood glucose reading of 118. The DON also stated that Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine), 15 units subcutaneously at bedtime for diabetes mellitus, hold if blood glucose is under a reading of 120, had been administered out of ordered parameters on:November 16, 2025, with a blood glucose reading of 113November 19, 2025, with a blood glucose reading of 90November 20, 2025, with a blood glucose reading of 98November 22, 2025, with a blood glucose reading of 88November 23, 2025, with a blood glucose reading of 86The DON further reviewed the clinical record and stated there was no evidence that the provider had been notified regarding the administration of Lantus outside of the ordered parameters, or updated orders from the provider on those dates, or why the medication was administered outside of parameters. The DON stated staff are expected to hold medications when the blood glucose result is outside of the ordered parameters, and to document the occurrence in a progress notes so that the provider can adequately adjust a resident's medication regime if necessary. The DON stated that the risk of administering insulin outside of the blood glucose parameters could result in residents exhibiting signs and symptoms of hypoglycemia. A policy titled, Physician Orders, with the last review date of May 2025, revealed that it is the policy of this facility to accurately implement orders only upon the written order of a person duly licensed. No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses.A policy titled, Medication Administration - Administration of Drugs, last review date July 2025, revealed that medications must be administered in accordance with the written orders of the attending physician.A policy titled, Medication Administration - Oral, with the last review date of December 2024, revealed that it is the policy of the facility, and that no medication is to be administered without a physician's written order. The policy included that any irregularity in administering must be reported to the doctor, if there is any question in regard to dosage, the person in doubt should not give the drug until information is obtained which clarifies the drug dosage.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#2) was free from physical abuse. The deficient practice could result in further incidents of staff to resident abuse. Findings include: Resident #2 was admitted on [DATE] with diagnosis including acute and chronic respiratory failure with hypoxia critical illness myopathy, other toxic encephalopathy, and dysphagia. A review of the Minimum Data Set (MDS) dated [DATE] revealed Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Further review of the MDS revealed no indicators for mood or behaviors and dependent for upper and lower mobility. A review of the care plan revealed a focus area indicating that the resident has a potential risk for alteration in thought process/cognitive loss related to multiple complex medical conditions and has ineffective coping skills as exhibited by episodes of agitation, and verbally aggressive and abusive towards staff. Interventions included encouraging communication with family and caregivers' residents' capabilities and needs. Further review of the Care Plan revealed resident expressed alleged staff to resident incident on November 19, 2024. Intervention included a psych consult follow up as ordered on November 20, 2024. A review of the progress notes revealed a psych follow-up entry dated November 20, 2024. On a mental capacity note, patient was AAOX4 during my interview today and able to name some of his medical problems as well as medications that he is currently taking. Patient demonstrated good concentration and short-term memory recall with an improvement in his MMSE score compared to the previous one done approximately 3 months ago. I believe patient now has the mental capacity to make his own medical decisions. A review of the PRN Skin Evaluation dated November 20, 2024 states no new skin alteration noted. no redness, swelling or open areas noted to right lower extremity. An interview was conducted on December 2, 2024 at 9:55 A.M. with resident #2. The resident stated that when his dinner arrived the hamburger patty was crisp, almost burnt, so he sent it back with the CNA/Staff 15. He stated a girl from dietary came into my room with the original tray and asked me what was wrong with the meal? I told her it was too hard, almost burnt and hard for me to eat and asked for a softer patty. He stated this is when the girl from dietary got upset and started yelling and said you're going to eat this, I told her I was not and that I didn't like her attitude with me. Resident #2 stated the girl from dietary was standing at the end of his bed and this is when she grabbed his left ankle and twisted it. Resident #2 stated I told her to stop and grabbed my water bottle and threw it at her, she told me how dare you and threw two water bottles at me and tipped over my urinal. I was soaked with urine and water. Resident #2 stated he reported her immediately and they took him for a shower. Resident #2 stated they told him they sent her home and not seen her since. A telephonic interview was conducted on December 2, 2024 at 1:32 p.m. with a Certified Nursing Assistant (CNA/staff #7). Staff #7 stated that she had resigned from the facility two weeks prior for another position, but was previously employed as a caregiver/sitter and also worked in dietary on tray line and as a dishwasher. She stated she recalled the incident and had never met the resident prior to the alleged incident. Staff #7 stated that she was in the kitchen when Staff #15 CNA entered the kitchen with a complaint about resident #2 dinner meal, stating the resident had complained that the hamburger patty was burnt. She stated the cook told CNA #15 they did not have any ready, that they were frozen and would take sometime to prepare another. Staff #7 stated she was not working in dietary at the time not was she assigned to the resident. Staff #7 stated she was not asked by CNA #15 nor dietary to inform the resident regarding his meal, that she was on break. Staff #7 stated she went to resident #2 room and introduced herself as working in the kitchen. She stated she informed the resident that since he thought that the hamburger was burnt it would take about an hour and if he would like something else. Staff #7 stated resident #2 told her to get the fuck out of my room. She stated when he cursed at me I realized I dealing with the wrong spirit. Staff #7 stated the resident asked he a second time to leave his room. Staff #7 stated I didn't leave his room when he told me to leave-I tried to reason with him, I thought I could make him understand that his burger really wasn't burnt and he could eat it or it would take an hour for another one, but it got worse. Staff # 7 stated resident #2 attempted to kick her while she was standing at the end of his bed so I grabbed his leg. Staff #7 then stated I didn't actually grab his leg, I swung my hand to move his leg to avoid him from kicking me. It was a reflex for me. Staff #7 stated she may Have lightly touched it when asked if she had made contact with resident #7's leg at any time. Staff #7 stated resident #2 pitched his water at me -that was my time to leave the room. A telephonic interview was conducted on December 2, 2024 at 2:50 p.m. with a certified nursing assistant (CNA/staff #15). Staff #15 stated she was assigned to the resident. Staff #15 stated the resident had concerns that his burger was burnt, so she took the tray back to the kitchen and was told me it would take some time because they would need to make it from scratch and to come back to for the burger. Staff #15 stated they were preparing dinner trays at the time. Staff #15 stated she returned to the kitchen approximately 20-30 minutes for the resident's meal and took the tray to the resident's room. Staff #7 stated there was no conversation between her and staff #7 about going to the resident's room and explaining why his try was going to be late. Staff # 7 stated If anyone was to go back and talk to the patient it would have been me. An interview was conducted on December 2, 2024 at 3:18 p.m. with the director of nursing (DON/Staff #24). The DON stated that the expectation when a resident asks staff to leave their room when requested as the resident would get upset and are free from abuse. Staff #118 further stated CNA #7 walked into a situation she did not know how to handle and should have walked away. A follow-up interview was conducted on December 2, 2024 at 3:50 p.m. with a Clinical resource/Registered Nurse (RN/Staff #50) and a Licensed Practical Nurse (LPN/Staff #10). Staff #50 stated she was at the interview with CNA #7 and had stated multiple times that she blocked the resident from kicking her. A review of the facility policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment revised October of 2023 revealed It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals.

Based on clinical record reviews, staff interviews, facility documentation, policies and procedures, the facility failed to ensure a safe transfer using a mechanical lift for one resident (#55). The deficient practice could result in resident sustaining an injury. Findings include: Resident # 55 was admitted on [DATE] with diagnoses of acute respiratory failure with hypoxia, cerebral infarction, dependence on ventilator, and hemiplegia. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance of two persons with bed mobility, transfers and toileting. The MDS also included the resident had impairment to both upper and lower extremities. Review of a care plan included the resident required assistance with Activities of Daily Living (ADLs) related to activity intolerance muscle weakness, limited mobility and fluctuate in ADL self-performance with interventions to include a Hoyer lift for transfers. The Hoyer Sling Inspection log revealed that the Hoyer slings was inspected by staff January 31, 2023. A change of condition note dated February 4, 2023 included that at approximately 2:30 p.m., the nurse entered that room and found the resident on the floor mat on her back. per the documentation, the CNAs (certified nurse assistants) in the room reported that the resident was being transferred from her bed to the shower bed by 2 CNAs and the RT (respiratory therapist). According to the documentation, the resident slide and fell on the floor mat at bedside; and that, the resident was assessed with no injuries but was sent to the hospital for further evaluation. A physician order on February 4. 2023 revealed that the resident was sent to Emergency Department for CT of head status post fall. A RT progress notes which was marked as an incorrect and duplicate entries were struck out in the clinical record on February 4 and 6, 2023. The documentation revealed that the RT was called into the room to assist with ventilator while resident was being transferred from to the shower bed. Per the documentation, the resident was a few inches from the bed and fell from the sling head first and onto the floor. The documentation also included that when the RT looked up, the front left loop was off of the Hoyer with the rest of the loops still attached to the Hoyer. Per the documentation, the resident was left in the same position until the fire department arrived; and that, the lead RT and lead RN (registered nurse) with two CNAs (certified nursing assistant) were in the room with the resident. It also included that the NP (Nurse Practitioner) was also notified. The IDT note dated February 6, 2023 included that according to the two CNAs and one RT who were inside the resident's room, the resident was being transferred from her bed to the shower bed when resident slid out of the Hoyer sling and onto the floor mat. It also included that priori to putting the resident on the sling the CNAs and the RT inspected it and ensured the size was appropriate for the patient and there were no concerns noted. Per the documentation, the CNAs and RT doubled check to ensure that all sling loops were connected when they lifted the resident above the bed; and that, the resident was balanced appropriately. The staff proceeded to move the resident away from the bed when they noted that the resident started to slide. The note included that all three staff members attempted to assist the resident when the resident slid out onto the floormat. Per the documentation the resident was assessed with no injuries; and was send out to the emergency room for CT scan of the head. The facility documentation included that on February 6, 2023, the Hoyer lifts at Station 1 East and West units were tested ; and both Hoyer were working properly and passed the test. In an interview with two certified nursing assistants (CNA/ staff #15 and #20) conducted on February 15, 2023 at 3:30 p.m., both CNAs stated that it is always takes two and sometime three persons to use a Hoyer transfer. They both said that they received education on Hoyer transfers and felt comfortable using a Hoyer lift. An interview conducted on February 15, 2023 with a licensed practical nurse (LPN/staff #25) who stated she was the unit manager on the unit when the accident with resident #55 happened. The LPN stated that resident #55 slid from the Hoyer sling and onto the floor mat at bedside. She stated that the resident was assessed and 911 was called; and that, the resident was sent out to the emergency room . The LPN stated that there should always be two or three staff to assist with transfer using a Hoyer if residents are on a ventilator. She further stated that it should be done by one person. A review of the facility's policy titled Transfer of a Resident, Mechanical Lift revealed to check all the lift's attachments before attempting to lift the resident and always reevaluate the resident's position, the location of slings and the security of the attachments before moving away from the bed or chair. A review of the facility's policy titled Incidents and Accidents included that it is their policy to implement and maintain measures to avoid hazards and accidents.

Based on review of the clinical record, observations, resident and staff interviews, and review of policy and procedure, the facility failed to ensure one resident (#2) had a call light within reach. The deficient practice could result in residents being unable to call for assistance. Findings include: Resident #2 was admitted on [DATE] with diagnoses that included acute respiratory failure, dysphagia, multiple sclerosis, and quadriplegia. A care plan initiated on May 9, 2019 for tracheostomy included a goal that the resident would have no complications related to the artificial airway. The interventions included the call light would be within reach and to keep call light or alternate call system within reach. A care plan initiated on May 9, 2019 for alteration in musculoskeletal status related to deficits in range of motion (ROM) included a goal that the resident would remain free from pain or discomfort. The interventions for this goal included to anticipate and meet needs and to be sure call light is within reach and respond promptly to all requests for assistance. A care plan initiated on May 9, 2019 for assistance with activities of daily living (ADL) due to ADL self-care performance deficit related to muscle weakness and musculoskeletal impairment included the resident is at risk for developing complications and further decline and included a goal that the resident's dignity would be maintained. The interventions for this goal included to keep the call light within reach, encourage to use to call assistance, and that the resident uses tent call light. It also included the resident may have difficulty with use of call light and requires frequent visual checks. During an observation conducted on November 21, 2022 at 1:45 pm of resident #2 in his room, the resident was lying in bed on his right side facing the window. The resident's TV was off and the device used to allow the resident to call for assistance with his head was behind him approximately 18 inches away. During an interview conducted with the resident at the time of the observation, resident #2 stated that he had wanted his TV on all day but hasn't had it on. Resident #2 stated he likes to watch his movies all day long. An interview was conducted on November 21, 2022 at 1:50 pm with a Registered Nurse (RN/staff #11). Staff #11 stated that when resident #2 wants his TV on or a movie played he calls for help. Staff #11 stated that they will do that for him if he asks. Another observation was conducted on November 22, 2022 at 9:32 am of resident #2 in his room. The resident's TV had a movie start up screen displayed and was playing the same song repeatedly. The TV required someone push the play button to start the movie. The resident was again laying on his right side facing the window. The gray tent shaped call light was behind the resident's head again an estimated 18 inches away. When the surveyor asked the resident to use the light, resident #2 was unable to reach it with his head. During an interview conducted on November 22, 2022 at 11:21 am with a Certified Nursing Assistant (CNA/staff #41), staff #41 stated that when residents are repositioned she makes sure that the call light is within reach. Staff #41 stated that resident #2 requires a push call light because he cannot use his hands or arms to call for help, he uses his head. Staff #41 stated resident #2 needs to be checked on a lot because he gets left out as he is quiet and does not push the call light often. Staff #41 stated that she places the call light and has the resident test it to see if it works before leaving the room. An interview was conducted on November 22, 2022 at 12:43 pm with another CNA (staff #22). Staff #22 stated that resident #2 has a call light that he can tap with his head. Staff #22 stated she checks on him every two hours and always makes sure before she leaves that he can reach it with his head. Staff #22 stated that resident #2 likes to watch movies all day long. During an interview conducted on November 23, 2022 at 10:48 am with a Licensed Practical Nursing (LPN/staff #19), staff #19 stated that residents that cannot use their hands are given a push button or tent call light that is pinned to the pillow so they can use their head. Staff #19 stated that the resident has the right to call for help when they need it. An interview was conducted on November 23, 2022 at 12:46 pm with the Director of Nursing (DON/staff #7). The DON stated the expectation is that the staff ensure the care plan is implemented by monitoring. The DON stated that any special needs are on the report sheet and told to the CNAs. The DON stated once something goes into the plan of care for ADLS, the nursing staff monitor the CNAs to make sure the plan of care is being followed, including the use of special communication devices. The DON stated that residents that cannot use their hands or arms can use a tent call light by laying their head on it. The DON stated that resident #2 should have his call light tent close to his head, usually on a pillow. A facility policy titled Dignity and Respect included that it is the policy of the facility that all residents be treated with kindness, dignity and respect. Schedules of daily activities allow maximum flexibility for residents to exercise choices regarding entertainment are elicited and respected by the facility. A facility policy titled ADL, Services to carry out included that it is the policy of the facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care.

Based on the clinical record reviews, resident and staff interviews, facility documents, and policy and procedure, the facility failed to ensure that there was sufficient nursing staff to meet the needs of multiple residents (#s 102, 30, 91, 135, 38, and 109). The deficient practice resulted in residents needs not being met and/or not being met timely. Findings include: -Resident #102 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognitive skills for daily decision making was severely impaired. The MDS assessment stated the resident was totally dependent with bed mobility, toilet use, and personal hygiene and required two-persons assistance. Record review of the Certified Nursing Assistant (CNA) Point of Care (POC) documentation dated June 15, 2022 - July 14, 2022 stated the resident was total dependence with bed mobility with two-person assistance. An interview was conducted with the resident's family on July 11, 2022 at 10:32 a.m. The family member stated that on Saturday there was lack of staff, 6-7 staff called off. The family member stated there was 1 CNA, no CNA on East or West side. She stated she was supposed to meet with the ADON (Assistant Director of Nursing), and that she also called the Administrator to set up a time to discuss the facility staffing. The family member stated a charge nurse told her that she notified the ADON the message about the meeting requested by the family, and that the ADON will talk to her on Sunday, but the ADON never came. The family member stated resident #102 was to be turned every 2 hours but the resident was not turned for 5 hours on Saturday. She stated a charge nurse came in twice to assist with turning after she asked the staff to turn the resident. The family stated resident #102 had a pressure ulcer for two years that finally healed. -Resident #30 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 indicating the resident was cognitively intact. The MDS revealed the resident was total dependence with toilet use, and extensive assistance with personal hygiene. The MDS assessment bowel and bladder included [CONDITION(S)] and indwelling catheter. An interview was conducted with the resident on July 11, 2022 at 1:42 p.m. The resident stated she had to wait for staff to answer the call light for 5 hours three weeks ago. She stated at 12:00 p.m., she needed a [CONDITION(S)] bag changed. She stated the [CONDITION(S)] bag had opened up and it was a mess, but the [CONDITION(S)] bag was not changed until the next shift. Resident #30 stated she usually has to wait longer for [CONDITION(S)] bag change or care between shift change. -Resident #91 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating the resident was cognitively intact. The MDS assessment stated the resident was total dependence with two-person support with toilet use, and extensive assistance with two-person support with personal hygiene Review of the CNA POC response history dated June 15, 2022 - July 14, 2022 revealed the resident was incontinent of bowel function, and frequently total dependence with personal hygiene. During an interview conducted with the resident on July 11, 2022 at 11:26 a.m., the resident stated that he has not been getting his brief changed on time. The resident stated he had to sit in his bowel movement for 2 hours, he fell asleep, and woke up still with bowel movement in his brief from 11:00 p.m. until 6:00 a.m. He stated within the last weeks his soiled brief was not getting changed timely and it happened 3-4 more times the past week. An interview was conducted with a Licensed Practical Nurse (LPN/staff #137) on July 13, 2022 at 3:13 p.m. Staff #137 stated at around 10:15 p.m. this past Saturday night (July 9, 2022), while giving the resident's medications, resident #91 told her he needed a brief change. She stated the CNA returned and told her the resident was sleeping. Staff #137 stated about an hour later, resident #91 family called and told her the resident needed to be changed. The LPN said she asked the CNA for a second time to change the resident and they did. -Resident #135 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating the resident had intact cognition. The MDS assessment stated that the resident was total dependence with bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS included the resident had an indwelling catheter, and was always incontinent of bowel function. During an interview conducted with the resident on July 11, 2022 at 12:36 p.m., the resident stated that there was not enough staff. The resident stated she had to wait for a while for her call light to be answered, about a couple of hours and it does not matter what shift. -Resident #38 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident's cognitive skills for daily decision making was moderately impaired. The MDS assessment included the resident was total dependence with two persons assistance with bed mobility, toilet use, and personal hygiene. Review of the CNA POC record history dated June 15, 2022 - July 14, 2022 revealed the resident was total dependence with personal hygiene and toilet use. During an interview conducted with the resident's family member on July 11, 2022 at 10:38 a.m., the family member stated the facility is short staffed especially on the weekend. The family stated the call light does not get answered for ½ to 2 hours. The family member stated the staff shut the light off but the resident was not getting changed. The family member stated the staffing on the weekend is usually short, especially on night shift. -Resident #109 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment dated [DATE] included a BIMS score of 15 indicating the resident had intact cognition. The MDS stated the resident was total dependence with bed mobility with two-person support, toilet use, and personal hygiene. Review of the CNA POC response history dated June 15, 2022 - July 14, 2022 revealed resident was incontinent of bowel function, total dependence with toilet use, and personal hygiene. An interview was conducted with the resident on July 11, 2022 at 12:02 p.m. The resident stated that staff told him to have a bowel movement in the bed and that they will change him. The resident stated he spoke to the CNA at 5:15 pm, and staff did not clean him up until 11:20 pm. Review of the Facility Assessment stated the facility hires and schedules staff for average census of 153, including staff to cover vacation, and sick time. The census has been fairly consistent at 153, and the high and lows are brief periods. The Assessment included the staffing plan for nursing services as follow: RNs (Registered Nurses)/LPNs station 1 (7 a.m.-7 p.m.) 5; RNs/LPNs station 1 (7 p.m.-7 a.m.) 4, a total of 9 licensed nurses. RNs/LPNs station 2 (7 a.m.-7 p.m.) 5; RNs/LPNs station 2 (7 p.m.-7 a.m.) 4, a total of 9 licensed nurses. RNs/LPNs station 3 (7 a.m.-7 p.m.) 4; RNs/LPNs station 3 (7 p.m.-7 a.m.) 3, a total of 9 licensed nurses. CNAs 6 a.m. - 2 p.m. 23; CNAs 2 p.m. - 10 p.m. 21; CNAs 10 p.m. - 6 a.m. 12, total CNAs 56. Review of the Daily Nurse Staffing Information documentation revealed the following: June 17, 2022: 39 CNAs were scheduled for 24 hours. The census was 140. June 19, 2022: 29 CNAs were scheduled for 24 hours. The census was 139 July 3, 2022: 27 CNAs were scheduled for 24 hours. The census was 139 July 9, 2022: 32 CNAs were scheduled for 24 hours. The census was 139 July 10, 2022: 35 CNAs were scheduled for 24 hours. The census was 140. An interview with the staffing coordinator (staff #259) was conducted on July 14, 2022 at 9:36 a.m. Staff #259 stated staffing station 1, 2, and 3 depends on the census of the floor. She stated that on June 17, 2022 she was short 9 CNAs because two called off and she was already short 7 CNAs. Staff #259 stated she reviews the daily staffing with the DON (Director of Nursing) and administrator. She stated the facility offers on line application with hiring bonus, and offered bonuses or gift cards for extra shifts. Staff #259 stated the potential outcome if the facility is short staff could include residents might not be changed on time, provided showers, or turned. An interview with the DON (staff #87) was conducted on July 14, 2022 at 2:31 p.m., who stated the staffing in the facility is based on census and acuity. The DON stated there is no staffing ratio and that her expectation for CNAs are 4-5 on the day shift, 3-4 for the evening shift, and 3-4 on the night shift. The DON stated she has open positions and hiring needs ever since COVID happened. She stated that she has not reviewed the facility assessment recently. The DON stated that she meets with the staffing coordinator and she gets notified of the facility daily staffing needs. She stated if she has the staff, the resident will be changed timely, repositioned, and they will receive assistance with meals. The DON stated a reasonable time if a resident pressed the call light and her expectation is within 10-15 minutes or as soon as possible. The DON stated if a resident is totally dependent with Activity of Daily Living (ADLs) and the resident had a bowel movement, her expectation is to change that resident immediately or within reasonable time. The DON stated 4-5 hours was not a reasonable time to wait when a resident had an incontinent episodes of bowel movement. On July 14, 2022, the administrator (staff #306) entered the conference room and stated related to staffing challenges, the facility is offering retention rewards and bonuses to encourage staff to stay. He also stated the managers goes on the floor and help as much as needed. Review of the facility policy and procedure, Sufficient Staff, stated the policy of the facility is to have sufficient nursing staffing with the appropriate competencies and skill sets to provide nursing and related services to promote resident safety and attain or maintain the highest practicable mental, psychosocial well-being of each resident as determined by the resident assessment and individual plans of care; and considering the number, acuity and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, staff interviews, and review of policy and procedure, the facility failed to maintain an ice machine in a sanitary manner. Findings include: During an observation of the second floor on April 14, 2015, a resident was seen using an ice machine that was in the hallway. In an interview with a licensed practical nurse (LPN) at 9:10 a.m. on April 15, 2015, the LPN stated that the ice machine in the hallway was used for residents. Another observation of the same ice machine on the second floor was conducted at 9:15 a.m. on April 15, 2015. The ice machine was observed to have an orange-brown gelatin like substance which was built up near where the ice came out of the machine. Also, there was a build up of a hard, dark colored substance where the ice came out of the machine. An interview was conducted with the maintenance director at 9:30 a.m. on April 15, 2015. He said that he could see the built up substances on the ice machine and he would put the machine out of commission. He said that the internal components of the ice machines are cleaned every six months by professionals. An interview with the Administrator was conducted at 1:20 p.m. on April 16, 2015, in which he said that housekeeping cleans the machine about every other day or so by using bleach and running hot water through the ice machine. Review of the facility's policy and procedure for the ice machine revealed that the inside of the machine should be washed with approved detergent and hot water and rinsed with clean water weekly. The policy noted to then use sanitizing solution and a clean cloth to sanitize the machine. The policy also included to make sure the areas were free from scale and/or mold.

Based on clinical record review, staff and pharmacy interviews, facility documentation and policy review, the facility failed to ensure pharmacy services were accurately provided regarding the correct dosage of a medication for one resident (#39). Findings include: Resident #39 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed that prior to readmission on September 19, 2013, the resident was receiving Lisinopril (antihypertensive) 20 mg (milligrams) daily. A review of the Hospital transfer orders dated September 19, 2013, included the resident had chronic hypertension and was to receive Lisinopril 20 mg by mouth daily. According to the admission physician's orders dated September 19, 2013, Lisinopril 10 mg one tablet by mouth everyday was ordered. Per the pharmacy order entry report, which included the last filled dates from September 19, through October 19, Lisinopril 10 mg tablets were filled. Review of the September 2013 MAR, revealed the order for Lisinopril 10 mg one tablet by mouth daily. Review of a pharmacy order report, revealed Lisinopril was last filled on November 11, 2013, however, 20 mg tablets were filled instead of 10 mg. Review of the clinical record revealed there was no physician's order to change the dosage of the Lisinopril from 10 mg to 20 mg. Review of the November 2013 MAR, revealed the order for Lisinopril 10 mg one tablet daily. A Monthly Order Summary Report dated December 2013, also included for Lisinopril 10 mg one tablet by mouth daily, with an original order date of September 19. Review of the December 2013 MAR, revealed the order for Lisinopril 10 mg one tablet daily. According to another pharmacy order report, Lisinopril 20 mg was filled on December 30, 2013, and again on January 25, 2014. However, the January and February 2014 MAR, included for Lisinopril 10 mg one tablet daily, with an original order date of September 19, 2013. During a medication administration observation for resident #39, conducted on February 13, 2014, the nurse preparing the resident's medications stated that the resident was to receive Lisinopril 10 milligrams by mouth daily, per the electronic medication administration record. However, contained in the medication cart for this resident were Lisinopril 20 mg tablets. The nurse was unable to locate the Lisinopril in a 10 mg dosage for this resident. The nurse immediately called the pharmacy to clarify the order. A physician's order was then obtained on February 13, 2014, to discontinue Lisinopril 10 mg and to give Lisinopril 20 mg by mouth daily for hypertension. During an interview conducted on February 13, 2013, immediately following the medication administration observation, the nurse stated that it was a medication error. An interview was conducted on February 13, 2014, with the corporate nurse who stated that a medication error report was being completed and that pharmacy was called regarding the medication error. She stated that the facility was investigating how the Lisinopril was changed to 20 mg, when it was supposed to be 10 mg. During an interview conducted on February 12, 2014, pharmacy staff stated that Lisinopril 20 mg was originally written and filled back on January 25, 2013, and Lisinopril 10 mg was originally written and filled on September 19, 2013. Pharmacy staff stated that the Lisinopril 10 mg was refilled on October 19, and was not refilled again after October 19. Staff further stated that they received a refill request on November 10, 2013, for Lisinopril 20 mg and it was refilled off the original order dated January 25, 2013. The pharmacy staff member also stated that when they get a request for a refill they process it and the only reason they would not process the request would be for example, if the medication was discontinued. Review of a facility policy regarding Medication Ordering and Receiving From Pharmacy, revealed that accurate records of medication order and receipt are maintained. The policy also included that a licensed nurse or appropriate personnel receiving medications from the pharmacy would verify the medications received with the prescriber orders and would promptly report discrepancies and omissions to the issuing pharmacy and the charge nurse and/or supervisor. Another policy regarding physician's orders included that medications are administered only upon a written order by a licensed and authorized person to prescribe such medications.

Based on clinical record review, staff and pharmacy interviews, facility documentation and policy review, the facility failed to ensure that one resident's (#39) drug regimen was free of unnecessary drugs, by failing to administer medication as ordered. Findings include: Resident #39 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed that prior to readmission on September 19, 2013, the resident was receiving [MEDICATION NAME] (antihypertensive) 20 mg (milligrams) daily. A review of the Hospital transfer orders dated September 19, 2013, included the resident had chronic hypertension and was to receive [MEDICATION NAME] 20 mg by mouth daily. According to the admission physician's orders dated September 19, 2013, [MEDICATION NAME] 10 mg one tablet by mouth everyday was ordered. Review of the September 2013 MAR, revealed the order for [MEDICATION NAME] 10 mg one tablet by mouth daily. Per the pharmacy order report, which included the last filled dates from September 19, through October 19, [MEDICATION NAME] 10 mg tablets were filled. According to another pharmacy order report, [MEDICATION NAME] was last filled on November 11, 2013, however, 20 mg tablets were filled instead of 10 mg. Review of the clinical record revealed there was no physician's order to change the dosage of the [MEDICATION NAME] from 10 mg to 20 mg. Review of the November 2013 MAR, revealed the order for [MEDICATION NAME] 10 mg one tablet daily. A Monthly Order Summary Report dated December 2013, also included for [MEDICATION NAME] 10 mg one tablet by mouth daily, with an original order date of September 19. Review of the December 2013 MAR, revealed an order for [REDACTED]. Per a pharmacy order report, [MEDICATION NAME] 20 mg was filled on December 30, 2013. Another pharmacy order report included that [MEDICATION NAME] 20 mg was again filled on January 25, 2014. However, the January and February 2014 MAR, included for [MEDICATION NAME] 10 mg one tablet daily, with an original order date of September 19, 2013. During a medication administration observation for resident #39, conducted on February 13, 2014, the nurse preparing the resident's medications stated that the resident was to receive [MEDICATION NAME] 10 milligrams by mouth daily, per the electronic medication administration record. However, contained in the medication cart for this resident were [MEDICATION NAME] 20 mg tablets. The nurse was unable to locate the [MEDICATION NAME] in a 10 mg dosage for this resident. The nurse immediately called the pharmacy to clarify the order. A physician's order was then obtained on February 13, 2014, to discontinue [MEDICATION NAME] 10 mg and to give [MEDICATION NAME] 20 mg by mouth daily for hypertension. During an interview conducted on February 13, 2013, immediately following the medication administration observation, the nurse stated that it was a medication error. An interview was conducted on February 13, 2014, with the corporate nurse who stated that a medication error report was being completed and that pharmacy was called regarding the medication error. She stated the nurse practitioner was notified and an order was received to discontinue [MEDICATION NAME] 10 mg and to give [MEDICATION NAME] 20 mg daily. She further stated that the facility was investigating how the [MEDICATION NAME] was changed to 20 mg, when it was supposed to be 10 mg. During an interview, pharmacy staff stated that [MEDICATION NAME] 20 mg was originally written and filled back on January 25, 2013, and [MEDICATION NAME] 10 mg was originally written and filled on September 19, 2013. Pharmacy staff stated that the [MEDICATION NAME] 10 mg was refilled on October 19, and was not refilled again after October 19. Staff further stated that they received a refill request on November 10, 2013, for [MEDICATION NAME] 20 mg and it was refilled off the original order dated January 25, 2013. Review of a facility policy regarding the administration of medication included that all current drugs and dosage schedules must be recorded on the resident's medication administration record. The policy also included that medications are checked against the order before they are administered and medications are administered according to the dose prescribed. Review of a facility policy regarding non-controlled medications from the pharmacy included that a licensed nurse or appropriate personnel receiving medications from the pharmacy would verify the medications received with the prescriber orders and would promptly report discrepancies and omissions to the issuing pharmacy and the charge nurse and/or supervisor. Another policy regarding physician's orders included that medications are administered only upon a written order by a licensed and authorized person to prescribe such medications.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure services provided met professional standards of quality, by failing to ensure physician orders [REDACTED].#310). Findings include: Resident #310 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Regarding the CPM machine: Review of the clinical record revealed a continuing care transfer information form dated April 18, 2013, which included the following: CPM (continuous passive motion) machine, 0-90 degrees four to six hours per day, not at night. Review of the admission orders [REDACTED]. Review of the TAR (Treatment Administration Record) for April 2013, revealed the physician orders [REDACTED]. However, written next to the physician's orders [REDACTED]. There was no documentation on the TAR that the CPM machine had been applied, per physician's orders [REDACTED]. Review of the April 2013 MAR indicated [REDACTED]. Further review of the clinical record revealed there was no documentation that the resident's CPM machine had been consistently implemented and monitored, as ordered by the physician. Regarding physician orders [REDACTED]. Continued review of the April 2013 MARs and TARs revealed the following physician's orders [REDACTED]. However, there was no documentation on the MARs or the TARs that the ordered treatments were done. There was also no clinical record documentation that showed the above orders had been consistently implemented. During an interview conducted on February 13, 2014, the corporate nurse stated that she was unable to locate any additional evidence that post surgical care and the CPM machine had been implemented as ordered. Review of a facility policy regarding continuous passive motion included that treatment would proceed upon receipt of a physician's orders [REDACTED].

Based on clinical record review, hospital record review, observation, staff interviews, and review of facility documentation and policy, the facility failed to ensure that one resident (#164) had adequate interventions in place to prevent a fall, resulting in injuries and hospitalization . Findings include: Resident #164 was readmitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. According to the resident's risk for injury care plan from February 29, 2012, the resident was in a vegetative state and his bed was to be kept in a low position. A review of physician's orders [REDACTED]. According to the fall risk evaluation from August 19, 2012, the resident was at a high risk for falls. The resident scored a 16, with scores above 10 representing high risk. Review of the nursing notes from August 20, 2012, documented that a certified nursing assistant (CNA) was providing care to the resident, when he started to bronchospasm. The notes included that the resident's legs went off the bed and then proceeded to slide out of bed. The CNA was unable to stop the fall; however, was able to guide the resident to the floor mat. No injury was sustained from the fall. There was no documentation of any corrective action taken after this fall (i.e. ensuring care is provided by two staff, bed bolsters) in order to prevent further falls from the bed. physician's orders [REDACTED]. According to the nursing notes from October 25, 2012, the resident was found on the floor in a sitting position, with his upper body resting on his bed. The bed alarm was sounding, and the low bed and floor mats were in place. The resident appeared to have had a coughing episode and slid out of bed. No apparent injury was noted. A review of the facility documentation on the incident included the resident had no prior falls, despite a previous fall occurring on August 20. As a result of the incident, physician's orders [REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required assistance from at least two people for bed mobility, toilet use, personal hygiene, and bathing. The resident was discharged to the hospital on December 9, 2012, and readmitted back to the facility on [DATE], with a [DIAGNOSES REDACTED]. According to the fall risk evaluation dated December 19, 2012, the resident was determined to be at high risk for falls, with another score of 16. Review of the readmission orders [REDACTED]. A review of the Activities of Daily Living (ADL) charting from December 2012, documented that the resident was bathed 10 times throughout the month. Out of the 10, nine of the baths were done with a one person assist. The resident only had a two or more person assist when he had a shower on December 8. A review of the nursing notes dated January 3, 2013 at 9:04 p.m. revealed that the resident had a skin tear near his right eye lid and a bruise about 5 centimeters (cm) above his right eye. At 1:46 a.m., it was documented that the resident had a swollen right leg. This documentation did not include an explanation of how the injuries occurred. A physician's orders [REDACTED]. The X-ray results for January 4 documented the resident had an angulated fracture of the right upper femoral shaft, which did not appear to be a pathologic fracture. The Nurse Practitioner's (NP) progress note from January 4, 2013, documented that the resident sustained [REDACTED]. The note further mentioned that it was highly suspicious that trauma was the cause. According to a nursing note entry dated January 4, 2013 at 3:41 p.m., the resident was sent to the hospital emergency room for an evaluation at 1:10 p.m. Another entry by the Director of Nursing (DON) at 8:30 p.m., documented that around 8:00 p.m. on January 3, 2013, staff (#1) was providing the resident a bed bath and the resident fell out of bed. The bed was in the higher position when the resident started to cough and thrust himself forward out of bed, landing onto the right side of the floor mat. Per the note, staff #1 stated that the resident was soapy and wet, and was unable to prevent the resident from falling. This note was the first time that the resident's fall was documented. A review of the facility's incident documentation from January 4, 2013, revealed that bed bolsters were not listed as an intervention in place at the time of the fall. According to hospital records from January 4, 2013, the resident had sustained a right and a left femur fracture, and was admitted to the intensive care unit. During an interview conducted on January 29, 2013 at 1:55 p.m., staff #1 stated that around 8:00 p.m. on January 3, he was giving the resident a bed bath with the bed in the high position. When he turned the resident towards him, the resident coughed and started shaking. Staff #1 reported that he tried to break the resident's fall, but was unable to because the resident was soapy. He stated that a snapping sound was heard when the resident fell . He stated that at the time the resident was a one person assist with bathing. Staff #1 mentioned that whenever you touch the resident he coughs, shakes a lot, and "his legs go all over the place." He reported that he usually works the midnight shift and has helped out with this resident before. As soon as this incident occurred he stated that he called for the nurse to come in. The nurse arrived as well as the Respiratory Therapists (RT) and they were able to get the resident back in bed and assessed his vital signs. Staff #1 reported that there was an in-service after the incident and now the resident requires a 2 person assist for everything. Staff #1 was interviewed further about the incident on January 30, 2013 at 9:00 a.m. He stated the resident fell on the side where he was standing. He reported that there were no bolsters on his bed at the time, and he was not aware of any order for the resident to have them. He stated if there was an order, he was sure that the bolsters would have already been on the bed. On January 30, 2013 at 10:22 a.m., the resident was observed to be lying in bed and the bolster pillows were in place, however, the bed was in the high position and no staff members were present in the room. On January 30, 2013 at 10:24 a.m., another CNA that has worked with the resident was interviewed. She stated that when providing care to the resident he sometimes coughs and when he coughs, his legs go sideways and the upper half of his body "pops up." She stated that the resident's bolster pillows and four side rails were up for the resident's safety. During an interview conducted on January 30, 2013 at 11:00 a.m., the DON stated that she did not know why the resident was a one person assist with bathing before. She reported that she was not aware of his bronchospasms prior to his last fall. The DON stated that she made sure that the resident had two people assisting him with ADLs when he came back to the facility. She also reported that the Unit Manager does the fall risk assessments when residents are admitted . On January 30, 2013 at 11:10 a.m., the Unit Manager who completed the resident's fall risk assessment on December 19, 2012, was interviewed. She reported that if a resident had not had a fall in a while an intervention may have been taken away in an effort to make sure the resident was under the least amount of restraints as possible. She stated the resident should have had bolsters for seizure precautions and after reviewing the clinical record stated that the bolsters should have been added as an intervention when he was readmitted to the facility. During another interview with the DON at 11:18 a.m. on January 30, 2013, she stated that the facility did not have an incident report for fall that occurred on August 20, 2012. Review of the facility's policy entitled "ADL, services to carry out," documented "maintenance and restorative programs will be provided to residents in accordance with the resident's comprehensive assessment." A review of the facility's policy on fall prevention revealed that "It is the policy of this facility to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury."

Based on staff interviews, review of clinical documentation and review of facility policy, the facility failed to ensure two residents (#s 36 and 275) were free from unnecessary medication administration. The facility failed to monitor one resident's (#54) glucose level per physician's order. The facility failed to ensure that two residents (#s 292 and 170) were administered insulin with adequate indications for use. Findings include: -Resident #292 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Physician Order dated January 20, 2013, revealed an order for [REDACTED].<60 give [MEDICATION NAME] 1 mg, 0 - 180 = 0; 181 - 240 = 2 U (units); 241 - 300 = 4 U; 301 - 400 = 6 U; 401 - 500 = 8 U; > 501 = 10 U, notify physician and draw stat BMP, re-check blood sugars in one hour and follow SSI, continue to recheck every hour until blood sugars are < 300. A review of the MAR for January 2013, revealed that at 9:00 p.m. on January 22, 2013, the resident's blood sugar level was 233 and 4 units of [MEDICATION NAME] was administered. During an interview conducted at 9:45 a.m. on January 30, 2013, the unit manager stated that when the resident's blood sugar level was 233, 2 units of [MEDICATION NAME]should have been administered. A review of the Care Plan for Diabetes Mellitus dated Janaury 21, 2013, revealed an approach of "Medications as ordered." A review of the Medication Administration policy and procedure revealed "Medications must be administered in accordance with the written orders of the attending physician." and "The seven rights of medication administration are as follows in order to ensure safety and accuracy of administration...Right Dose - Medications are administered according to the dose prescribed..." -Resident #170 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Physcian's Orders dated August 29, 2012, revealed an order for [REDACTED].<80 call the physician, 151 - 200 = 2 units (u), 201 - 250 = 4 u, 251 - 300 = 6, 301 - 350 = 8, 350 > 10 u. A review of the MAR for January 2013, revealed that at 6:30 a.m. on January 5, 2013, the resident's blood sugar level was 228 and 2 u of [MEDICATION NAME] regular insulin was administered. The MAR indicated [REDACTED]. During an interview conducted at 10:00 a.m. on January 30, 2013, a licensed practical nurse, after reviewing the MAR, stated that at 6:30 a.m. on January 5 and 11, 2013, the nurse administering the sliding scale insulin should have administered 4 u of [MEDICATION NAME] regular insulin. -Resident # 54 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician orders dated December 1, 2012, revealed the order for [MEDICATION NAME] to be administered per sliding scale. For a glucose level of 301 to 400 administer 6 units of insulin. For a glucose level of 401 through 500 administer 8 units of insulin and recheck glucose level in 1 hour and follow sliding scale insulin, continue to recheck every hour until glucose level is less than 300. A review of the December 2012, MAR indicated [REDACTED]. Despite the physician's orders the nursing notes and the MAR indicated [REDACTED]. On December 1, 2012, at 9:00 PM the resident's glucose level was documented as 342, however, instead of the 6 units of insulin ordered, documentation indicated that the resident was administered 8 units of insulin. An interview conducted on January 30, 2013, with a a registered nurse (RN) revealed that with continuation of monitoring the glucose levels, the nurse is to write in additional times, write in the levels and initial when the glucose level was obtained and if insulin was administered. -Resident #36 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of clinical documentation revealed a physician order dated October 10, 2012 which states "only give blood pressure (BP) meds for systolic blood pressure (SBP) over 140". The clinical record revealed a MAR for the month of December, 2012 which documents seven occasions the resident's BP medication was given when the resident's SBP was under 140. A review of the December, 2012 MAR indicated [REDACTED]. An interview was conducted with the LPN on January 24, 2013. The LPN stated that she would give the [MEDICATION NAME] if the resident's SBP was over 140. -Resident #275 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of clinical documentation for resident #275 on January 25, 2013 revealed a physician order for [REDACTED]. On January 25, 2013 the resident's MAR indicated [REDACTED]. On December 7, 8, and 9, 2012, there was no documention of the resident's BP before the [MEDICATION NAME] was administered. An interview was conducted on January 25, 2013, with an LPN. The LPN stated that if the SBP was over 100, she would administer the [MEDICATION NAME]. A review of the facility policy titled Medication Administration included "medications must be administered in accordance with the written orders of the attending physician".

Based on observations, staff interviews, and review of facility policy and procedure, the facility failed to ensure that a medication box containing controlled medications subject to abuse was separately locked and permanently affixed to the inside of one medication refrigerator, and failed to ensure daily glucometer calibration was documented consistently on one resident unit. Findings include: During a medication storage observation conducted January 30, 2013 at 9:10 a.m., the third floor medication storage room refrigerator was inspected. A plastic utility box was removed, placed on the counter, and unlocked by facility staff. Inside the box were multiple vials of injectable Ativan (a benzodiazepine, sedative hypnotic) 2 milligrams per milliliter. During an interview conducted during the observation, the consultant nurse stated that she was aware of the regulation that refrigerated controlled medications were required to be not only separately locked, but permanently affixed to the inside of the refrigerator; she was unable to explain why this unit was not in compliance with the regulation. During the same observation, the glucometer calibration/quality control records for Station 1 were reviewed. In January, glucometer calibration was not documented as completed for Station 1 west on January 10, 11, 12, 23, 24, 25, and 28. For Station 1 east, calibration was not completed on January 14, 15, 16, 18, and 23. During an interview conducted January 30, 2013 at 10:10 a.m., a staff nurse on Station 1 stated that daily glucometer calibration was necessary to ensure the accuracy of the blood glucose results, for multiple residents. A facility policy, entitled Drug Storage, did not include that refrigerated medications subject to abuse, other than Schedule II, were required to be stored under separately locked permanently affixed compartments. A facility policy entitled Glucometer Calibration included that a licensed nurse would calibrate the glucometer once a day.

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure the respiratory therapy department was aware of, and correctly documented, one resident's (#109) advanced directive status. Findings include: Resident#109 was readmitted to the facility January 20, 2012, with [DIAGNOSES REDACTED]. Review of the clinical record included two respiratory therapy care plans; one dated January 9, 2013, had a yellow line drawn through it, the other care plan was dated January 22, 2013. Review of both care plans revealed the only difference was that the current, more recent care plan documented the resident was a full code, i.e. all available resuscitative measures would be initiated should the resident experience heart or lung failure. Further review of the clinical record included advance directive documents, signed by the resident's medical power of attorney, which indicated the resident wanted to be "do not resuscitate" (DNR) status, specifically refusing certain life prolonging interventions. During an interview conducted January 28, 2013, a respiratory therapy supervisory staff member stated that the current care plan was correct. She stated that it did not matter that the resident's advanced directive indicated DNR status, that it did not matter what the resident or the resident's representative wanted, that they always followed the physician's orders [REDACTED]. During an interview conducted later that same day, social services staff stated that physician's orders [REDACTED]. She stated that the respiratory therapy staff was incorrect when she stated that only physician ordered advanced directives were followed. A facility policy, entitled Advance Directives, stated that it is the policy of the facility that a resident's choice about advance directives will be respected.

Based on clinical record review, interview, and facility policy review, the facility failed to adequately assess one resident (#299) for fall risk and failed to ensure that two residents (#s 292 and 170) were administered insulin per the physicians' orders. The sample size was 12. Findings include: Issue regarding insulin: -Resident #292 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Physician Order dated January 20, 2013, revealed an order for [REDACTED].< 60 give [MEDICATION NAME] 1 mg, 0 - 180 = 0; 181 - 240 = 2 U (units); 241 - 300 = 4 U; 301 - 400 = 6 U; 401 - 500 = 8 U; > 501 = 10 U, notify physician and draw stat Basic Metabolic Panel, re-check blood sugars in one hour and follow Sliding Scale Insulin, continue to recheck every hour until blood sugars are < 300. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview conducted at 9:45 a.m. on January 30, 2013, the unit manager stated that when the resident's blood sugar level was 233, 2 units of [MEDICATION NAME]should have been administered. A review of the Care Plan for Diabetes Mellitus dated January 21, 2013, revealed an approach of "Medications as ordered." -Resident #170 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Physician's Orders dated August 29, 2012, revealed an order for [REDACTED].< 80 call the physician, 151 - 200 = 2 u, 201 - 250 = 4 u, 251 - 300 = 6 u, 301 - 350 = 8, 350 > 10 u. A review of the MAR for January 2013, revealed that at 6:30 a.m. on January 5, 2013, the resident's blood sugar level was 228 and 2 u of [MEDICATION NAME] regular insulin was administered. The MAR indicated [REDACTED]. During an interview conducted at 10:00 a.m. on January 30, 2013, a licensed practical nurse, after reviewing the MAR, stated that at 6:30 a.m. on January 5 and 11, 2013, the nurse administering the sliding scale insulin should have administered 4 u of [MEDICATION NAME] regular insulin. A review of the Medication Administration policy and procedure revealed "Medications must be administered in accordance with the written orders of the attending physician." and "The seven rights of medication administration are as follows in order to ensure safety and accuracy of administration....Right Dose - Medications are administered according to the dose prescribed..." Issue regarding assessment: -Resident #299 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged to the veterans hospital on May 25, 2012. A review of the resident's interim care plan lacked evidence that fall potential had been addressed. A review of the fall risk assessment dated [DATE], revealed that the resident was documented as 10 indicating that a total score above 10, represents a high risk. Further review of the fall risk evaluation tool revealed the instructions to score medications by "medications taken currently or within the last seven days. The evaluation was documented on the day of admission therefore seven days of administrated medications were not used to adequately evaluate the resident's medication to score his risk factors. Had the facility used the 72 hour period that their policy allows to complete the fall risk assessment or requested the hospital records regarding medication history or used the medication ordered, which could potentially increase the risk factor, the resident would have scored as a high risk for falls. A review of the MAR indicated [REDACTED]. If these four medications had been reviewed within the 72 hour period allowed, the resident would be at a high risk for falls according to the facility's fall assessment tool, allowing for the development of a care plan and interventions in place to prevent a fall. A review of the occupational therapy evaluation dated May 9, 2012, revealed that the resident required contact guard assist with commode transfers and due to the documented physical impairments and associated functional deficits, the patient is at risks for falls. A review of the nursing notes dated May 11, 2012, at 11:00, revealed that the resident had fallen resulting in a skin tear of left elbow. A review of the care plan dated May 12, 2012, revealed fall potential was developed with the intervention to remove hazards from environment. An interview conducted on January 25, 2013, with a registered nurse (RN) revealed that she would consider all the medications ordered when scoring a fall risk assessment because the fall risk is done on admission and the resident may or may not have received any medications as yet when the assessment is done. An interview with the director of nursing conducted on January 25, 2013, revealed that the nurse assessing the resident for fall risks should only take into considerations only the medications that the resident has received . She further stated that a fall risk assessment is to be completed after a resident has experienced a fall. The director of nursing stated that a full comprehensive review means the initial 14 day assessment. A review of the facility policy, fall risk assessment, revealed the following, "It is the policy of this facility to identify the resident who is at risk for potential falls and to initiate a preventative plan of care to reduce fall occurrence...It is the responsibility of nursing to complete a fall risk assessment form within 72 hours of admission, full comprehensive review, and quarterly thereafter."

Based on staff interviews, observations, review of clinical documentation and Manual of Nursing Practice, the facility failed to provide care and services for one resident (#114) to prevent further decline in left hand mobility. Findings include: Resident #114 was admitted to the facility on [DATE], and discharged on [DATE], with [DIAGNOSES REDACTED]. A review of clinical documentation on January 28, 2013 revealed a physician order [REDACTED]. A review of clinical documentation on January 28, 2013 revealed a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During observations conducted in the mornings on January 27 and 28, 2013, the resident did not have a splint applied to his contracted left hand. In an interview conducted on January 28, 2013 with the Director of Therapy (DT), the DT was asked what the process would be if the resident had an order for [REDACTED]. In an interview conducted on January 28, 2013 with a CNA, the CNA stated it would be the CNA's job to place a splint on the resident and would be documented in the medication administration record. A review of the "Manual of Nursing Practice - 8th Edition, Lippincott, Williams and Wilkins stated, "that the professional standards of professional performance includes implementing a physicians order properly and performing a nursing procedure in a proper manner."

Based on clinical record review, review of facility documentation, review of State Agency documentation, and staff interview, the facility failed to ensure that one resident (#1) did not leave the facility despite a physician's orders [REDACTED]. Once the resident was permitted to leave the building, the facility failed to adequately supervise resident #1 per his care plan and the resident was subsequently found deceased in a swimming pool approximately three miles from the facility. Findings include: Resident #1 was admitted to the facility [DATE], and readmitted on [DATE], with pertinent [DIAGNOSES REDACTED]. Clinical record review revealed an annual history and physical dated [DATE], that included resident #1 was positive for persistent vegetative state with eyes closed, and received nothing per oral. A supplemental patient care evaluation dated [DATE], included that the resident utilized a tracheostomy with oxygen at 2 liters per minute. Review of a quarterly Minimum Data Set assessment dated [DATE], included that the resident was comatose with no discernible consciousness, was totally dependent on staff for activities of daily living and was always incontinent of both bowel and bladder. Active [DIAGNOSES REDACTED]. The resident was also assessed to have shortness of breath or trouble breathing when sitting at rest, to be at risk of developing pressure ulcers, and was receiving both suctioning and oxygen therapy. Additional record review revealed that family member #1 (FM1) was resident #1's legal guardian, and that resident #1 was a full code status with a primary goal of longevity. Review of physician's orders [REDACTED]. In addition, resident #1 was to receive 240 cubic centimeters of water via feeding tube at 5:00 p.m. daily. Also included in current physician's orders [REDACTED]. Review of resident #1's care plans for Activities of Daily Living-Self Care Deficit re-evaluated on [DATE], included that nursing staff was to provide all activities of daily living care and to turn and reposition the resident shifting weight to enhance circulation. A care plan for Risk For Injury also re-evaluated [DATE], included that rounds would be made every two hours related to the resident's lack of awareness, motor deficits, urinary incontinence, and inability to make decisions for himself. The documented resident goal was that the resident would sustain no fall or injury. Review of progress notes included a late entry nursing note on [DATE], at 3:00 a.m., which documented that at approximately 3:00 p.m. on [DATE], a visitor (FM2) came to take resident #1 for a walk and watch fireworks around the building in his wheelchair. FM2 stated that FM1 had asked him to do this for her. Further included was that FM1 was contacted to verify that she wanted FM2 to walk resident #1 and have him watch fireworks. Also included was that the nurse instructed FM2 to not take the resident out of the surrounding of the building since the resident was a respiratory patient and if he should have shortness of breath he could be returned to the building for a respiratory treatment. FM2 was documented to have verbalized his understanding and then left with resident #1 at approximately 4:00 p.m. on [DATE]. Lastly, documented was that the nurse called FM1 at 8:00 p.m. on [DATE], to instruct her to have FM2 bring resident #1 back to the building for his medication. The police were documented to have arrived at the facility approximately 10 to 15 minutes later. A review of the Weather Channel monthly forecast revealed the high temperature in Phoenix, Arizona, on [DATE] was 88 degrees Fahrenheit. Review of facility incident documentation dated [DATE], included that resident #1 had left the building at around 4:00 p.m. with FM2 to wheel him around the facility. Also documented was that at around 8:10 to 8:15 p.m., law enforcement came to inform the facility that resident #1 was found drowned in a pool. Review of State Agency documentation included that the pool was located approximately three miles south of the facility. Additional clinical record review included no evidence that the resident's physician had been contacted regarding resident #1 leaving the building with an unfamiliar person, FM2. In addition, no documentation was revealed regarding a plan to provide supervision and services while the resident was out of the building, including repositioning to prevent skin breakdown, hydration since the resident was dependent on a feeding tube and had physician ordered water boluses, replacing the oxygen bottle if necessary, and care and services regarding his incontinency status. In addition, and despite the fact that FM2 was instructed to return the resident to the building if he experienced shortness of breath, no evidence was revealed that FM2 was knowledgeable about signs and symptoms related to shortness of breath, or that given resident #1's persistent vegetative state, that the resident would respond to shortness of breath in an observable and recognizable manner. No documented evidence was located that prior to the nurse calling the resident's FM1 at 8:00 p.m. on [DATE], four hours after the resident's departure, any attempts had been made to locate the resident and ensure he had stayed in the vicinity or provide necessary care and services for resident #1's complex needs. In an interview conducted [DATE], the nurse caring for resident #1 on [DATE], at 4:00 p.m., when the resident left with FM2, stated the following: -She was working the 2 p.m. to 10 p.m. shift on [DATE], when an unknown man arrived about 3:00 p.m. and stated resident #1's FM1 had asked him to take the resident on pass around the building. The unknown man identified himself as FM2. Resident #1 had a trach connected to oxygen. -When the nurse called FM1 to get her OK for the resident to leave with FM2, FM1 asked where the fireworks were going to be and the nurse stated she did not know but that resident #1 could not leave the vicinity of the facility because of his respiratory status. -When it was time to give resident #1 medications she realized he was not back and that the fireworks would be after dark and she presumed they would be watching them from the parking lot of the building. She further stated she had not attempted to check on resident #1 prior to 8:00 p.m. when she called FM1 and told her to have FM2 bring resident #1 back. FM1 stated she did not know if she had FM2's number. -When FM1 would come to the facility, she would see FM1 wheeling resident #1 in the hallway but did not know where they would go. -When asked specifically about the fact that resident #1 could not go out on pass, stated she did not think staying in the vicinity of the building was considered going out on pass since she believed going out on pass is an activity such as going to a movie, restaurant, home, or appointment. -When asked specifically who would monitor resident #1 in a situation such as with FM2 when he was in the vicinity but not on pass to ensure he was getting his cares and his oxygenation status was appropriate, stated she really did not know.

Based on staff interview and clinical record and facility policy reviews, the facility failed to ensure services provided by the facility met professional standards of quality, as evidenced by one resident (#1) was administered a medication without a physician's order. Findings include: Resident #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Nurse's Notes dated January 26, 2012, revealed that the resident's hair treated with "RID" (a topical medicated treatment). A review of the clinical record revealed no physician's orders for the treatment proved to the resident. During an interview conducted at 2:00 p.m. on May 17, 2012, the nurse who wrote the Nurse's Note on January 26, 2012, stated that he administered the medicated topical treatment to the resident's hair. He also stated that after reviewing the resident's clinical record, he realized that he had not obtained a physician's order for the treatment he provided. A review of the facility Physician Orders policy and procedure revealed that "No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses."

Based on observation, staff interviews, and review of facility policy, the facility failed to ensure that a subcutaneous injection was administered using proper technique to one resident (#17). The sample size was one of 10. Findings include: During a medication administration observation conducted on October 19, 2011 at 8:00 a.m., licensed staff was observed to administer [MEDICATION NAME] (used to prevent blood clots) 40 milligrams via subcutaneous route to resident #17. However, the licensed staff was not observed to either squeeze or grasp the skin at the injection site prior to injecting the medication. An interview was conducted on October 19, 2011, with the licensed staff, who stated that she did not use the above mentioned technique because it tends to bring blood to the surface of the injection site and that she had not thought to do so. A second interview was conducted on October 24, 2011, with the Director of Nursing, who stated that the skin at the injection site of a subcutaneous injection should be grasped prior to the injection the medication. A facility policy titled, Subcutaneous Injections, included, "It is the policy of the facility to administer a small quantity of medication through the skin into the subcutaneous fat." The policy also included the following: "8. Grasp the skin between your thumb and forefinger to elevate the subcutaneous tissue."

Based on observations, staff interviews, and review of facility policy, the facility failed to ensure that expired medications and laboratory supplies were not available for resident use. Findings include: Observations were conducted on October 18, 2011, of the three nursing unit medication rooms. The first floor nursing unit medication room was observed to have approximately 100 expired laboratory blood specimen collection tubes and third floor nursing unit medication room was observed to have four vials of expired Heparin, used for intravenous flushes. An interview was immediately conducted with the first floor unit manager, who stated that the medication room was to be inspected by either the charge nurse or the unit manager, weekly, and that all expired medications and other supplies were to be disposed of at that time. The unit manager was unable to state when the medication room was last inspected for expired medications and laboratory supplies or why the expired items were available for resident use. A second interview was also conducted with the third floor nursing unit licensed staff, who stated that the evening or night shift nurses were responsible to inspect the medication room for expired medications, but was unable to stated how frequently or when it was last inspected. An interview was also conducted on October 24, 2011, with the Director of Nursing, who stated that the unit managers or Assistant Director of Nursing were responsible to inspect the medication rooms, weekly. A facility policy titled, Drug Storage, included, " It is the policy of this facility to ensure the proper and safe storage of drugs and biological (sp). The policy also included the following: "4. Additional drug storage requirement including: -Expiration dates"