Every finding on record at Oak Forest Health and Rehabilitation

Based on observations, record review, resident, staff and family interviews, the facility failed to maintain a bathroom sink in good repair in 1 of 12 resident rooms and a clean environment in 8 of 12 resident rooms on 1 of 2 halls which affected sixteen (16) residents reviewed for environmental concerns (Resident #71, Resident #65, Resident #56, Resident #61, Resident #108, Resident #115, Resident #119, Resident #86, Resident #42, Resident #25, Resident #30, Resident #68, Resident #112, Resident #100, Resident #67, and Resident #137). The findings included: a. An observation of Resident #71/Resident #65's shared room on 7/20/8/26 at 10:48 AM revealed all corners and baseboards had a layer of dirt, hair, and food particles. Behind the entrance door to the room a brown material covering 4 floor tiles caused the surveyor's shoes to stick to the floor. Privacy curtains throughout the room were soiled with a white pasty substance and oily spots. Eight of eight of the Packaged Terminal Air Conditioner (PTAC) levers were covered with a layer of dust and debris. Five of the eight levers were covered with raised, black round particles. The floor under the PTAC unit had buildup of dust, paper, a plastic tube feeding cap, and black raised particles. A yellow-brown smear was present on the wall to left side of PTAC. In the bathroom a triangle shaped piece of floor tile approximately 3 inches by 6 inches was missing at base of toilet. Debris and yellow toilet paper were seen behind the toilet. The bathroom door had visible brown spatters on the door handles, the door frame, and the door. Resident #71's tube feeding pump, the base of the tube feeding pole, and the bedframe were covered with dried feeding formula. Dried feeding formula was observed on the floor at the base of the pole. Four plastic caps and paper were noted under the bed. The bedside table base for Resident #71's bedside table base was covered with raised, brown material that was able to be scraped off. Behind both beds there was paper and trash on the floor. An observation of Resident #71/Resident #65's room on 7/20/8/26 at 2:28 PM revealed the room remained in the same condition. The two residents were unable to be interviewed. An observation and interview of Resident #71/Resident #65's room was conducted with Housekeeper #1 on 7/20/26 at 2:46 PM. She confirmed she had completed the daily cleaning for the room before lunch. She was unable to explain the concerns identified and stated she had cleaned the room to the best of her ability and training. b. An observation of Resident #108/Resident #115's shared room and bathroom on 7/20/26 at 10:54 AM revealed dirt, dust, and hair build up along all baseboards, particularly in corners. Red raised matter was seen on the wall to right side of Resident #108's bed and there were food particles and straw wrappers under the bed by front wheels. The floors throughout the room were sticky, causing the surveyor's shoe to adhere to the floor. A brown residue in drip pattern was noted on the second drawer of Resident #115's bureau. The floor under the PTAC unit had a layer of dirt and 2 plastic wrappers were observed. The top of the PTAC unit was covered with a brown residue; 2 of the 8 levers were covered with a layer of dust and there were food particles on the control panel. In the bathroom the hot water faucet knob was lying on the top of the sink. Resident # 108 was unable to be interviewed. The quarterly Minimum Data Set (MDS) for Resident #115 dated 7/15/26 revealed she was cognitively intact. An interview was conducted with Resident #115 on 7/20/26 at 10:58 AM. She said she was unaware the faucet was not in place in the bathroom and did not know how long it had been sitting on top of the sink. She explained that since she relied on a wheelchair for locomotion, she did not know the floors were sticky. The resident further stated she liked having her room clean and did not want her visitors to see a dirty room. An observation of Resident #108/Resident #115's room on 7/20/26 at 2:30 PM revealed the room to be in the same condition. An observation and interview of Resident#108/115's room was conducted with Housekeeper #1 on 7/20/26 at 2:48 PM. She confirmed she had completed the daily cleaning for the room. She was unable to explain the concerns identified and stated she had cleaned the room to the best of her ability and training. c. An observation of Resident #119/Resident #86's shared room and bathroom on 7/20/26 at 11:11 AM revealed a yellow stain covering 6 floor tiles in bathroom. Behind the toilet there were two missing floor tiles. The top and filter grill of the PTAC unit were covered with a buildup of gray and brown matter; 8 of 8 levers were covered with a layer of dirt and dust. A layer of dirt and dust was seen along the baseboards and corners throughout the room and all corners of the bathroom had raised dirt and hair buildup. An observation of Resident #119/Resident #86's room on 7/20/26 at 2:32 PM revealed the room remained in the same condition. The two residents were unable to be interviewed. An observation and interview of Resident #119/Resident #86's room was conducted with Housekeeper #1 on 7/20/26 at 2:50 PM. She confirmed she had completed the daily cleaning for the room. She was unable to explain the concerns identified and stated she had cleaned the room to the best of her ability and training. d. An observation of Resident #42/Resident #25's room on 7/20/26 at 11:15 AM revealed a layer of dirt and dust along the baseboards throughout the room. Under the PTAC unit there was a buildup of food particles, dirt, and hair. Eight of eight levers of the unit were covered with raised, round, black particles. An observation of Resident #42/Resident #25's room on 7/20/26 at 2:36 PM revealed the room remained in the same condition. The two residents were unable to be interviewed. An observation of Resident#42/Resident #25's room was conducted with Housekeeper #1 on 7/20/26 at 2:53 PM. She confirmed she had completed the daily cleaning for the room before lunch. She was unable to explain the concerns identified and stated she had cleaned the room to the best of her ability and training. e. An observation of Resident #56/Resident #61's room on 7/20/26 at 11:22 AM revealed a floor throughout the room with dirt and particles built up along the baseboards. The light switch behind the entrance door was covered with yellow and brown residue. Eight of eight levers of the PTAC unit were covered with a layer of dust, hair, and black raised material. The bathroom door, door frame and handle had visible brown splatters. The floor tile under the shared bureau was pulled up from the floor. The bathroom smelled of urine; dirt and debris buildup and yellow toilet paper was observed behind toilet. The floor mats on both sides of Resident #61's bed were covered with spatters of brown material. The two residents were unable to be interviewed. On 7/20/2026 at 11:23 AM an interview was conducted with Resident #61's family member who was visiting. She stated the dirty room was unacceptable, and the family had been bringing in supplies and cleaning the room. The family member explained she has spoken to the Housekeeping Supervisor several times about environmental issues, but each time was told the facility would get to it when we have room open. An observation of Resident #56/Resident #61's room on 7/20/26 at 2:38 PM revealed the room remained in the same condition. An observation of Resident#56/Resident #61's room was conducted with Housekeeper #1 on 7/20/26 at 2:56 PM. She confirmed she had completed the daily cleaning for the room. She was unable to explain the concerns identified and stated she had cleaned the room to the best of her ability and training. f. An observation of Resident #30/Resident #68's room on 7/20/26 at 11:27 AM revealed the floor of the entire room had a buildup of dust and dirt in all corners. In the bathroom paper, white particles, dust, and dirt were visible along the baseboards. An approximately 2-foot section of laminate on the sink table ledge was pulled away from the sink and hanging. Behind the toilet an approximately 1-inch piece of brown plastic wood laminate and a piece of blue plastic wrapper were observed. Three circular patches of black, raised sticky residue were observed along the wall to the right of entry door. A metal drink can top noted on the floor behind the door. Resident #30's privacy curtains had visible splatters. Five of the eight PTAC levers were covered with dirt, food particles, and black round raised particles. The floor tile was peeled up under Resident #68's bureau. A red splatter was seen next to the Resident #30's bureau handle to bureau. The two residents were unable to be interviewed. An observation of Resident #30/Resident #68's room on 7/20/26 at 2:40 PM revealed the room remained in the same condition. An observation of Resident#30/Resident #68's room was conducted with Housekeeper #1 on 7/20/26 at 2:59 PM. She confirmed she had finished her shift all had completed the daily cleaning for the room. She was unable to explain the concerns identified and stated she had cleaned the room to the best of her ability and training. g. An observation of Resident #100/Resident #112's room on 7/20/26 at 11:32 AM revealed a dirty fall mat beside Resident #100's bed. The top of the PTAC unit was covered with dirt and orange particles. Eight of eight levers had raised black particles; the filter grill was covered with adhered dust and dirt. A black hair was noted on lever #8. The two residents were unable to be interviewed. An observation of Resident #100/Resident #112's room on 7/20/26 at 2:42 PM revealed the room remained in the same condition. An observation of Resident#100/Resident #112's room was conducted with Housekeeper #1 on 7/20/26 at 3:02 PM. She stated her shift was over and confirmed she had completed the daily cleaning for the room. She was unable to explain the concerns identified and stated she had cleaned the room to the best of her ability and training h. An observation of Resident #67/Resident #137's room on 7/20/26 at 11:45 AM revealed a build up along all baseboards, particularly in corners. On the floor under Resident #67's headboard, food and black raised residue were seen. The padded bed extender at the foot of bed had built up residue, food, and dried spills. An orange dried residue was noted on the privacy curtain. Tissues were observed on floor in front of the bathroom entrance. Splatters of red, raised matter were present on the right wall entering the room. On the floor under Resident #137's bed food particles were seen. Food particles were seen on 8 of 8 levers of the PTAC unit. The control panel of the PTAC unit was covered with a black and brown residue sticky to the touch. An observation of Resident #67/Resident #137's room on 7/20/26 at 2:45 PM revealed the room remained in the same condition. An observation of Resident#67/137's room was conducted with Housekeeper #1 on 7/20/26 at 3:03 PM. She confirmed she had completed her shift and the daily cleaning for the room. She was unable to explain the concerns identified and stated she had cleaned the room to the best of her ability and training. An interview was conducted with Housekeeper #1 on 7/20/26 at 1:30 PM. She stated that her shift was fulltime 7:00 AM to 3:00 PM with the responsibility of two hallways and several common areas to clean daily. Housekeeper #1 shared that after a room was cleaned, she did not go back to through again as she had too many rooms assigned daily. The housekeeper explained her daily responsibilities for each room included pulling trash from rooms and replacing the liner, sweeping and dry mopping the floors of the room and bathroom, scrubbing the toilet, cleaning the overbed table and wiping down surface areas in the room to include the blinds, overbed tables, nightstands, doorknobs, and light switches. She shared that floor cleaning included sweeping first followed by mopping under the beds. Housekeeper #1 stated each room received a deep cleaning monthly and the Housekeeping Supervisor checked completed work after a deep clean and did daily and random work audits and advised if a deep cleaning was scheduled. An interview was conducted on 7/21/26 at 10:03 AM with the Housekeeping Supervisor who explained daily room cleaning responsibilities included pulling trash, dusting, wiping high touch areas in hall/day rooms and public restrooms. He further stated that the disinfectant used required a 10-minute time on high touch surfaces following by wiping off residue. He confirmed each housekeeper was assigned approximately 30 rooms for daily cleaning and 2 rooms on each hallway were scheduled weekly for a deep cleaning. He further explained that weekly deep cleans were for residents who were mobile. If a resident were bedbound, then the deep cleaning would be scheduled around weekly shower schedules. The Housekeeping Supervisor shared that deep cleaning consisted of wiping all walls down, deep cleaning room and bathroom floors. He stated beds would be moved from wall, nightstands pulled out and a Floor Technician would clean all floors. He further shared that windowsills and blinds are cleaned at this time. The Housekeeping Supervisor stated he had no schedule for deep cleaning of rooms as he has been in this industry for years and has an audit list in his head. The Housekeeping supervisor shared that if he sees an issue when doing the daily room audit, he would pull the assigned housekeeper in to do a correction at that time and if the housekeeper is gone for day, as supervisor he would do the needed cleaning and then counsel the housekeeper the following day. He confirmed he had been through the rooms of Resident #71, Resident #65, Resident #56, Resident #61, Resident #108, Resident #115, Resident #119, Resident #86, Resident #42, Resident #25, Resident #30, Resident #68, Resident #112, Resident #100, Resident #67, and Resident #137 on 7/20/26 and did not see any environmental concerns. Observations were conducted with the Housekeeping Supervisor on 7/21/26 from 10:04 AM to 10:24 AM of Resident #71, Resident #65, Resident #56, Resident #61, Resident #108, Resident #115, Resident #119, Resident #86, Resident #42, Resident #25, Resident #30, Resident #68, Resident #112, Resident #100, Resident #67, and Resident #137's rooms. The Housekeeping Supervisor stated findings were not acceptable but stated he was not sure why the rooms were not cleaned per facility standards. He further stated the issues identified could be attributed to needed room renovations, staff turnover and work ethics but was still unacceptable and would be fixed. An observation and interview were conducted with the Administrator on 7/22/26 from 7:22 AM- 7:45 AM of Resident #71, Resident #65, Resident #56, Resident #61, Resident #108, Resident #115, Resident #119, Resident #86, Resident #42, Resident #25, Resident #30, Resident #68, Resident #112, Resident #100, Resident #67, and Resident #137's rooms. The Administrator shared she was not aware of the cleaning issues as she did not conduct room inspections but relied on reports from the Housekeeping Supervisor. During the observations of these rooms the Administrator stated the facility owner was aware of flooring issues and there was a renovation plan to address this concern but stated the cleanliness of rooms did not meet the facility standards and what she witnessed was unacceptable. The Administrator stated she did not know why the Housekeeping Supervisor was unaware and he had been given a paper audit tool to use for room audits. The Administrator stated the biggest concern at hand was cleanliness and there was no explanation for dirty rooms other than staff accountability. She was unsure why the Housekeeping Supervisor was not using room audit sheets provided to him nor why the rooms were dirty if he was walking through them daily.

Based on observation, record review, Resident and staff interviews, the facility failed to follow a physician order for supplemental oxygen for 1 of 1 resident reviewed for respiratory care (Resident #38).The findings included:Resident #38 was admitted on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia (low oxygen levels). The quarterly Minimum Data Set, dated [DATE] noted that the resident was cognitively intact and was not coded for oxygen use.A review of the care plan dated 7/21/26 revealed a focus area of oxygen therapy related to congestive heart failure and ineffective gas exchange with interventions that included delivery of oxygen as ordered. Review of physician orders revealed an order dated 7/21/26 for supplemental oxygen use at 2 Liters/minute (L/min) per nasal cannula (a flexible plastic tube that delivers extra oxygen through the nose to help people who are having difficulty breathing) each shift for oxygen saturations below 90 %. On 7/21/26 at 10:32 AM Resident #38 was observed asleep in bed wearing a nasal cannula oxygen tube connected to a portable oxygen unit next to her bed. The oxygen flow was being delivered at 4 L/min. The resident did not show any signs of discomfort or difficulty breathing. On 7/21/26 at 2:35 PM during an observation and interview with Resident #38, she was observed resting in bed with supplemental oxygen in place at 4 L/min. Resident #38 was alert and oriented and did not show any signs of discomfort or difficulty breathing. She stated she was unaware of the oxygen flow rate as the oxygen unit was out of her line of vision. Resident #38 further stated she was unable to roll over independently and adjust the oxygen rate and would never do so even if she could reach it. An interview was conducted with Nurse #1 on 7/21/26 at 2:45 PM regarding Resident #38's supplemental oxygen order. He confirmed he was the primary nurse for Resident #38 on 7/21/26 from 7:00 AM to 3:00 PM. Nurse #1 explained he checked the rate of oxygen ordered and what the resident was receiving to ensure the rate ordered matched the rate the resident was receiving. He further explained that he checked the order when taking the assignment and again when giving medications. Nurse #1 further stated it was the responsibility of the nurse to check oxygen flow rate and oxygen saturation. Nurse #1 did not remember how much oxygen Resident #38 was receiving. Nurse #1 pulled up the order with the state surveyor present and stated Resident #38 was ordered to receive 2L/minute. The Medication Administration Record (MAR) for 7/21/26 was reviewed at this time with Nurse #1 and revealed the nurse had documented Resident #38 was receiving oxygen at 2L/min by nasal cannula. A bedside observation of Resident #38 was completed with Nurse #1 on 7/21/26 at 2:47 PM. The nurse observed the oxygen flow rate and confirmed that it was set to 4 L/min and changed it to 2 L/min. Nurse #1 further stated he felt certain the resident had been on 2 L/min when he gave Resident #38 her medications but stated he did not recall her oxygen saturation rate when he checked it. He was unable to explain why Resident #38 was on supplemental oxygen at 4L/min when the order was for 2 L/minute. An interview was conducted on 7/21/26 at 3:25 PM with the Director of Nursing (DON). She explained it was the nurse's responsibility to validate orders for oxygen, ensure the rate ordered matched what a resident was receiving, and the resident was not experiencing any respiratory distress. The DON stated she was unsure why Nurse #1 was unaware the resident was receiving supplemental oxygen at 4L/minute.

Based on observations and staff interviews, the facility failed to secure two full oxygen cylinders stored in a resident's room for 1 of 1 resident reviewed for being free of accident hazards (Resident #65). Resident #65 did not have a current order for oxygen use.The findings included: Resident #65 was admitted on [DATE] with diagnoses that included heart failure, cognitive impairment, stroke, and renal insufficiency. The quarterly Minimum Data Set (MDS) dated [DATE] documented the resident was moderately cognitively impaired and used supplemental oxygen. A review of Resident #65's July 2026 Physician orders revealed no current order for supplemental oxygen. On 7/20/26 at 11:00 AM two full oxygen cylinders were observed in Resident #65's room. One cylinder was standing upright in a corner beside the bed. The second cylinder was leaning against the upright cylinder. Neither cylinder was secured. Resident #65 was not in the room at the time of the observation. On 7/20/26 at 11:30 AM an observation of Resident #65's room was conducted with Nurse #2 who confirmed both oxygen cylinders were full and unsecured. She stated oh-that's not safe and asked the surveyor to stay with the oxygen cylinders while she retrieved a storage container. She returned in less than 3 minutes with a rolling caddy for each unsecured cylinder and then returned them to the designated oxygen storage closet. During an interview on 7/20/26 at 11:45 AM Nurse #2 confirmed she was Resident #65's assigned nurse that day. Nurse #2 stated portable oxygen cylinders were stored in a designated locked closet on each floor of the facility. She further shared that when an oxygen cylinder was taken to a resident's room, it should be transported and secured in an upright position using an individual caddy. The nurse stated it was unsafe for an oxygen cylinder to be placed leaning on another cylinder and unsecured as it could fall and become a dangerous projectile. Nurse #2 explained that nursing staff had been trained to store oxygen cylinders in an upright position in a rolling caddy when in use in a resident room. She reported that she had not observed the oxygen cylinders in Resident #65's room when she administered medication earlier that morning and did not know why the cylinders were in the room as Resident #65 had not been receiving supplemental oxygen for several weeks. On 7/20/26 at 3:20 PM, an interview was conducted with the A-Wing Unit Manager who explained that oxygen cylinders should be placed upright in a secure holder when in a resident room. She stated that she had not noticed the oxygen cylinders stored in Resident #65's room on 7/20/26 and having them stored unsecured in a resident's room was unsafe because they could tip over and rupture the tank leading to a potential fire hazard. During an interview with the Director of Nursing (DON) on 7/21/26 at 12:27 PM, she explained that oxygen cylinders should be stored in the designated oxygen storage closet, and if a cylinder was needed in a resident's room, it must be kept in a transport caddy. The DON added that oxygen cylinders should not be left unsecured in a resident's room because it was a potential fire hazard. She did not know why the two full oxygen cylinders in Resident #65's room were left unsecured. An interview was completed with the Administrator on 7/22/26 at 8:02 AM. She stated it was unsafe to leave oxygen cylinders unsecured, and the cylinders must be kept in a transport caddy when used in a resident room. She further explained that if a full oxygen tank fell it had the potential to become a projectile object and harm residents and staff. The Administrator did not know why the two full oxygen cylinders in Resident #65's room were left unsecured.

Based on record review, resident, staff, Registered Dietitian, and dialysis center Administrator interviews, the facility failed to serve breakfast or provide snacks before dialysis treatment for 2 of 3 resident reviewed for dialysis (Resident #140 and Resident #6). Findings included: 1.Resident #140 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis. Review of Resident #140 physician order dated 06/05/26 revealed the resident received dialysis every Monday, Wednesday, and Friday. Review of Resident #140's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and was coded for dialysis. An interview with Resident #140 on 07/20/26 at 2:15 PM revealed since admission she had not been provided breakfast or snacks prior to her dialysis appointments. Resident #140 further revealed she left for dialysis at 5:30 AM and returned around 11:00 AM. Resident #140 indicated she would prefer to have breakfast but did not think it was available due to breakfast being served after she left the facility for dialysis. Resident #140 stated that she would like to have breakfast and snacks provided before going to dialysis. A phone interview with the Administrator at the dialysis center on 07/22/26 at 11:00 AM revealed that residents were allowed to bring food items to dialysis. It was further revealed Resident #140's treatments started at 6:30 AM and they expected Resident #140 to eat breakfast prior to dialysis and encouraged Resident #140 to bring a snack to dialysis to help with weakness. A phone interview with Nurse #4 on 07/22/26 at 12:00 PM revealed she had been assigned Resident #140 for the past month during third shift and Resident #140 had not received breakfast or snack prior to her dialysis appointments. Nurse #4 indicated that the resident left the facility around 5:30 AM and dietary staff had not provided food items for breakfast or to send with the resident to her dialysis appointments. Nurse #4 indicated she had voiced concerns to other nursing staff prior. An interview conducted with the Registered Dietitian (RD) on 07/22/26 at 12:40 PM revealed she had not been made aware that Resident #140 had missed meals before dialysis. The RD further revealed she would expect Resident #140 to eat breakfast before dialysis and be provided snacks so Resident #140 did not become weak during her dialysis treatments. An interview conducted with the facility Administrator on 7/23/26 at 10:25 AM revealed she was not aware Resident #140 had missed breakfast before dialysis or that Resident #140 was also not provided with snacks to take with her. The Administrator further revealed she expected Resident #140 to not miss any meals and dietary and nursing staff to communicate about resident's needs. An interview conducted with the Dietary Manager on 07/23/26 at 12:30 PM revealed dietary staff did not arrive at the facility until 6:00 AM. It was further revealed she was not aware Resident #140 left the facility at 5:30 AM and had not been provided breakfast or snacks for dialysis. The Dietary Manager indicated it was a miscommunication between dietary and nursing staff. The Dietary Manager stated she expected the dietary staff to have Resident #140's food items ready before the resident's dialysis appointments. An interview conducted with the Director of Nursing (DON) on 07/23/26 at 1:00 PM revealed she had not been made aware Resident #140 had missed meals before dialysis. The DON further revealed she would expect dietary staff to have food items prepared for nursing staff to give to Resident #140 before leaving for her dialysis appointments. 2. Resident #6 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus and stage 4 chronic kidney disease. The review of the physician's order dated 4/24/26 revealed Resident #6 received dialysis every Monday and Friday. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 was cognitively intact and received dialysis treatments. During an interview on 7/21/26 at 10:57 a.m. Resident #6 revealed she was transported from the facility between 5:00 a.m. and 5:30 a.m. for her 6:00 a.m. appointment at the dialysis center every Monday and Friday. Resident #6 stated that on the days of her dialysis appointment the facility did not provide her breakfast or snacks to take with her. The resident stated that prior to her leaving for the dialysis center, the facility's dietary department never offered her breakfast or provided a packed snack to consume while at dialysis. A telephone interview with the Administrator at the dialysis center on 7/22/26 at 11:46 a.m. revealed that residents were allowed to bring food items to dialysis. The dialysis center's expectation was for Resident #6 to eat a small breakfast prior to dialysis treatment. During an interview on 7/22/26 at 12:35 p.m., the Dietary Manager (DM) stated there were six residents receiving dialysis treatments, but only three residents (including Resident #6) received early breakfast trays before leaving for the dialysis center. The DM revealed the Dietary Cook's duties began at 6:00 a.m. and the nursing assistants would deliver the early breakfast trays to the three residents in their rooms. The DM stated she was not made aware of any dialysis residents scheduled to leave for dialysis before 6:00 a.m. However, the nourishment rooms' refrigerators were restocked between 8:30 p.m. and 9:00 p.m. with juices, cakes, peanut butter crackers, yogurt, sandwiches, and boiled eggs (when available). An interview conducted with the Registered Dietitian (RD) on 07/22/26 at 12:40 p.m. revealed she had not been made aware that Resident #6 had missed meals before dialysis. The RD further revealed she would expect Resident #6 to eat breakfast before dialysis and be provided snacks to avoid the resident becoming weak during her dialysis treatments. During an interview on 7/23/26 at 10:25 a.m., the facility Administrator revealed she was not aware Resident #6 had missed breakfast before dialysis or that Resident #6 was also not provided with snacks to take with her. The Administrator stated that she expected Resident #6 to not miss any meals and dietary and nursing staff to communicate about the resident's dietary needs.

Based on observations, record review and resident, staff and Medical Director interviews, the facility failed to secure medications stored at the bedside for 1 of 1 resident reviewed for medication storage (Resident #31).Findings included:Resident #31 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD).Review of Resident #31's physician's order dated 12/11/25 revealed the resident was ordered Symbicort Aerosol inhaler (is a combination inhaler containing a steroid and formoterol a long-acting bronchodilator used for the long-term maintenance treatment) 160-4.5 MCG/ACT (micrograms per actuation) two times a day orally for chronic obstructive pulmonary disease (COPD).Resident #31's Minimum Data Set (MDS) dated [DATE] revealed the resident was moderately cognitively impaired.Resident #31's Medication Administration Record (MAR) revealed on 07/19/26 Nurse #4 documented she had administered Resident #31 her Symbicort Aerosol at 8:00 PM. An observation and interview were conducted on 07/20/26 at 12:45 PM with Resident #31 in her room. It was observed that she had an inhaler sitting on her bedside table. Resident #31 said Nurse #4 that worked 3rd shift on 07/19/26 had left it on her bedside table. Resident #31 stated she had not used it and left it on her bedside for staff to retrieve.An observation and interview with Nurse #3 on 07/20/26 at 12:55 PM revealed that she had completed the morning medication pass and indicated Resident #31's inhaler had been missing. It was further revealed that management had been notified and an order for a new inhaler had been placed. Nurse #3 observed Resident #31's inhaler and indicated it was the resident's inhaler that was missing and the resident did not have an order to self-administer. Nurse #3 stated Nurse #4 was the last to give Resident #31 her inhaler.A phone interview with Nurse #4 on 07/22/26 at 12:00 PM admitted she had left Resident #31's inhaler at her bedside during 3rd shift on 07/19/26 during medication pass. Nurse #4 further revealed she had administered Resident #31's inhaler and left it in the resident's room by accident when she had assisted the resident with a snack. Nurse #4 indicated Resident #31 was not able to self-administer. Nurse #4 stated she should have put Resident #31's inhaler back in the medication cart before assisting the resident.An interview with the Administrator on 07/23/26 at 10:25 AM revealed that she was not aware of an inhaler being left at the bedside of Resident #31. The Administrator further revealed she expected ordered medications not to be left out to residents who did not have an order to self-administer.An interview was conducted on 07/23/2026 at 12:50 PM with the Medical Director revealed Resident #31 did not have an order to self-administer medication. The Medical Director further revealed that he expected staff to not leave medications at bedside.An interview with the Director of Nursing (DON), conducted on 07/23/26 at 1:00 PM revealed Resident #31 was unable to self-administer medications. The DON stated that Nurse #4 should not have left Resident #31's inhaler at the bedside.

Based on observation, record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to provide care in a safe manner when Resident #71 was rolled out of her bed during incontinent care hitting the floor. Resident #71 was sent to the Emergency Department (ED) and diagnosed with a fracture of her left distal (away from the center) clavicle, a closed fracture of the second rib on the left side, and a large left-sided scalp hematoma. The facility also failed to conduct smoking assessments when Resident #117 was not assessed for smoking. The deficient practice occurred for 2 of 4 sampled residents reviewed for supervision to prevent accidents (Resident #71 and Resident #117). Findings included: 1. Resident #71 was admitted to the facility on [DATE] with diagnoses which included dementia, adult failure to thrive, contractures of left and right extremities, right hip osteoarthritis, dysphagia, and a history of pulmonary embolism. The revised care plan dated 1/17/25 revealed Resident #71 had an activities of daily living (ADL) self-care performance deficit related to limited mobility and dementia. Interventions included: extensive, two-person staff assistance to re-position and turn in bed; and two-person assistance using a mechanical lift for transfers. Resident #71's physician orders revealed on 2/27/25 the Resident was ordered 5 milligrams of Eliquis (blood thinner medication) via a gastrostomy tube two times a day due to her history of pulmonary embolism/deep vein thrombosis (DVT). The annual Minimum Data Set assessment dated [DATE] indicated Resident #71was severely cognitively impaired, dependent on staff for bed mobility and transfer, had impairment of bilateral upper and lower extremities, had an indwelling catheter, was always incontinent of bowel, had a feeding tube, and had no falls since her last annual assessment. Review of a progress note by Nurse #3 dated 4/13/25 documented that at 6:15 a.m. nursing assistant (NA#3) reported she was performing personal care on Resident #71 and when she turned the Resident on her side to place a brief on her, the Resident rolled off the opposite side of bed. NA#3 reported that the Resident's bed was waist level to her during this time. Resident #71 had a golf ball sized hematoma to the left side of her head. The on-call health provider was notified and ordered the Resident to be sent out for further evaluation. Resident #71's normal mental baseline remained the same. The Resident left facility via ambulance via stretcher at 7:15 a.m. NA#3 was educated on the importance of requesting assistance with residents that required the assistance of two people to help prevent falls or potential injuries while performing personal care and transferring residents. A telephone interview was conducted on 5/20/25 at 5:30 p.m. with Nurse #3 who revealed she last worked at facility approximately 3.5 weeks ago. She revealed she worked at the facility on 4/13/25 during the 11:00 p.m. to 7:00 a.m. shift. Nurse #3 stated that at approximately 6:35 a.m. NA #3 informed her Resident #71 was on the floor in her room. The Nurse reported that she entered Resident #71's room and observed Resident #71 lying on her back, on the floor on the right side of the bed awake and moaning. Nurse #3 stated NA #3 informed her that as she was on the left side of the bed changing the Resident's brief, the NA #3 rolled the Resident away from her to apply the brief but Resident #71 rolled off the bed onto the floor. Nurse #3 stated she conducted a physical assessment of Resident #71 and noted a golf ball sized knot on the left side of her head, above her left ear but no bleeding. Nurse #3 stated she informed NA #3 that she should have requested her assistance with the Resident's care because the Resident required two staff for assistance with bed mobility and transfers due to the resident was very contracted and stiff. Nurse #3 stated she reminded NA #3 and pointed to a small note on yellow paper on the wall above the resident's head of bed which read two person assist. The Nurse reported NA #3 responded she did not notice the note. Nurse #3 stated that at approximately 6:45 a.m., with the use of the mechanical lift, she and NA#3 returned Resident #71 to her bed where her vital signs were taken and were within normal limits. Nurse #3 stated she notified the on-call physician of the incident who ordered the resident sent to the emergency room due to the large hematoma to her head. She revealed 911 was called and emergency medical services (EMS) arrived at approximately 7:15 a.m. Nurse #3 stated that throughout the incident, Resident #71 did not lose consciousness, had no bleeding, and was no longer moaning. Nurse #3 revealed she reported the resident's fall to the on-coming Charge Nurse (Nurse #4). On 5/20/25 at 8:47 a.m., an interview was conducted with Nurse #4 who stated she worked as the first shift Charge Nurse on 4/13/25. She recalled that upon her arrival to begin her shift (timecard indicated Nurse#4 reported to work at 6:51 a.m. on 4/13/25), Nurse #3 informed her Resident #71 had a fall and had an injury to the side of her head. Nurse #4 stated this prompted her to conduct an observation of the resident. Nurse #4 stated she observed the Resident was awake in bed, nonverbal (which was normal) at her baseline, with a large hematoma (palm size) to the left side of her head. Nurse #4 stated she immediately told Nurse #3 to phone the physician STAT (immediately). The physician gave orders to send the Resident to the emergency room, immediately. Nurse #4 revealed she was unsure if Resident #71 received blood thinning medication because she was not her assigned nurse; but there was no blood, and the hematoma was not purple and the Resident was not flinching in pain. Nurse #4 revealed she interviewed Nurse #3 and NA #3 on the amount of time since the resident was returned to her bed and both estimated no longer than thirty minutes. Nurse #4 stated she interviewed the NA #3 who reported that when she was providing incontinence care to Resident #71 she (NA) rolled the resident onto her side, and the Resident rolled off the other side of the bed. NA #3 admitted she did not have assistance and was aware Resident #71 was a two person assist with bed mobility and transfers but she had no help. When Nurse #4 asked if NA #3 asked assistance from her nurse, NA #3 response was no. Nurse #4 stated she immediately notified the Director of Nursing who instructed her to have the Schedular notify NA#3 (who had left at end of the shift) that she was suspended pending investigation. Nurse #4 stated NA #3 had not returned to the facility since the incident on 4/13/25. The review of the facility's Initial Falls Review form dated 4/13/25 documented Resident #71 rolled or fell out of the bed which was in the low position. NA#3 went in to perform personal care for Resident #71 and during the interaction NA#3 rolled the resident over to place brief on when the resident rolled off the opposite side of the bed resulting in a hematoma to left side of her head. The Resident remained alert, pupils were equally round and reactive to light, equal hand grasp, and moved all extremities. The Nurse Practitioner was notified and ordered to send the resident out to the emergency room. NA #3 was unable to be reached for an interview. The Hospital Discharge summary dated [DATE] revealed Resident #71 presented to the hospital's emergency room on 4/13/25 after a fall from the bed when being turned by staff at the nursing home. Reportedly staff was caring for the resident when they went to roll her back over they rolled her off the bed and the resident landed on her left side. As a result of the x-rays and computed tomography (CT scan), Resident #71 was diagnosed with a fracture of her left distal clavicle, a closed fracture of the second rib of the left side, and a large left-sided scalp hematoma. Also, a Complete Blood Count (CBC) test showed Resident #71 had a slightly elevated white count and a slightly elevated procalcitonin (a protein produced in response to bacterial infections). A urinalysis showed minimal infection. Resident #71 was diagnosed with possible sepsis along with her new fractures. The resident developed a low-grade temperature of 100.6 degrees Fahrenheit while in the emergency room. The Resident was hospitalized to allow for the administration of intravenous antibiotics before being discharged back to the facility. On 5/18/25 at 1:03 p.m., Resident #71 was observed in bed awake, nonverbal and covered with bed linen. An interview with the Administrator on 5/19/25 at 2:17 p.m. revealed NA #3 was terminated from the facility on 4/13/25 due to her failure to follow policy related to bed mobility. She also revealed Nurse #3 (an Agency nurse), last worked at the facility on 4/21/25. On 5/21/25 at 11:47 a.m., the Nurse Practitioner (NP) was interviewed and revealed she was not the on-call provider on 4/13/25 but based on the triage timing documented by the on-call provider, the time frame of the call was appropriate as well as the nurse's assessment. The NP indicated the nurse should always assess a resident before contacting the provider to be able to provide answers quickly to questions about a resident's injuries and/or health status. On 5/22/25 at 11:18 a.m. the Director of Nursing was interviewed and stated during admission, a resident's mobility and transfer ability would be assessed by nursing and therapy and the determination made if a resident required 1 or 2 staff assistance with bed mobility and the use of a mechanical lift for transfers. This determination would be documented in the Kardex (a resident's care plan used by staff when providing care) which all nursing assistants had been educated. 2. Resident #117 was admitted to the facility on [DATE] with diagnoses which included tobacco use. Review of Resident #117's annual Minimum Data Set (MDS) dated [DATE] revealed the resident was alert and oriented and was coded for tobacco use. Review of Resident #117's care plan revised on 03/18/25 revealed Resident #117 was at risk for injuries related to the preference of smoking. The goal was Resident #117's smoking related injuries would be minimized through current interventions. Review of Resident 117's smoking assessments revealed a smoking assessment was completed on 03/24/24 and the next assessment was not completed until 08/27/24. Smoking assessments were completed quarterly after 08/27/24. The smoking assessments from 03/24/24 and 08/27/24 concluded Resident #117 was an unsupervised smoker because he was able to demonstrate and understand the smoking policy, times, and place to smoke. An observation and interview conducted with Resident #117 on 05/20/25 at 2:00 PM revealed Resident #117 was outside in the designated smoking area smoking independently. Resident #117 stated he had always been an independent smoker in the facility. During the observation, Resident #117 was observed to safely ash his cigarette into an appropriate receptacle, and he was observed to not have any burns on his clothing, or his skin. An interview conducted with the Director of Nursing (DON) on 05/21/25 at 3:40 PM revealed she had expected quarterly smoking assessments to be completed. It was indicated nurses were notified by the medical record system what assessments were pending and needed to be completed during their shift, including smoking assessments, and they were expected to complete the assessments during their shift. The DON further revealed she was not aware Resident #117 had gone beyond the quarterly time frame without having had a smoking assessment conducted.

Based on observations, record review, and staff interviews, the facility failed to allow residents who had been assessed as a safe independent smoker the choice to smoke unsupervised for 2 of 3 residents reviewed for choices (Resident #114 and Resident #117). The findings included: Review of Policy Title: Smoking Agreement signed and dated 12/23/24 by Resident #114 stated independent smoker may smoke in designated areas when they would like to smoke. They must also adhere to the rules as outlined. 1. Resident #114 was admitted to the facility on [DATE] with diagnoses which included tobacco use. Review of Resident #114's quarterly Minimum Data Set (MDS) dated [DATE] revealed his cognition was intact. Review of Resident #114's care plan revised on 04/04/25 revealed Resident #114 was at risk for injuries related to the preference of smoking. The goal was Resident #114's smoking related injuries would be minimized. Review of Resident #114's quarterly smoking assessment dated [DATE] revealed Resident #114 was able to hold the cigarette safely without a device, extinguish cigarette safely, and ambulate independently. Resident #114 was assessed as able to smoke safely independently. An observation conducted on 05/20/25 at 12:30 PM revealed the designated smoking area door posted a sign that stated smoking was allowed from 8:00 AM- 8:00 PM daily. Observation and interview conducted with Resident #114 on 05/20/25 at 2:00 PM revealed Resident #114 was outside in the designated smoking area smoking independently. Resident #114 stated he was upset that times had been put in place and independent smokers were unable to smoke after 8:00 PM. Resident #114 stated he preferred to smoke independently in the evenings after 8:00 PM. An interview conducted with Nurse Aide (NA) #5 on 05/21/25 at 12:10 PM revealed she worked both 1st and 2nd shift. NA #5 stated multiple residents that smoked had complained that they were not able to smoke after 8:00 PM. NA #5 indicated Resident #114 had complained to her. NA #5 indicated she had spoken to multiple nursing staff before and told them that residents were upset. An interview conducted with the Director of Nursing (DON) and Administrator on 05/21/25 at 3:40 PM revealed Resident #117 was an independent smoker. The DON and Administrator stated they had not had any complaints from residents having to smoke at assigned times. It was indicated the assign times were implemented several months back and was a decision made by department heads. 2. Resident #117 was originally admitted to the facility on [DATE] with diagnoses which included tobacco use. Review of Resident #117's annual MDS dated [DATE] revealed his cognition was intact and was coded for tobacco use. Review of Resident #117's care plan revised on 03/18/25 revealed Resident #117 was at risk for injuries related to the preference of smoking. The goal was Resident #117's smoking related injuries would be minimized. Review of Resident #117's quarterly smoking assessment dated [DATE] revealed Resident #117 was able to hold the cigarette safely without a device, extinguish cigarette safely, and ambulate independently. Resident #117 was assessed as able to smoke safely independently. Observation conducted on 05/20/25 at 12:30 PM revealed on the door going out to the designated smoking area revealed smoking was allowed from 8:00 AM- 8:00 PM daily. Observation and interview conducted with Resident #117 on 05/20/25 at 2:00 PM revealed Resident #117 was outside in the designated smoking area smoking independently. Resident #117 stated he was upset that times had been put in place and independent smokers were unable to smoke after 8:00 PM. Resident #117 stated he used to be able to go out anytime to smoke and liked to smoke before 8:00 AM and after 8:00 PM. An interview conducted with Nurse Aide (NA) #5 on 05/21/25 at 12:10 PM revealed she worked both 1st and 2nd shift. NA #5 stated multiple residents that smoked had complained that they were not able to smoke after 8:00 PM. NA #5 indicated Resident #117 had complained to her. NA #5 indicated she had spoken to multiple nursing staff before and told them that residents were upset. An interview conducted with the Director of Nursing (DON) and Administrator on 05/21/25 at 3:40 PM revealed Resident #117 was an independent smoker. The DON and Administrator stated they had not had any complaints from residents having to smoke at assigned times. It was indicated the assign times were implemented several months back and was a decision made by department heads.

Based on record reviews, and staff, Pharmacy Consultant and Medical Director interviews, the facility failed to protect the resident's right to be free from misappropriation of narcotic medications (Oxycodone) for 2 of 3 residents reviewed for misappropriation of property (Resident #2 and Resident #3). The findings included: a. Resident #2 was admitted to the facility on [DATE] with diagnoses that included chronic pain. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated she was moderately cognitively impaired and received opioid medications. Physician's orders for Resident #2 revealed an order dated 5/28/25 for Oxycodone 5 milligrams (mg) every 8 hours by mouth as needed (PRN) for pain. Resident #2's Medication Administration Record (MAR) for May 2025 revealed that from 7:00 PM on 5/28/25 to 7:00 AM on 5/29/25, Resident #2 did not report pain and did not receive PRN Oxycodone. b. Resident #3 was admitted to the facility on [DATE] with diagnoses that included chronic pain. The admission MDS assessment dated [DATE] indicated she was moderately cognitively impaired and received opioid medications. Physician's order for Resident #3 revealed an order dated 5/8/25 for Oxycodone 5 mg every 8 hours via feeding tube for pain. Resident #3's MAR for May 2025 revealed that Nurse #5 administered 5 mg of Oxycodone tablet on 5/29/25 at 6:00 AM. The controlled drug form revealed Nurse #5 signed out Oxycodone 5 mg for Resident #3 on 5/29/25 at 6:00 AM. The Initial Allegation Report submitted to the State by the Administrator on 5/29/25 at 11:10 AM revealed an allegation of misappropriation of property was made on 5/29/25 when narcotic discrepancies were found on two residents (Resident #2 and Resident #3) narcotic records involving Nurse #5. The Investigation Report completed by the Administrator on 6/5/25 revealed that on 5/29/25 at 10:30 AM during the audit of narcotic process the Director of Nursing (DON) found that two cards of narcotics and the second page of Narcotic Count Sheet were missing from the C-100 hall medication administration cart: Oxycodone 5 mg tablets (30 tablets for Resident #2 and 54 tablets for Resident #3, 84 total). The DON initiated an investigation, suspended Nurse #5 who was assigned for C-100 hall medication administration cart from 7:00 PM on 5/28/25 to 7:00 AM on 5/29/25, and notified the Medical Director, Law Enforcement, the State, Adult Protective Service (APS), Drug Enforcement Administration (DEA), the Administrator, and Pharmacy. The DON conducted an interview with Nurse #5 who indicated that she counted narcotics during the shift change report with another nurse at the beginning and the end of her shift, and did not realize that two cards of narcotics were missing. The administration interviewed all the RN's, LPN's and Medication Aides, who had work on that specific medication cart, and there were no concerns related to Resident #2's and Resident #3's Oxycodone, and no suspicious behavior or narcotic discrepancies reported. All the staff members who worked on C-100 medication administration cart were sent for urine drug screens with negative results. Law Enforcement did not have charges related to the allegation and did not investigate further. On 6/11/25 at 10:30 AM during an interview, the DON indicated that the discrepancy with the narcotic count for the C-100 medication administration cart was discovered the morning of 5/29/25. She reported that during the narcotic process audit, the DON noted that on C-100 hall, two narcotic cards (30 tablets for Resident #2 and 54 tablets for Resident #3, 84 total) and the second page of the Narcotic Count Sheets were missing from the medication administration cart. The investigation started immediately and Nurse #5, the last nurse, assigned for this cart, was suspended. All medication carts were audited, and no additional missing narcotics were found. Nursing staff conducted pain assessments for all residents, including Residents #2 and #3, and no issues with pain on that shift were reported. Urine drug screen tests were conducted for all the staff who worked on C-100 hall medication administration cart with negative results. The DON interviewed Nurse #6 and Nurse #5, the outgoing and one oncoming nurses for 5/28/25 second shift, who reported no narcotic discrepancy. The DON notified the Medical Director, Law Enforcement, State, APS, DEA, the Administrator, and Pharmacy. The DON reviewed the facility cameras in the C-100 hall area, including the medication administration cart area. On 5/29/25, multiple employees were observed walking past the medication cart, but nobody had touched the medication cart, and no other suspicious behavior was noted. The pharmacy requested to bill the missing medications to the facility. The DON stated that two nurses were responsible for completion of the narcotic count at the change of shifts: one outgoing and one oncoming nurse. She further stated any discrepancy found must be reported immediately and an investigation would be started. On 6/11/25 at 2:45 PM during a phone interview, Nurse #7 indicated that she worked on 5/29/25 from 7:00 AM to 7:00 PM and received the change of shift report from Nurse #5 at 7:30 AM. Nurse #5 did not report a narcotic discrepancy. Nurse #7 indicated Both nurses counted the narcotics on C-100 hall medication administration cart, signed the narcotic book and did not see a problem. A couple of hours later, the DON notified her about two missing narcotic cards from the same medication administration cart. Nurse #7 did not know how the narcotics were lost. On 6/11/25 at 10:40 AM during a phone interview Nurse #5 indicated that from 7:00 PM on 5/28/25 to 7:00 AM on 5/29/25 she was assigned to C-100 hall medication administration cart. Nurse #5 stated that on 5/28/25 at 7:00 PM, she received the shift change report from Nurse #6 and the narcotic count was correct. On 5/29/25 at 7:30 AM, she gave the shift change report to Nurse #7 (agency) and did not find the discrepancy. After an hour and a half, the DON notified Nurse #5 that during the narcotic process audit, it was discovered that two Oxycodone tablets cards were missing from C-100 hall medication administration cart. Nurse #5 reported that during her shift, Resident #3 received her scheduled Oxycodone 5 mg at 6:00 AM, and Resident #2 did not require as needed pain medication. Nurse #5 confirmed that she did not leave the narcotic keys unattended and did not know how the narcotic loss occurred. Law Enforcement did not contact her in regards to missing narcotics. On 6/12/25 at 8:50 AM during a phone interview, Nurse #6 indicated that on 5/28/25 from 7:00 AM to 7:00 PM, she was assigned to C-100 hall medication administration cart. At the end of her shift, she reconciled the narcotics with the upcoming nurse, Nurse #5, and the count was correct. There was no problem with narcotics during her shift. She became aware of missing narcotics from the C-100 hall medication administration cart the next day (5/29/25). On 6/11/25 at 3:30 PM during a phone interview, the Pharmacist indicated that the pharmacy was notified of the missing narcotic cards by the DON, and helped the facility report the diversion to the DEA. She stated that the Pharmacy Consultant regularly performed monthly random narcotic audits of the medication carts, medication rooms, and did not report issues or concerns before or after this incident. On 6/12/25 at 10:00 AM during a phone interview, the Medical Director indicated that he was notified about the missing narcotics. He asked the staff to assess the residents for the pain. The staff reported that on 5/29/25, Resident #2 did not need her PRN narcotic, and Resident #3 received Oxycodone according to the order. On 6/12/25 at 10:30 AM during a phone interview, the Administrator indicated that her expectation was for the nursing staff to keep the narcotic drawer and medication cart locked at all times when not in use, medication cart keys on nurses at all times, for nursing staff to count narcotics on the cart each shift, and both ongoing and oncoming staff sign off the narcotic count was completed and was correct. The Administrator stated that the allegation of misappropriation of resident property was not substantiated because the investigation was unable to identify how the medications were missing.

Based on record review, observation and staff interviews, the facility failed to develop and implement care plan interventions for 2 of 5 residents reviewed for smoking (Resident #30 and Resident #159). The findings included: 1. Resident #30 was admitted to the facility on [DATE] with diagnoses which included hypertension and nicotine dependence. Review of Resident #30's most current smoking assessment was dated 04/29/25. Review of Resident #30's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact and required limited assistance with activities of daily living (ADL). Review of Resident #30's care plan revealed no goals or interventions regarding Resident #30's smoking. Observation and interview conducted with Resident #30 on 05/20/25 at 2:00 PM revealed Resident #30 smoking independently. Resident #30 indicated he had been smoking since admission. An interview conducted with MDS Coordinator #1 on 05/21/25 at 3:20 PM revealed she was not aware Resident #30 had not been care planned for smoking. MDS Coordinator #1 stated through record review and communication with nursing staff Resident #30 should have been care planned for smoking. An interview conducted with the Director of Nursing (DON) and Administrator on 05/21/25 at 3:20 PM revealed Resident #30 smoked independently but they were not aware the resident had not been cared planned for smoking. The interview further revealed all residents that smoked were expected to be care planned for goals and interventions. 2. Resident #159 was admitted to the facility on [DATE] with diagnoses which included hypertension and nicotine dependence. Review of Resident #159's admission Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and required extensive assistance for ADL. Review of Resident #159's care plan revealed no goals or interventions regarding smoking. Review of Resident #159's most current smoking assessment was dated 04/29/25. Observation and interview conducted with Resident #159 on 05/20/25 at 2:10 PM revealed Resident #159 smoking independently. Resident #159 indicated he started smoking two weeks after he was admitted . An interview conducted with MDS Coordinator #2 on 05/21/25 at 3:25 PM revealed she was not aware Resident #159 had not been care planned for smoking. MDS Coordinator #1 stated through record review and communication with nursing staff Resident #30 should have been care planned for smoking. An interview conducted with the Director of Nursing (DON) and Administrator on 05/21/25 at 3:20 PM revealed Resident #159 smoked independently but they were not aware the resident had not been cared planned for smoking. The interview further revealed all residents that smoked were expected to be care planned for goals and interventions.

Based on observation, record review, and resident and staff interviews, the facility failed to shave facial hair for 1 of 3 dependent residents reviewed for assistance with activities of daily living (ADL) (Resident #56). The findings included: Resident #56 was admitted to the facility on [DATE] with diagnoses which included stroke, muscle weakness, hypertension, osteoporosis, and dysphagia. Review of Resident #56's care plan, revised 10/18/24, revealed the resident had an ADL self-care performance deficit due to left side hemiplegia (weakness on one side of the body), sequelae of poliomyelitis (Post-Polio Syndrome), muscle weakness, and a need for assistance with personal care. The goal was Resident #56 would receive staff assistance with all aspects of daily care to ensure that all needs are met. Interventions listed for Resident #56 included total assistance with bathing and required staff assistance with grooming and personal hygiene. Review of Resident #56's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bathing and personal hygiene. An observation and interview conducted with Resident #56 on 05/18/25 at 11:55 AM revealed the resident was laying in bed watching television. Resident #56 had several hairs located on her chin, at an estimated length of one inch. Resident #56 stated she did not like having chin hair and she preferred for her chin and face to be kept trimmed. Resident #56 indicated she often had to ask staff to shave her chin for her. An interview conducted with Nurse Aide (NA) # 5 on 05/21/25 at 12:10 PM revealed she had cared for Resident #56 consistently and was assigned to Resident #56 on this date. NA #5 indicated Resident #56 rarely refused care and preferred to have a clean shaved face. NA #5 stated she was unsure why Resident #56's face had not been shaved but it needed to be. An interview conducted with Nurse #3 on 05/21/25 at 12:30 PM revealed she was the nurse assigned to Resident #56 and was not aware the resident had facial hair. Nurse #3 did not recall Resident #56 being resistive to personal care and expected residents to be clean shaved if preferred. A follow up interview with Nurse #3 on 05/21/25 at 2:30 PM revealed she had observed Resident #56 and indicated the resident had long chin hairs that needed to be shaved. Nurse #3 stated she shaved Resident #56 without any issue. An interview conducted with the Administrator and Director of Nursing (DON) on 05/21/25 at 3:40 PM revealed they were unsure why Resident #56 had not been clean shaven and they expected residents to remain clean and shaved as preferred.

Based on observation, record review, and resident and staff interviews, the facility failed to arrange or coordinate podiatry care for 1 of 3 dependent residents reviewed for assistance with activities of daily living (ADL) (Resident #134). The findings included: Resident #134 was admitted to the facility on [DATE] with diagnoses which included stroke and hypertension. Review of Resident #134's care plan, revised 01/08/25, revealed the resident had an activities of daily living self-care performance deficit due to Cerebrovascular Accident (CVA) (stroke). The goal was for Resident #134 to improve the current level of functioning, including improvement in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene. Review of Resident #134's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with personal hygiene. The MDS further revealed the resident was coded for not being ambulatory. An interview and observation with Resident #134 on 05/21/25 at 11:30 AM revealed the resident's great toenails on both feet to be extending beyond the end of her toes, and were thick, and yellow in color. Resident #134 stated she had an ingrown toenail and was unable to wear shoes or socks because it was hurting and uncomfortable and had been that way for several days. Resident #134 stated a Nurse Aide had trimmed a couple toenails on her smaller toes a couple days prior but had not been seen by podiatry and would like to have a podiatry visit. An interview conducted with Nurse #5 on 05/21/25 at 3:30 PM revealed she was not aware Resident #134's was supposed to be seen by podiatry last week but was not seen. Nurse #5 further revealed she was unsure why she had not been seen by podiatry but observed Resident #134's toenails and stated they needed to be done. An interview was conducted with the Director of Nursing (DON) and Resident #134 in conjunction with an observation of Resident #134 on 05/21/25 at 2:00 PM. Resident #134 stated she could not wear enclosed shoes due to her toes hurting and the length of her great toenails. The DON revealed the podiatrist the facility used created a list of which residents were to be seen for their visit. The DON indicated Resident #134 had an ingrown toenail and needed to be seen by the podiatrist. The DON further stated she was going to contact the Podiatrist and make sure Resident #134 was seen as soon as possible but she went ahead and put her on the list for the next scheduled podiatry visit on 6/26/25. An interview conducted with the Administrator and DON on 05/21/25 at 3:40 PM revealed Resident #134 had not been assessed by podiatry since admission. The DON stated Resident #134 was on the list to be seen during the previous podiatry visit in May 2025 but was unsure why she had not been seen. The interview further revealed they expected for residents' toenails to remain trimmed and if there were issues, podiatry would be consulted.

Based on record review, observations, and staff interviews, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 1 of 5 residents reviewed with urinary catheters (Resident #14). The findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses which included unspecified hydronephrosis (swelling of one or both kidneys due to a buildup of urine), presence of urogenital implants, and neuromuscular dysfunction of the bladder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was moderately cognitively impaired. The assessment indicated Resident # 14 was dependent upon staff for all his activities of daily living (ADL). Resident #14 was coded for an indwelling urinary catheter. Resident #14's care plan revised 3/7/25 indicated Resident #14 had a goal of being free from a urinary tract infection due to the presence of an indwelling suprapubic catheter. Interventions included keeping the urinary collection bag below the level of the urinary bladder. An initial observation was conducted on 5/18/25 at 10:39 AM of Resident #14 as he was lying in his bed. The bed was noted to be in a low position. A urinary catheter drainage bag was observed to be hanging off the bedframe on the resident's right side of the bed with a solid, blue-colored privacy flap covering the bag facing the window. The entire bottom of the urinary catheter drainage bag was resting on the floor. Additional observations were conducted on 5/19/25 at 11:25 AM and on 5/20/25 at 4:00 PM. Resident #14's bed was noted to be in the low position, and a urinary catheter drainage bag was observed to be hanging off the bedframe on the resident's right side of the bed. The entire bottom of the urinary catheter drainage bag was resting on the floor during both observations. During an interview with Nurse Aide (NA) #1 on 5/20/25 at 4:19, she stated urinary catheter bags were not supposed to be touching the floor to prevent risk of infection. NA #1 stated she had noticed Resident #14's urinary catheter bag had been on the floor several times during her shift, and she had picked it up and repositioned the urinary catheter drainage bag so that it was not resting on the floor. An interview was conducted with the Director of Nursing (DON) on 5/21/25 at 11:51 AM. She stated she had educated all staff to keep urinary catheter bags off the floor, and there was a hook on the bag to hang it on the resident's bed. The Unit Manager was interviewed on 5/21/25 at 4:50 PM. She stated the resident's urinary drainage bag should not touch the floor. She further stated she had placed a basin underneath Resident #14's urinary catheter bag that day to prevent it from touching the floor since the resident preferred to keep his bed low.

Based on record review and staff and Pharmacist interviews, the facility failed to have an effective system and safeguards in place to prevent drug diversion when they did not ensure narcotic medications for discharged residents were secured for 2 of 3 residents (Resident #1 and Resident #271) reviewed for medication management. As a result, a total of 75 doses of Oxycodone (a narcotic medication) 5 milligrams (mg) were unaccounted for. Findings included: a. Resident #122 was admitted to the facility on [DATE] and was readmitted on [DATE]. His diagnoses included diabetes and diabetic neuropathy. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #122 was cognitively intact and received opioid medications. Resident #122 had a Physician's Order dated [DATE] for Oxycodone (narcotic/opioid pain medication) 5 mg every 4 hours as needed for pain. The Medication Administration Record for [DATE] for Resident #122 indicated he received Oxycodone 5 mg as needed for pain on [DATE], [DATE], and [DATE]. On [DATE] a discharge with an anticipated return Minimum Data Set assessment indicated Resident #122 was discharged to the hospital. During an interview with the Director of Nursing (DON) on [DATE] at 11:06 am she stated the pharmacy had notified the facility on [DATE] when the pharmacy tote (a tote bag used to store medications to be returned to the pharmacy) was returned to the pharmacy there was a Narcotic Count Form for Oxycodone 5 mg with 45 doses ordered for Resident #122 and the medication correlating to the form was missing from the tote. The DON stated Resident #122 was discharged to the hospital on [DATE] and his medication should have been sent back to the pharmacy when he was discharged . The DON stated they immediately began an investigation. She stated Nurse #1 and Nurse #2 were interviewed and suspended pending an investigation; Nurse #1 and Nurse #2 both received narcotic drug tests; and the facility changed the process for returning unused narcotic medications to the pharmacy. Nurse #2 was interviewed by phone on [DATE] at 12:40 pm and she stated she counted 45 doses of Oxycodone 5 mg that was ordered for Resident #122 with Nurse #1 after the resident was discharged and placed the medication in the pharmacy tote and placed two numbered zip lock seals on the tote. Nurse #2 stated she left the tote in the Unit Managers office to be picked up by pharmacy. Nurse #2 stated when she worked as the night shift supervisor, she kept the Unit Manager's office door locked. Nurse #2 stated there were several staff (the Unit Managers and Administrative Staff) that had keys to the Unit Manager's office, but she was not aware of anyone leaving the Unit Manager's office unlocked. Nurse #1 was interviewed by phone on [DATE] at 11:37 am and stated she did not remember the date Nurse #2, the night shift supervisor, had asked her to reconcile narcotic medications with her that needed to be sent back to the pharmacy. Nurse #1 stated she did count the medications for Resident #122 with Nurse #2, and they put the medications in the pharmacy tote and placed the numbered zip lock tag on the tote. She stated she did not know when the pharmacy tote was returned to the pharmacy and did not know how long the pharmacy tote was left in the Unit Manager's office before it was sent back to the pharmacy. Nurse #1 stated on [DATE] she was suspended pending an investigation, she was drug tested, she received education regarding returning narcotic medication to the pharmacy, and the facility changed the process for sending unused narcotics back to the pharmacy. The Pharmacist was interviewed by phone on [DATE] at 2:59 pm and stated she received the facility's pharmacy tote on [DATE] and found a Narcotic Count Form for Oxycodone 5 mg, 45 doses, in the returned pharmacy tote. The Pharmacist stated the tote was sealed with two zip tie seals that were numbered, and the Medication Return Form in the tote had the corresponding numbers from the two zip ties. The Pharmacist stated she notified the facility that the narcotic medication was not in the tote when she received it at the pharmacy. The Pharmacist stated the Oxycodone 5 mg should have been secured under two locks to prevent diversion of the medication. During an interview with the DON on [DATE] at 11:06 am she stated that Resident #122 had not been charged for the medication and the medication was provided by the hospital when Resident #122 was admitted to the facility, so they had not considered the missing medication a misappropriation of Resident #122's property. b. Resident #271 was admitted to the facility on [DATE] with diagnoses that included and lung cancer. An admission Minimum Data Set assessment dated [DATE] indicated Resident #271 was cognitively intact and received opioid medications. A Physician's Order dated [DATE] indicated Oxycodone 5 mg for Resident #271 three times a day for pain. The Medication Administration Record for Resident #271 for [DATE] indicated he received Oxycodone 5 mg by mouth three times a day for pain from [DATE] to [DATE]. The medical record indicated Resident #271 died in the facility on [DATE]. The Director of Nursing was interviewed on [DATE] at 11:06 am and she stated during an investigation into missing narcotic medication for Resident #122 they discovered that a medication card of Oxycodone 5 mg that was ordered for Resident #271 was also missing. The Director of Nursing stated the Narcotic Count form for Resident #271's Oxycodone 5 mg with 30 doses was found in an unlocked desk drawer in the Unit Manager's office and the medication correlating to the form was missing. Nurse #2 stated she was the Night Shift Supervisor, and she was responsible for ensuring the narcotic medications were reconciled and sent back to the pharmacy when a resident was discharged . Nurse #2 stated after Resident #271's death, she placed the resident's medication in an unlocked desk drawer in the Unit Manager's office and the door to the office was locked but there were other staff members that had keys to the office. Nurse #2 stated all nurse management and supervisors had access to the office. Nurse #2 stated she kept the door to the office locked when she worked but she did not know if it was left open when she was not working. Nurse #2 stated she did not know that she should keep narcotic medications double locked until they were sent to the pharmacy. During an interview with the Pharmacist by phone on [DATE] at 2:59 pm she stated when the facility investigated the 45 missing doses of Oxycodone 5 mg for Resident #122, they notified her there was another card of 30 doses of Oxycodone missing for Resident #271. The Director of Nursing was interviewed on [DATE] at 11:06 am and she stated that the investigation into the missing Oxycodone for Resident #271 revealed Nurse #2, the night shift supervisor, had placed the medication in the drawer in the Unit Manager's office and had planned to return it to the pharmacy. She stated Nurse #2 stated she was not aware the medication should not be left in the desk drawer which was not locked. The Director of Nursing stated the facility changed the process for sending narcotic medications back to the pharmacy to prevent any further diversion of narcotic medications. The Director of Nursing stated Resident #271 was not charged for the 30 doses of Oxycodone 5 mg since the medication was provided by the hospital when Resident #271 was admitted to the facility and the facility did not investigate it as misappropriated for that reason. The Administrator was interviewed by phone on [DATE] at 2:25 pm and stated the facility should have ensured Resident #271 and Resident #122's narcotic medication was secured with two locks to prevent diversion of narcotic medications.

Based on record review, observations, and interviews with staff and the Pharmacist, the facility failed to store unused narcotics prescribed to Resident #122 and #271 in a separately locked, permanently affixed compartment. The narcotics for Resident #122 were stored in a pharmacy tote with a numbered zip lock tag and the doses for Rsdt #271 were placed in an unlocked desk drawer in the Unit managers office by the Nurse #2, the night shift supervisor. The Unit Manager's office was not always locked and several staff had keys to the office. On 5/1/2025, the Pharmacy identified that 45 doses of oxycodone, 5 milligrams, were missing for Resident #122 when they received the narcotic count sheet without the narcotic medication in the medication tote that was delivered to the pharmacy. The facility initiated an investigation and discovered 30 doses of oxycodone, 5 milligrams, missing for Resident #271. This deficient practice affected two of two discharged residents reviewed for drug storage (Resident #122 and #271). Findings included: The facility's Controlled Medication Storage Policy stated all narcotic medications are stored under double lock in a locked cabinet or safe designated for that purpose. 1. Resident #122 was admitted to the facility on [DATE] and had a recent readmission on [DATE]. Resident #122 had a Physician's Order dated 2/6/2025 for Oxycodone 5 mg every 4 hours as needed for pain. On 3/25/2025 a discharge with an anticipated return Minimum Data Set assessment indicated Resident #122 was discharged to the hospital. Nurse #1 was interviewed by phone on 5/22/2025 at 11:37 am and stated she did not remember the date Nurse #2, the night shift supervisor, had asked her to reconcile narcotic medications with her that needed to be sent back to the pharmacy. She stated she did count the medications for Resident #122 with Nurse #2, and they put the medications in the pharmacy tote (a plastic bin that medications are place in to transport to and from the pharmacy) and placed the numbered zip lock tag on the tote. She stated she did not know when the pharmacy tote was returned to the pharmacy and did not know how long the pharmacy tote was left in the Unit Manager's office before it was sent back to the pharmacy. Nurse #2 was interviewed by phone on 5/22/2025 at 12:40 pm and she stated she counted 45 doses of Oxycodone 5 mg that was ordered for Resident #122 with Nurse #1 and placed the medication in the pharmacy tote with the numbered zip lock tag on the tote which Nurse #2 stored in the unit managers office. She stated she did not remember the date they put the medication in the pharmacy tote and did not know the date the pharmacy tote was sent to the pharmacy. Nurse #2 stated when she worked as the night shift supervisor, she kept the door to the Unit Manager's office locked at all times, but she knew there were several staff that had keys to the Unit Manager's office, but she was not aware of anyone leaving the Unit Manager's office unlocked. The Pharmacist was interviewed by phone on 5/23/2025 at 2:59 pm and she stated when the facility's pharmacy tote was received in the pharmacy on 5/1/2025 the zip lock seals were in place and the Narcotic Return Form for Oxycodone 5 mg (45 doses) was not in the pharmacy tote. The Pharmacist stated she notified the facility's Director of Nursing (DON). During an interview with the DON on 5/22/2025 at 11:06 am she stated the pharmacy had notified the facility on 5/1/2025 when the pharmacy tote was returned to the facility there was a Narcotic Count Form for Oxycodone 5 mg with 45 doses ordered for Resident #122 and the medication was missing from the tote. The DON stated at that time the narcotics that were being sent back to the pharmacy were being stored in the Unit Manager's office and the door was not always locked, several people had keys to the office, and the medications were kept in an unlocked desk drawer. The DON stated they were not able to determine when the misappropriation occurred, but they had changed the process for sending narcotics back to the pharmacy. The DON stated the facility had installed a safe in the DON office, which was observed during the interview, and the process for storing and returning narcotic medications had changed. The DON stated the Assistant Director of Nursing (ADON) counted all narcotics that should be returned to the pharmacy (either when a resident was no longer taking them or the resident was discharged ) and placed them in the safe and they were kept in the safe until the pharmacy courier picked them up to return them to the pharmacy. The DON stated she and the ADON put the seals on the pharmacy tote after they counted the medications again and sent them with the courier to the pharmacy. 2. Resident #271 was admitted to the facility on [DATE]. A Physician's Order dated 3/12/2025 indicated Resident #271 should have Oxycodone 5 mg three times a day for pain. Nurse #2 was interviewed by phone on 5/22/2025 at 12:40 pm and stated she was the Night Shift Supervisor, and she was responsible for ensuring the narcotic medications were reconciled and sent back to the pharmacy when a resident was discharged . Nurse #2 stated she put Resident #271's medication in an unlocked desk drawer in the Unit Manager's office and the door to the office was locked but there were other staff members that had keys to the office. Nurse #2 stated all nurse management and supervisors had access to the office. Nurse #2 stated she kept the door to the office locked when she worked but she did not know if it was left open when she was not working. The Director of Nursing was interviewed on 5/22/2025 at 11:06 am and she stated during an investigation into the missing narcotic medication for Resident #122 they discovered that a medication card of Oxycodone 5 mg that was ordered for Resident #271 was also missing. The Director of Nursing stated the Narcotic Count form for Resident #271's Oxycodone 5 mg with 30 doses was found in an unlocked desk drawer in the Unit Manager's office and the medication was missing. The Director of Nursing stated Nurse #2, the night shift supervisor, had placed the medication in the drawer and had planned to return it to the pharmacy. The DON stated Nurse #2 stated she was not aware the medication should not be left in the desk drawer which was not locked. The Administrator was interviewed by phone on 5/22/2025 at 2:25 pm and stated the facility should have ensured Resident #271 and Resident #122's narcotic medication was secured with two locks to prevent diversion of narcotics. The facility submitted a plan of correction for past noncompliance but it was not acceptable to the state agency.

Based on observation, record review, and staff and resident interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of the use of continuous positive airway pressure (CPAP) machine for 2 of 3 residents whose MDS assessments were reviewed (Residents #1 and #2). The findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea and acute respiratory failure with hypoxia. Resident 1's plan of care, dated 1/9/25, indicated oxygen therapy related to continuous positive airway pressure (CPAP) for obstructive sleep apnea with an intervention to encourage to wear the CPAP as ordered by the physician. Resident #1 had an active physician's order, dated 9/2/24, for CPAP machine to apply at bedtime and remove when awake for sleep apnea. Review of the Medication Administration Record (MAR) for September 2024 - January 2025 revealed Resident #1 used the CPAP machine as ordered with often refusal episodes. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 1/14/25, revealed Resident #1 was cognitively intact and was not coded for use of a CPAP machine or non-invasive mechanical ventilator. On 2/12/25 at 8:35 AM, during the observation and interview, Resident #1 had a CPAP machine located on the nightstand near bed. Resident #1 indicated she had the CPAP machine for a long time and used it at night while sleeping. On 2/12/25 at 1:55 PM, during the phone interview, MDS Nurse #1 indicated that if Resident #1 used the CPAP, it should have been coded as non-invasive mechanical ventilator on the Quarterly MDS assessment. MDS Nurse #1 continued she was not aware she had to answer the mechanical ventilation area in order to accurately code Resident #1 for use of the CPAP. On 2/12/25 at 2:10 PM, during an interview, the Administrator expected the MDS nurses to be responsible for coding Resident 1's MDS assessment accurately. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea. Resident 2's plan of care, dated 12/13/24, indicated oxygen therapy related to continuous positive airway pressure (CPAP) for obstructive sleep apnea with an intervention to encourage to wear the CPAP as ordered by the physician. Resident #2 had an active physician's order, dated 8/2/24, for CPAP machine to apply at bedtime and remove when awake for sleep apnea. Review of the MAR for December 2024 - January 2025 revealed Resident #2 used the CPAP machine as ordered. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 11/15/24, revealed Resident #2 was moderately cognitively impaired and was not coded for use of a CPAP machine or non-invasive mechanical ventilator. On 2/12/25 at 11:20 AM, during the observation and interview, Resident #2 had a CPAP machine located on the bedside table. Resident #2 indicated he had the CPAP machine for years and used it at night while sleeping. On 2/12/25 at 1:55 PM, during the phone interview, MDS Nurse #1 indicated that if Resident #2 used add the CPAP, it should have been coded as non-invasive mechanical ventilator on the Significant Change MDS assessment. MDS Nurse #1 continued she was not aware she had to answer the mechanical ventilation area in order to accurately code Resident #2 for use of the CPAP. On 2/12/25 at 2:10 PM, during an interview, the Administrator expected the MDS nurses to be responsible for coding Resident 2's MDS assessment accurately.

Based on record reviews, interviews with resident, staff, Nurse Practitioner (NP), and Medical Director, the facility failed to protect a resident from a significant medication error when on 10/18/24, Nurse #1, an agency nurse, administered the wrong medications to Resident #1. On 10/18/24, Nurse #1 administered Resident #1's prescribed medications during the morning medication pass and then later in the morning administered medications prescribed for Resident #2 to Resident #1. The wrongly administered medications included olanzapine (antipsychotic medication), lamotrigine (anticonvulsant medication), gabapentin (anticonvulsant medication), paroxetine (antidepressant medication), haloperidol (antipsychotic medication), and clonazepam (antianxiety medication). Nurse #1 identified the medication administration error, reported the medication administration error to Resident 1's family and NP, and interventions were put into place to monitor the resident. On 10/19/24, Resident #1 became lethargic, he was sent to the Emergency Department (ED) for further evaluation. While in the ED, Resident #1 had an elevated blood pressure (145/94), mumbled responses, was not following commands, and was unable to provide any information. He was admitted to the hospital with diagnoses which included acute kidney injury, differential diagnoses including medication side effects, dehydration, and required intravenous fluid administration. Resident #1 was discharged from the hospital to another nursing home on 10/24/24 and was documented to be at his baseline upon discharge. This deficient practice was found for 1 of 3 residents reviewed for significant medication errors (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE], with diagnoses including bipolar disorder, dementia, anxiety disorder, heart failure and chronic kidney disease. Review of his quarterly Minimum Data Set (MDS) assessment, dated 9/2/24, revealed Resident #1 was moderately cognitively impaired. The resident received antipsychotic, antidepressant, antianxiety and antibiotic medications during the assessment period. The plan of care for Resident #1, dated 8/20/24, indicated the risk for adverse side effects of psychotropic and antidepressant medications, with interventions to provide treatment according to physician's orders, monitor behavior, medications side effects, and report the changes to the provider. The prescribed morning medications per physician's orders for Resident #1 included: quetiapine (antipsychotic) 25 mg and sertraline (antidepressant) 25 mg. The Medication Administration Record (MAR) for October 2024 documented on 10/18/24 at 9:58 AM, Resident #1 received his prescribed medications, including quetiapine 25 mg and sertraline 25 mg. The October 2024 prescribed morning medications per the physician's orders for Resident #2 included the following significant medications: Olanzapine 10 mg (antipsychotic medication), lamotrigine 100 mg (anticonvulsant medication), gabapentin 100 mg (anticonvulsant medication), paroxetine 20 mg (antidepressant medication), haloperidol 0.5 mg (antipsychotic medication), and clonazepam 0.25 mg (antianxiety medication). The Incident Report, created by Nurse #1 and dated 10/18/24 at 12:40 PM, revealed Nurse #1 went to the common area, where [Resident #1] was seated. She addressed [Resident #1] by the name of [Resident #2], and [Resident #1] replied yes. Nurse #1 gave [Resident 2's] medications to [Resident #1]. Nurse #1 obtained the vital signs, which were within normal limits: blood pressure 112/52 (normal blood pressure range 120/80), pulse 65 beats per minute (normal pulse is 60-100 beats per minute), and respirations were 17 breath per minute (normal respiration range is 12-18 breaths per minute). Nurse #1 called the Unit Manager, the provider, family member, and continued frequent monitoring. The Incident Report included an attached list of wrongly administered medications. The nurses' note dated 10/18/24 at 12:40 PM indicated Nurse #1 reported the medication administration error for Resident #1 to Nurse Practitioner (NP) #1 and NP #1 provided new orders to check vital signs every four hours for the current shift, and continue monitoring. On 10/18/24 at 3:51 PM, Resident 1's blood pressure (BP) became low. Nurse #1 reported it to NP #1, who ordered one Liter (L) of normal saline (intravenous solution) at the rate of 100 milliliter (ml) per hour for hypotension (low blood pressure). Review of physician's orders on 10/18/24 at 3:51 PM for Resident #1 revealed one L of normal saline at the rate of 100 ml per hour for hypotension. The Medication Administration Record (MAR) reflected the order for the normalsSaline solution on 10/18/24 and documented it was completed. During a phone interview on 11/5/24 at 10:10 AM Nurse #1 indicated she was an agency nurse and 10/18/24 was her second time in the facility. During the medication administration on 10/18/24 between 9:00 AM and 10:00 AM she gave Resident #1 his prescribed morning medications. Nurse #1 continued the morning medication pass and at approximately 11:00 AM she prepared medications for Resident #2. Nurse #1 went to the common area and addressed Resident #1 by Resident #2's name and the resident replied yes, which she felt the response indicated he was Resident #1. Nurse #1 gave Resident 2's medications to Resident #1. When Nurse #1 returned to her medication administration cart to document, she realized she accidently gave the wrong medications to Resident#1. Nurse #1 immediately called the Unit Manager and assessed Resident #1. The resident was not in distress and his vital signs were within normal limits. Nurse #1 notified the Nurse Practitioner (NP #1) and Resident #1's family. NP #1 gave an order to check the resident's vital signs every four hours, monitor for hypotension (low blood pressure), bradycardia (low heart rate), and notify provider of any abnormal results. After approximately one hour of monitoring, Resident #1's blood pressure (BP) became low (98/51). Nurse #1 explained she reported the low BP to NP #1 and received the new order for one L of normal saline intravenously, at the rate of 100 ml per hour, for hypotension. Resident #1 was asleep in bed and remained with stable vital signs to the end of Nurse #1's shift at 7:00 PM. She reported the medication administration error to Nurse #2 during the shift change report. On 11/5/24 at 9:15 AM, during an interview, Nurse Aide #1, who worked on 10/18/24 first shift (7:00 AM to 3:00 PM), indicated Resident #1 was alert, could make his needs known, was walking around facility in the morning, and resting in bed after lunch. Nurse Aide #1 mentioned that Resident #1 often wandered around the facility but at times preferred to have a rest in his bed after lunch. Nurse Aide #1 was aware the resident received wrong medications on 10/18/24, and observed Nurse #1 check his vital signs several times during the shift. On 11/5/24 at 11:30 AM and interview with Nurse #5 (Unit Manager) revealed she received report from Nurse #1 on 10/18/24 at 12:30 PM about accidentally administering Resident #2's medications to Resident #1. Upon assessment the resident was seated in bed, was not in distress, dnd stated he was fine. The resident's vital signs were within normal limits: BP 112/52, pulse 63 beats per minute, and respirations 17 breath per minute. During the monitoring between 2:00 PM and 3:00 PM Resident #1's blood pressure became low (98/61). NP #1 was notified by Nurse #1 and the NP ordered intravenous fluids of one liter of normal saline at the rate of 100 ml per hour. Nurse #1 started the intravenous fluids on Resident #1. The resident remained in bed, his vital signs stabilized and overall he appeared to be in stable condition. The Unit Manager observed the resident approximately at 4:00 PM when she found he was in bed, sleepy, and had a BP 120/70. Review of the nurses' notes, dated 10/19/24, documented at 12:53 AM, revealed Nurse #2 notified NP #2 about Resident 1's changes in condition, including altered level of consciousness. Nurse #2 documented the resident was lying in bed with eyes closed and had limited response to stimulation. NP #2 gave an order to send Resident #1 to the hospital for hospital evaluation. On 11/5/24 at 10:45 AM, during a phone interview, Nurse #2 indicated on 10/18/24 at 7:00 PM, she received shift change report from Nurse #1, who informed her about the medication administration error for Resident #1. Nurse #2 stated usually, Resident #1 was wandering around and talking. Nurse #2 explained during the monitoring, the resident had normal vital signs, however he was sleepy with limited response to stimulation. On 10/19/24 at approximately 1:00 AM Nurse #2 communicated Resident #1's altered mental status to NP #2, and received an order to send Resident #1 to the Emergency Department (ED) for evaluation. The resident left the nursing home via Emergency Medical Service (EMS). Review of the EMS report dated 10/19/24 revealed at 12:56 AM the EMS team arrived at Resident #1 to address the resident's altered mental status after administration of the wrong medications. Nurse #2 informed the EMS team she noticed the changes in Resident #1's behavior: he was ambulatory and more talkative at baseline, but this shift he remained in bed and did not eat or speak much. Upon assessment, Resident #1 was able to answer questions with delayed responses and kept his eyes closed during the conversation. He had the right forearm intravenous catheter in place. The staff stated he just finished an intravenous fluid administration. At 12:56 AM his vital signs were BP 162/104, pulse 88 beats per minute, respirations 14 breath per minute, and oxygen saturation 98% (normal oxygen saturation range is 95-100%) on room air. EMS took the resident to the ED. Review of the hospital records, dated 10/19/24 at 1:55 AM, revealed Resident #1 arrived at the ED via EMS with chief complaint of altered mental status. Per nursing home staff on 10/18/24 at 9:00 AM, the resident accidently received multiple wrong medications, became less alert/responsive, and more confused. In the ED, the resident presented with mumble responses, he was not following commands, had an elevated blood pressure of 145/94 and urinalysis, suggested a Urinary Tract Infection (UTI). Resident #1 was admitted to a general admission unit of the hospital for additional antibiotic therapy, hydration, and differential diagnosis including medication side effects and infection. On 11/5/24 at 1:50 PM a phone interview was conducted with Nurse Practitioner (NP) #1. NP #1 indicated on 10/18/24 she was informed of the medication administration error by Nurse #1. At the time of the report Resident #1 was stable, with no distress and NP #1 ordered to check his vital signs every four hours with continued monitoring for hypotension and bradycardia. NP #1 did not expect a long-term systemic (overall) negative effect, or changes in mental status due to the resident having received the wrong medications. She explained she was more concerned about the possibility of his blood pressure becoming low. At approximatelly 3:00 PM the nursing staff reported low blood pressure (98/61) for Resident #1. NP #1 stated she ordered intravenous fluid administration, monitoring vital signs for hypotension, low heart rate, and planned to assess Resident #1 on 10/19/24. During a phone interview on 11/6/24 at 11:20 AM the Medical Director indicated he was notified (could not recall the exact date) about the medication administration error for Resident #1. The Medical Director discussed the medication error with the NP #1 (could not recall the exact date), who communicated with the nursing staff at the facility on 10/18/24. The Medical Director agreed with the orders for monitoring, treatment, and hospital evaluation after the wrong medications were adminsitered to Residnet #1. The Medical Director mentioned that considering the single doses of wrongly admininstared medications, he was not worried about a potential negative outcome for Resident #1. On 11/5/24 at 11:55 AM, during an interview, the Director of Nursing (DON) stated she expected the nurses and medication aides to use the six rights of medication administration (right medication, right dose, right time, right route, and the right documentation), and identify the residents prior to medication pass. Nurse #1 was an agency nurse, who recently started to work in the facility, and did not know the residents. The facility's Administrator was notified of Immediate Jeopardy on 11/5/24 at 3:30 pm. The facility implemented the following corrective action plan: All current residents in the facility with orders for medication had the potential to be affected by the deficient practice. On 10/18/24 the Director of Nursing (DON) identified residents that were potentially impacted by this practice by completing a 100% (percent) audit on all current alert and oriented residents with brief interviews for mental status (BIMs) of 13 or greater (indicating the resident was interviewable) to ensure there were no issues with medication administration. This was completed on 10/18/24. The results included: 100 of 100 residents with medication orders had no concerns with medication administration. On 10/18/24 A body audit was completed by the DON, Assistant DON (ADON), and Unit Managers, on all non-verbal, non-alert residents with BIMS of 12 or lower to ensure there were no issues related to medication administration. This audit consisted of signs or symptoms related to change in condition, increased confusion, or mental status changes. The results included: 48 of 48 residents with no signs or symptoms, which were felt may indicate issues related to a possible error in medication administration. On 10/18/24 the DON implemented corrective action for those residents which included: no corrective action needed; no deficient practice identified. On 10/18/24 The DON, ADON, unit managers, and Staff Development Coordinator (SDC) began interviewing nurses and medication aids during med pass observations on if they had performed medication errors. The results: 46 of 46 Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and med aids denied medication errors including giving medications to the wrong resident. On 10/18/24 The DON reviewed all incident reports for the last 14 days to identify any recent medication errors. The results: 0 of 8 incident reports were related to medication errors. Education: On 10/18/24, the Staff Development Clinician (SDC) began in-servicing all Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and medication aides, (including agency) on Preventing Medication Error policy. This training included all current staff including agency. This training included: Following the 6 rights of medication administration The right person The right medication The right dose The right time The right route The right documentation The Director of Nursing ensured that any of the above identified staff who did not complete the in-service training by 10/22/24 would not be allowed to work until the training was completed. This education will be ongoing and included in our new hire and agency orientation packet for all RNs, LPNs, and medication aids. The DON, Assistant DON, unit managers, and SDC, will monitor medication administration passes 3 times weekly for 2 weeks and monthly for 3 months for using the Quality Assurance (QA) monitoring tool Med Pass Audit. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action is initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, Minimum Data Set Coordinator, Therapy, Health Information Management, and the Dietary Manager. On 10/18/24 the decision was made to initiate this into the QA process and to review it in QA. IJ Removal Date: 10/23/24 On 11/8/24, the facility's corrective action plan was validated on-site by record review, observations, and interviews. Individual interviews with a sample of residents revealed they received their prescribed medications without concern. A medication administration observation was conducted on 11/8/24. The observation consisted of administration of medications for 3 different residents, by 2 nurses. The nurses and the medication aides were observed implementing the rights of medication administration before administering the medications from start to finish. No concerns were identified. Interviews with nurses and the medication aides revealed they were required to complete in-services for the 6 rights of medication administration and the facility's new process for medication administration. Record review of the in-service documents dated 10/18/24, 10/19/24 and 10/22/24 noted the DON completed the in-person in-services for the 6 rights of medication administration and the facility's new process for medication administration with nurses and medication aides. An interview with the DON on 11/8/24 revealed that the in-services were provided to Nurse #1 and all other nurses and medication aides that had not worked since the medication error, as well as to any new nurses and medication aides before they were allowed to administer medications. The corrective action plan's completion date of 10/23/24 was validated.

Based on record reviews, and interviews with staff, Nurse Practitioner (NP) and the Medical Director, the facility failed to protect a resident from non-significant medication errors for 1 of 3 residents reviewed for medication administration (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE], with diagnoses including bipolar disorder, dementia, anxiety disorder, heart failure and chronic kidney disease. Review of his quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was moderately cognitively impaired. Review of the of the Medication Administration Record (MAR) for October 2024, revealed that on 10/18/24 at 9:58 AM, Resident #1 received his prescribed medications, including seroquel, 25 mg (milligrams), zoloft, 25 mg, acidophilus 1 tablet, Anoro Ellipta Inhaler (inhaler for asthma/COPD) 1 puff, ferrous sulfate 325mg, magnesium oxide 400 mg, multivitamin 1 tablet, proscar 5 mg, vitamin B12 500 mcg (micrograms), vitamin C 500 mg, and flomax 0.4 mg. Review of Resident 2's physician's orders for October 2024 revealed medications, including metformin (anti-diabetic medication) 500 mg, aspirin (nonsteroidal anti-inflammatory medication) 81 milligram (mg), Levocarnitine (nutritional supplement) 500 mg, Baclofen, 5 mg (muscle relaxant medication). The Incident Report, created by Nurse #1 and dated 10/18/24 at 12:40 PM, revealed Nurse #1 went to the common area, where [Resident #1] was seated. She addressed [Resident #1] by the name of [Resident #2], and [Resident #1] replied yes. Nurse #1 gave [Resident 2's] medications to [Resident #1] including metformin 500 mg, aspirin 81 mg, levocarnitine 500 mg, and baclofen 5 mg. Nurse #1 realized the medication administration error, obtained the vital signs, which were within normal limits. Nurse #1 called the Unit Manager, the Provider, family member and continued frequent monitoring. During a phone interview on 11/5/24 at 10:10 AM Nurse #1 indicated she was an agency nurse and 10/18/24 was her second time in the facility. During the medication administration on 10/18/24 between 9:00 AM and 10:00 AM she gave Resident #1 his prescribed morning medications. Nurse #1 continued the morning medication pass and at approximately 11:00 AM she prepared medications for Resident #2. Nurse #1 went to the common area and addressed Resident #1 by Resident #2's name and the resident replied yes, which she felt the response indicated he was Resident #1. Nurse #1 gave Resident 2's medications to Resident #1. When Nurse #1 returned to her medication administration cart to document, she realized she accidently gave the wrong medications to Resident#1. Nurse #1 immediately called the Unit Manager and assessed Resident #1. The resident was not in distress and his vital signs were within normal limits. Nurse #1 notified the Nurse Practitioner (NP #1) and Resident #1's family. NP #1 gave an order to check the resident's vital signs every four hours, monitor for hypotension (low blood pressure), bradycardia (low heart rate), and notify provider of any abnormal results. She reported the medication administration error to Nurse #2 during the shift change report. The nurses' note dated 10/18/24 at 12:40 PM indicated Nurse #1 reported the medication administration error for Resident #1 to Nurse Practitioner (NP) #1 and NP #1 provided new orders to check vital signs every four hours for the current shift, and continue monitoring. On 11/5/24 at 11:30 AM and interview with Nurse #5 (Unit Manager) revealed she received report from Nurse #1 on 10/18/24 at 12:30 PM about accidentally administering Resident #2's medications to Resident #1. Upon assessment together with Nurse #1, the resident was not in distress, seated in bed, and stated he was fine. The resident's vital signs were within normal limits: BP 112/52, pulse 63 beats per minute, and respirations 17 breath per minute. Nurse #1 notified the Nurse Practitioner (NP) and family. NP ordered to check resident's vital signs every four hours and report the abnormalities. On 11/5/24 at 1:50 PM a phone interview was conducted with Nurse Practitioner (NP) #1. NP #1 indicated on 10/18/24 she was informed of the medication administration error by Nurse #1. At the time of the report Resident #1 was stable, with no distress and NP #1 ordered to check his vital signs every four hours with continued monitoring for hypotension and bradycardia. NP #1 did not expect a long-term systemic (overall) negative effect, or changes in mental status due to the resident having received the wrong medications. NP #1 stated had planned to assess Resident #1 the next day (10/19/24). On 11/6/24 at 11:20 AM, during the phone interview, the Medical Director indicated that he was notified about the medication administration error that occurred for Resident #1. He did not expect negative outcome from the non-significant medications administered to Resident #1. The facility implemented the following corrective action plan for identified deficient practice: All current residents in the facility with orders for medication had the potential to be affected by the deficient practice. On 10/18/24 the Director of Nursing (DON) identified residents that were potentially impacted by this practice by completing a 100% (percent) audit on all current alert and oriented residents with brief interviews for mental status (BIMs) of 13 or greater (indicating the resident was interviewable) to ensure there were no issues with medication administration. This was completed on 10/18/24. The results included: 100 of 100 residents with medication orders had no concerns with medication administration. On 10/18/24 A body audit was completed by the DON, Assistant DON (ADON), and Unit Managers, on all non-verbal, non-alert residents with BIMS of 12 or lower to ensure there were no issues related to medication administration. This audit consisted of signs or symptoms related to change in condition, increased confusion, or mental status changes. The results included: 48 of 48 residents with no signs or symptoms, which were felt may indicate issues related to a possible error in medication administration. On 10/18/24 the DON implemented corrective action for those residents which included: no corrective action needed; no deficient practice identified. On 10/18/24 The DON, ADON, unit managers, and Staff Development Coordinator (SDC) began interviewing nurses and medication aids during med pass observations on if they had performed medication errors. The results: 46 of 46 Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and med aids denied medication errors including giving medications to the wrong resident. On 10/18/24 The DON reviewed all incident reports for the last 14 days to identify any recent medication errors. The results: 0 of 8 incident reports were related to medication errors. Education: On 10/18/24, the Staff Development Clinician (SDC) began in-servicing all Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and medication aides, (including agency) on Preventing Medication Error policy. This training included all current staff including agency. This training included: Following the 6 rights of medication administration The right person The right medication The right dose The right time The right route The right documentation The Director of Nursing ensured that any of the above identified staff who did not complete the in-service training by 10/22/24 would not be allowed to work until the training was completed. This education will be ongoing and included in our new hire and agency orientation packet for all RNs, LPNs, and medication aids. The DON, Assistant DON, unit managers, and SDC, will monitor medication administration passes 3 times weekly for 2 weeks and monthly for 3 months for using the Quality Assurance (QA) monitoring tool Med Pass Audit. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action is initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, Minimum Data Set Coordinator, Therapy, Health Information Management, and the Dietary Manager. On 10/18/24 the decision was made to initiate this into the QA process and to review it in QA. The completion date of the corrective action plan: 10/23/24 On 11/8/24, the facility's corrective action plan was validated on-site by record review, observations, and interviews. Individual interviews with a sample of residents revealed they received their prescribed medications without concern. A medication administration observation was conducted on 11/8/24. The observation consisted of administration of medications for 3 different residents, by 2 nurses. The nurses and the medication aides were observed implementing the rights of medication administration before administering the medications from start to finish. No concerns were identified. Interviews with nurses and the medication aides revealed they were required to complete in-services for the 5 rights of medication administration and the facility's new process for medication administration. Review of the in-service documents dated 10/18/24 and 10/23/24 noted the DON completed the in-person in-services for the 6 rights of medication administration and the facility's new process for medication administration with nurses and medication aides. An interview with the DON on 11/8/24 revealed that the in-services were provided to Nurse #1 and all other nurses and medication aides that had not worked since the medication error, as well as to any new nurses and medication aides before they were allowed to administer medications. The corrective action plan's completion date of 10/23/24 was validated.

Based on observations and staff interviews, the facility failed to ensure the area surrounding 1 of 1 trash compactor remained free from garbage, refuse, and standing water. Findings included: During the initial tour of the facility on 2/12/24 at 10:00 a.m. a large trash compactor was observed outside, behind the facility. The area surrounding the trash compactor was littered with used plastic gloves, plastic cup lids, plastic straws, cardboard boxes, broken plastic pieces and pieces of plaster/tile. There were also 2 plastic trash barrels without lids, filled with trash less than three feet from the trash compactor. The follow-up observation on 2/14/24 at 1:10 p.m., revealed the area surrounding the trash compactor contained trash and debris scattered on the ground, including soiled plastic gloves, plastic cup lids, straws, face masks, and a broom lying in a pile of broken plaster. Also, behind the trash compactor, there was one uncovered trash barrel filled with trash and standing water. During an interview on 2/14/24 at 1:15 p.m., the Dietary Manager (DM) acknowledged the trash and debris surrounding the trash compactor needed cleaning. She revealed she was unsure which department was responsible for maintaining the trash compactor and its surrounding area. On 2/14/24 at 1:20 p.m., the Housekeeping Supervisor revealed the housekeeping floor technicians were responsible for maintaining the garbage disposal area, ensuring any trash/debris was removed from the ground. After observing the debris and trash surrounding the trash compactor, the Housekeeping Supervisor stated that the area would be cleaned immediately.

Based on observations, record review, and staff interview the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey completed on 6/14/21. This was for 2 deficiencies that were cited in the area of Food Procurement, Store/Prepare/Serve-Sanitary (F812) and Infection Prevention & Control (F880) that were cited on the recertification survey on 6/14/21 and then recited on the current recertification and complaint survey of 2/15/24. The continued failure of the facility during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This citation is cross referred to: F812: During the recertification survey on 2/15/24, the facility failed to ensure meal trays used to serve residents' meals were in good condition for 1 of 1 tray line observation. This practice had the potential for cross contamination of food from chipped and cracked meal trays. During the recertification survey on 6/14/21, the facility failed to sanitize dishware for meal service by failing to ensure the wash and final rinse cycles of the dishwashing machine operated at accurate temperatures. Also, the facility failed to maintain sanitary conditions in the kitchen by not ensuring opened food items in the refrigeration/freezing units and dry storage areas were resealed, labeled, and dated; and by failing to ensure the food preparation areas, food storage areas, and food service equipment were maintained clean and free from debris. The facility also failed to ensure the food items stored in the snack/nourishment refrigerators in 2 of 2 residents' nourishment rooms were clean, and food items not provided by the facility were dated and labeled. These practices had the potential to affect food served to residents. F880: During the recertification survey on 2/15/24, the facility failed to follow the Centers for Disease Control and Prevention's (CDC) transmission-based precautions for 1 of 2 residents (Resident #93) reviewed for contact precautions. A nursing staff member, Nurse #2, entered Resident #93's room, who was on contact precautions, without the required Personal Protective Equipment (PPE) including gloves and a gown, she was observed to check the resident's blood pressure, touch the resident's clothing, touch the resident's bed linens, repositioned the resident's ventilator tubing, touched the side rails, and then proceeded to provide care to Resident #93's roommate (Resident # 58) without washing her hands or using hand sanitizer. Upon completion of providing care to Resident #93's roommate (Resident #58), Nurse #2 then exited the residents' room without washing her hands or using hand sanitizer. During the recertification survey on 6/14/21, the facility failed to ensure staff performed hand hygiene prior to entering a resident's room and after providing personal assistance to another resident during meal tray delivery in 2 of 2 observations of one staff member. During an interview on 2/15/24 at 3:15 PM with the facility's administrator. She stated that the QA members were made up of Administrator, the Director of Nursing, Dietary Manager, Business office manager, Maintenance Director, Social Worker, Activities Director, and Housekeeping Director. The Nurse Practitioner and the Medical Director were always invited to attend. She stated that she and the director of nursing were aware of the concerns regarding this survey and the repeat of several citations. She stated that all of the issues will be looked into, and a thorough plan of correction will be drawn up and implemented to ensure these citations would not be repeated again in the future.

Based on observations and staff interviews, the facility failed to ensure meal trays used to serve residents' meals were in good condition for 1 of 1 tray line observation. This practice had the potential for cross contamination of food from chipped and cracked meal trays. Findings included: During a visit to the kitchen on 2/14/24 at 12:45 p.m., 33 meal trays with chipped, rough edges were observed stacked on the meal tray line, ready for use, during the plating of meals prepared for the residents. The Dietary Manager was present for the observation and did not offer an explanation or comment why the chipped/rough edged meal trays were stacked on the trayline, ready for use by the residents receiving plated meals in their rooms. On 2/15/24 at 11:16 a.m. the Administrator acknowledged some of the meal trays were chipped with rough edges. She revealed that prior to this survey the facility ordered more meal trays.

Based on record review, observations and staff interviews, the facility failed to provide care in a safe manner and failed to ensure fall mat was in place for 1 of 3 residents reviewed for accidents (Resident #1). Resident #1 sustained a fall from his bed after the Nurse Aide walked away after raising the height of the bed and failed to ensure the fall mat was placed next to his bed when she left to retrieve items from his closet. The fall resulted in a 6.5 centimeter laceration to the forehead, 2 centimeter laceration to the nose, 1.5 centimeter laceration to the upper lip, 1 centimeter laceration inside of the mouth, and an 8 millimeter parenchymal hematoma corresponding in location to a previous hematoma (Resident #1). The resident was sent to the Emergency Department and discharged the following day where he required sutures for his lacerations. The findings included: Resident #1 was originally admitted to the facility on [DATE] with diagnoses which included nontraumatic intracerebral hemorrhage and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was rarely/never understood, was severely impaired for decision making, and had short-term and long-term memory problems. He required extensive assistance with 2 staff members for bed mobility. Resident #1 was care planned on 10/29/23 for an actual fall with risk for further falls due to poor communication/comprehension and frequent attempts to get out of bed. The interventions included, in part, fall mats to floor at beside and bed in lowest position. A physician order dated 11/11/22 indicated a fall mat was to be on the floor at bedside every shift. A nursing note dated 11/21/23 at 11:25 AM read Resident #1 was noted to be lying slightly on his right side on the floor in front of his bed. He was alert and responsive and had some bleeding coming from the middle of his forehead, bridge of nose, and upper left nostril. A full assessment was completed including vital signs, neuro-assessment, and pain. Supervisor, Nurse Practitioner, and Resident #1's Responsible Party were notified. An order to send to the Emergency Department was received. Resident #1 was sent to the hospital for evaluation. A review of the Incident Summary dated 11/21/23 indicated Resident #1 was noted to be lying slightly on his right side on the floor in front of his bed. He was alert and responsive and had some bleeding coming from middle of his forehead, bridge of nose, and upper left nostril. A full assessment was completed including vital signs, neuro-assessment, and pain. Resident #1 stated he fell out of bed. An investigation of the fall was initiated. Nurse Aide #1 (NA) completed a reenactment of the fall and was suspended pending the investigation. All staff were educated and a 100% audit on bed mobility and transfers were completed on all care plans. NA #1's written statement dated 11/21/23 stated she arrived in the morning and the previous shift NA gave her report of all her assigned residents. She stated she had not worked on the assignment in months and was not familiar with the care plan for everyone but was told she could assist everyone on her own. She tried logging into the charting system to go over the care plan for each resident but received an error. She started doing rounds when she heard therapy tell the nurse they were going to get up Resident #1 today. She went to his room next. She moved the fall mat and lowered his head and legs and lifted the bed up to her knees. She turned away to pick clothes out of the closet a few feet away. When she looked back, his leg was crossed over the other hanging off as well as his right arm. She stated she was not sure if he willed himself off the bed or if the weight from his legs and arms pulled him down, but she saw him fall and hit his head then laid on his side. She immediately got the nurse and vital were taken. Attempts to interview NA #1 were not successful. Review of the Emergency Department discharge summary dated 11/22/23 indicated Resident #1 presented to the Emergency Department after a mechanical fall out of the bed. Resident #1 was at the facility when a NA was in his closet with her back turned towards him and Resident #1 rolled off the bed onto the ground. He was alert, oriented, did not verbalize pain, and was not in acute distress. He was noted to have a laceration on the left side of his forehead with blood from his nose, laceration to his nose, laceration to his upper lip, and inside of his mouth all of which required sutures. A Computed Tomography (CT) Scan was performed which showed a small 8-millimeter parenchymal hematoma corresponding in location to a previous hematoma, an acute nasal arch fracture, and a large frontal scalp contusion and laceration without underlying fracture. Neurosurgery was consulted and recommended no acute neurosurgical intervention was necessary. An interview occurred with Nurse #1 on 12/18/23 at 12:25 PM. She recalled Resident #1's fall on 11/21/23 and explained she was retrieved by the NA. When she entered the room, Resident #1 was lying face down on the floor between the bed and fall mat with blood covering his face. During the assessment, she noticed resident had a laceration to his face and Resident #1 denied pain. She stated Resident #1 was unable to state what happened, but she noticed the fall mat was not near the bed. 911 was called for further evaluation at the Emergency Department. The facility provided the following corrective action plan for the past non-compliance with a compliance date of 11/24/23. Corrective action for resident involved: Resident assessed by the nurse, Medical Director notified, and Responsible Party updated. Resident was sent to the hospital for evaluation. Corrective action for potentially impacted residents: On 11/21/23 the DON identified residents that were potentially impacted by this practice by completing the Kardex access and use for all CNA present at the time. This was completed on 11/21/2023. The results included: 3 out of 13 CNAs had not been able to log onto PCC and had not viewed the Kardex. On 11/21/2023 the DON implemented corrective action for those residents which includes: resolving sign in issues for those 3 CNAs and completing bed mobility audits on all current residents. Systemic changes: On 11/21/2023, the DON and SDC in-serviced all nursing staff (including agency) on bed mobility policy. This training will include all current staff including agency. This training included: Preventing Injuries with Bed Mobility. The Director of Nursing will ensure that any of the above identified staff who does not complete the in-service training by 11/24/23 will not be allowed to work until the training is completed. Quality Assurance: Beginning 11/28/23 the DON will monitor Kardex access and use weekly for 4 weeks and monthly for 2 months for concerns with logging in to PCC and looking at Kardex. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored, and ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, HIM, and the Dietary Manager. The date of compliance was 11/24/23. As part of the validation process, the plan of correction was reviewed and verified through review of the audit sheet, the in-service records, and staff interviews. Multiples observations were conducted on 12/18/23 of Resident #1's fall mat placement. Each observation showed Resident #1's fall mat was next to his bed while he was in bed. Other observations of other residents with fall mats were conducted on 12/18/23, which revealed fall mats were in place while the residents were in bed. Interviews with the staff involved with the incident dated 11/21/23 were completed and with current staff. Interviews revealed they had received in-service education on preventing injuries with bed mobility. Additionally, interviews with Nurse Aides revealed they had access to the electronic medical chart so they can review each resident's Kardex before starting their assignment. The validation process verified the facility's date of compliance of 11/24/23.

Based on record review, staff interviews, and nurse practitioner interviews, the facility failed to provide care in a safe manner and/or implement fall safety interventions developed and care planned by its interdisciplinary team (IDT) for 4 of 5 residents (Residents #2, #335, #7 and #132) reviewed for falls. Resident #2 sustained a fall from his bed that resulted in a fracture of the left femur neck requiring open reduction and internal fixation (surgical intervention). Resident #335 sustained a fall from his bed that resulted in a non-displaced fracture to his right femur that was conservatively managed (no surgical intervention). The plan of correction implemented after Resident #2 had fallen failed to keep resident #335 safe from falls and injury. The findings included: Example 1 Resident #2 was admitted on [DATE] with a diagnosis of [CONDITION(S)], and cerebral infarction. A review of a care plan dated 10/12/21 revealed Resident #2 was a fall risk. The one intervention noted was to anticipate and meet the Resident's needs as much as possible. There were no interventions to specify the number of staff required to provide bed mobility assistance. A Quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #2 was totally dependent on staff for bed mobility and required two staff members for assistance. A review of the Kardex from 12/12/2021 revealed Resident #2 was total dependence for bed mobility and required two staff members for assistance. A note written by Nurse #2 dated 12/12/2021 stated that Nurse Aide #2 (NA #2) had rolled Resident #2 over on right side to change him and that the Resident used his left arm to pull himself over. The nurse also stated NA #2 tried to pull him back but was unsuccessful in keeping him from rolling off the bed. A statement written by NA #2 dated 12/12/21 stated she had Resident #2 turned on his side while bathing him and that he used his left arm to pull himself over and he rolled off the bed. NA #2 then stated she called for help and Nurse #2 came and assessed the Resident and assisted with putting him back in bed. A review of the hospital radiology report dated 12/12/21 revealed a nondisplaced fracture involving the greater trochanter with possible extension to the anterior cortex of the femoral neck. A hospital discharge record dated 1/3/22 revealed Resident #2 had an acute closed fracture of the neck of the left femur and underwent open reduction and internal fixation of his fracture on 12/13. In an interview on 9/27/22 at 4:17 PM with NA #3, she stated Resident #2 was not able to hold on to the side of the bed to assist with care. She explained Resident #2 was totally dependent on staff for all his personal care and hygiene. She explained that he required the total assistance of two people with bed mobility, turning and repositioning. She revealed the information on how much assistance a resident needed could be found in the Kardex. During a phone interview with Nurse #2 on 9/27/22 at 5:22 PM, she stated she was passing medications when she and the Respiratory Therapist heard a loud boom. When they entered the room, they saw Resident #2 lying on the floor. She stated she and NA #2 got the lift and put the Resident back in bed. Nurse #2 said NA #2 told her that when she rolled the Resident over, he reached over and pulled himself too far and fell out of the bed. Nurse #2 explained Resident #2 required two people to provide his care. She further explained information regarding a resident's care needs could be found on the Kardex. Multiple attempts to reach NA #2 were unsuccessful. In an interview with the Assistant Director of Nursing (ADON) on 9/28/22 at 10:03 AM she stated they expected the NAs to provide care according to the Kardex. She further stated Resident #2 was a two-person physical assist with bed mobility. The ADON explained that NAs are trained upon hire to use the Kardex and staff are checked off on skills competencies yearly. The facility also offered skills fairs throughout the year to reinforce skills. The ADON provided the Plan of Correction (POC) for review. The POC included education of all full time, part time, as needed and agency nurses on providing bed mobility according to the Kardex, and ensuring staff knew how to review the Kardex. The Director of Nursing (DON) would ensure that any of the above identified staff who did not complete the in-service training by 12/20/2021 would not be allowed to work until the training was completed. The in-service was incorporated into the new employee facility orientation for the above identified staff. The DON or designee would monitor this issue using the Bed Mobility Quality Assurance Tool for monitoring compliance with bed mobility assistance. The monitoring included reviewing staff providing bed mobility according to Kardex and ensuring the staff knew how to review the Kardex. The Tool would be completed weekly times six weeks or until resolved by the Quality Assurance (QA) Committee. Reports would be presented weekly to the QA committee by the Administrator or DON to ensure corrective action was initiated as appropriate. Compliance would be monitored, and ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA meeting was attended by the Administrator, DON, MDS Coordinator, Therapy, Health Information Management, and the Dietary Manager. In an interview with the Assistant Administrator on 9/29/22 at 3:00 PM she stated that she expected the nursing staff to follow the Resident's care plan regarding the number of staff required to provide assistance with bed mobility. 2. Resident #335 was admitted to the facility on [DATE] with diagnoses [CONDITION(S)], [CONDITION(S)] ([CONDITION(S)]), and persistent vegetative state. A Quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #335 was totally dependent on staff for bed mobility and required 2 staff members for assistance. The plan of care for Resident #335 included the focus area of falls related to [CONDITION(S)] and [CONDITION(S)]. This focus area was initiated on 2/4/21 and last revised on 2/2/22. Interventions included frequent monitoring. A note dated 7/12/22 by Nurse #1 stated that the Nurse Aide #1 (agency aide) was changing Resident #335 and when she turned him, he slipped out of her hand and rolled to the floor. A review of Resident #335's hospital record dated 7/12/22 showed an x-ray of the right hip that was positive for an acute displaced basicervical femoral fracture with valgus alignment (a fracture through the base of the femur bone with good alignment). The report also stated that the fracture would be managed conservatively and no surgical intervention was needed at that time. A statement written by Nurse Aide #1 (NA#1) dated 7/12/22 stated that she turned Resident #335 on his left side to provide incontinent care and he slipped from her hand and fell to the floor off the left side of the bed landing with his weight on his right hip and back. NA #1 then stated that she immediately went to get the Assistant Director of Nursing (ADON) and then assisted him back into the bed using a lift. NA#1 stated that she was not aware he was a 2 person assist, she was not aware how to look on the care guide for resident information, she did not receive an electronic chart sign on, and she did not sign an orientation packet. During an interview with Nurse #1 on 9/27/22 at 10:52 AM, she stated she was aware that Resident #335 had always been a two person assist and that is stated on his care guide for staff to see. Nurse #1 stated was on lunch break when the incident occurred. She stated she was told that the resident fell by Nurse Aide #1 and the ADON when she returned to the floor. Nurse #1 stated there were no obvious injuries but Resident #335 was unable to let the staff know when he was in pain due to his diagnosis. She stated that Resident #335 was assessed by the ADON and she assisted in preparing him for transport to the hospital for assessment. Multiple attempts to contact Nurse Aide #1 were unsuccessful. During an interview with the ADON on 9/27/22 at 2:43 PM, she stated NA#1 alerted her that Resident #335 fell off the bed. She stated that she assessed him, completed vital signs, and then helped assist him into bed using the lift. She stated NA#1 told her she was not aware Resident #335 was a two person assist, she did not have an electronic sign on, and she didn't sign the orientation packet. The ADON stated the care guides were all electronic and the aides needed a sign on to assess them. She also stated the aide did receive training but was unsure if she actually signed the orientation packet and it was never located. She stated the facility was in the process of completing a plan of correction to address this issue including in-servicing for all staff, organizing on-boarding material for new directs hires and all contract staff, and conducting weekly audits. She also stated, as a part of the plan of correction, they plan on assuring that all staff is able to access the care guides for each resident. She stated they are currently in the auditing phase and they are discussing the need for ongoing audits in their morning meetings and within the interdisciplinary team during quality assurance meetings. 3. Resident #7 was admitted to the facility on [DATE] from a hospital. His cumulative diagnoses included dementia and Parkinson ' s disease. Review of a Fall Incident Report dated 5/31/22 at 3:45 PM revealed Resident #7 had an unwitnessed fall and was found lying on the floor on the right side of his bed. The resident stated that he was reaching for his call bell that had fallen to the floor. He reported he went too far to retrieve the call bell and fell out of bed. No injuries were reported. An additional note made on the Fall Incident Report was dated 6/1/22. This notation indicated Resident #7 had an air mattress at the time of the fall which increased his risk for falls. The note read, Mattress will be replaced with regular mattress to decrease risk of fall. The resident ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS reported Resident #7 was assessed by staff as having severely impaired cognitive skills for daily decision making. Resident #7 required supervision with transfers and eating, limited assistance for walking in his room and locomotion on the unit, and extensive assistance for the remainder of his Activities of Daily Living (ADLs). The resident ' s MDS assessment revealed he had one fall without injury since his prior assessment. Resident #7's care plan included the following areas of focus: --I have had an actual fall with risk for further (Date Initiated 6/1/22). The planned interventions included, in part: Change mattress (Date Initiated: 6/1/22). --I have a communication problem related to hearing deficit (Date Initiated 4/14/22). The planned interventions included, in part: Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, avoid isolation (Date Initiated 4/14/22). An observation was conducted on 9/26/22 at 3:36 PM of Resident #7 as he was lying on an air mattress on his bed. His bed was not in the low position at the time of the observation. On 9/27/22 at 9:50 AM, Resident #7 was observed to be lying on an air mattress on the bed. His bed was not placed in the low position. An observation was conducted on 9/27/22 at 3:55 PM as Resident #7 was lying in bed. Nurse #5 was in his room at the time of the observation. Upon leaving the room, the nurse confirmed Resident #7 was lying on an air mattress which was powered on. The bed was not in the low position at the time of the observation. An interview was conducted on 9/27/22 at 4:15 PM with Nurse Aide (NA) #4. NA #4 was assigned to care for Resident #7 on 2nd shift. During the interview, the NA was asked how she would find out what kind of care and assistance a resident required. The NA stated she typically received report from the off-going NA. Additionally, NA #4 stated she had log-in access for an electronic tablet which provided information on resident care. Upon request, the NA demonstrated how she could obtain access to a resident ' s Care Guide. The Care Guide detailed the resident ' s care needs. On 9/27/22 at 4:25 PM, a printed copy of Resident #7's Care Guide was provided for review. The Care Guide included a section on Safety which included the following interventions, in part: --Change mattress; --Ensure /provide a safe environment: Call light in reach, adequate low glare light, bed in lowest position and wheels locked. Avoid isolation. An observation conducted on 9/28/22 at 9:04 AM revealed Resident #7 was lying on a standard mattress placed on his bed (not an air mattress). The bed was not in the lowest position. On 9/28/22 at 12:00 PM, another observation revealed the resident ' s bed had a standard mattress and his bed had been placed in the low position. An interview was conducted on 9/28/22 at 2:42 PM with the MDS Nurse #1. During the interview, the MDS Nurse discussed the facility ' s process for reviewing a resident after he/she had experienced a fall. The nurse stated falls were discussed during the daily stand up (clinical) meetings on Monday through Friday each week. At that time, potential interventions to promote the resident ' s safety were discussed. If a new intervention was implemented, the MDS nurse was responsible to put the changes/revisions into the resident ' s care plan. If the new interventions were not yet decided upon and needed to be discussed later, the Director of Nursing (DON) would typically make the revisions to the care plan. On 9/28/22 at 2:55 PM, an interview was conducted with the facility's Assistant Director of Nursing (ADON). During the interview, the observations made on 9/26/22 and 9/27/22 were discussed. It was noted Resident #7' s care plan interventions had not been implemented as planned at the time of these observations. The ADON stated new care plan interventions were communicated to the direct care nursing staff when they were put into the care plan. She explained that when the interventions were care planned, they were typically put into the computer so they would be carried over into the Care Guide (available via the electronic tablet for NAs). Both nurses and NAs had electronic access to this resource. When asked, the ADON stated she would expect nursing staff to be following a resident ' s care plan. 4. Resident #132 was admitted to the facility on [DATE] from a hospital. Her cumulative diagnoses included Alzheimer's disease and functional [CONDITION(S)] (complete inability to move due to severe disability or frailty caused by another medical condition). Review of a Fall Incident Report dated 7/2/22 at 6:00 AM revealed Resident #132 had an unwitnessed fall and was found lying on top of a floor mat with her bed in a safe position. The resident was unable to provide a description of what had happened. No injuries were reported at the time of the incident. An additional note made on the Fall Incident Report was dated 7/4/22 and indicated the resident's current safety interventions included a low bed and mats placed on the floor. It also included a notation which read, Will place a beveled mattress on bed to define perimeter. Resident #132 's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. This MDS reported the resident was assessed by staff as having severely impaired cognitive skills for daily decision making. Resident #132 was totally dependent on staff for all of her Activities of Daily Living (ADLs). The resident 's care plan included the following areas of focus: I have had an actual fall with risk for further falls. Poor communication and comprehension, functional [CONDITION(S)] (Date Initiated 6/12/21; Revision on 9/21/22). The planned interventions included, in part: --Concave mattress placed on resident's bed (Date Initiated 7/6/22); --Low bed (Date Initiated: 6/12/21; Revision on 7/6/22); --Mats to floor (Date Initiated 7/19/21). An observation was conducted on 9/26/22 at 9:56 AM as the resident was lying in her bed on a concave mattress. Her bed was not in the low position. No fall mats were placed on either side of the bed. On 9/26/22 at 3:35 PM, another observation was conducted as the resident was lying in bed asleep on a concave mattress. Her bed was not in the low position. No fall mats were placed on either side of the bed. Additional observations were conducted on 9/27/22 at 9:48 AM and on 9/27/22 at 4:00 PM of the resident lying on a concave mattress while in bed. The resident 's bed was not in the low position and there were no fall mats placed on the floor during these observations. An interview was conducted on 9/27/22 at 4:15 PM with Nurse Aide (NA) #4. NA #4 was assigned to care for Resident #132 on 2nd shift. When asked about Resident #132, the NA reported the resident could fidget at times resulting in slight movements and the removal of clothing. During the interview, the NA was asked how she would find out what kind of care and assistance a resident required. The NA stated she typically received report from the off-going NA. Additionally, NA #4 stated she had log-in access for an electronic tablet which provided information on resident care. Upon request, the NA demonstrated how she could obtain access to a resident ' s Care Guide. The Care Guide detailed the resident ' s care needs. On 9/27/22 at 4:25 PM, a printed copy of Resident #132 ' s Care Guide was provided for review. The Care Guide included a section on Safety which included the following interventions, in part: --Concave (beveled) mattress placed on resident's bed; --Mats to floor. An observation conducted on 9/28/22 at 9:04 AM revealed Resident #132 was lying on a concave mattress on her bed with a fall mat placed on each side of her bed. The bed was not in the lowest position. On 9/28/22 at 11:19 AM, another observation revealed the resident was lying in bed with a concave mattress, a fall mat on each side of her bed, and her bed placed in the low position. An interview was conducted on 9/28/22 at 2:42 PM with the MDS Nurse #1. During the interview, the MDS Nurse discussed the facility ' s process for reviewing a resident after he/she had experienced a fall. The nurse stated falls were discussed during the daily stand up (clinical) meetings on Monday through Friday each week. At that time, potential interventions to promote the resident ' s safety were discussed. If a new intervention was implemented, the MDS nurse was responsible to put the changes/revisions into the resident ' s care plan. If the new interventions were not yet decided upon and needed to be discussed later, the Director of Nursing (DON) would typically make the revisions to the care plan. On 9/28/22 at 2:55 PM, an interview was conducted with the facility ' s Assistant Director of Nursing (ADON). During the interview, the observations made on 9/26/22 and 9/27/22 were discussed. It was noted Resident #132 ' s care plan interventions had not been implemented as planned at the time of these observations. The ADON stated new care plan interventions were communicated to the direct care nursing staff when they were put into the care plan. She explained that when the interventions were care planned, they were typically put into the computer so they would be carried over into the Care Guide (available via the electronic tablet for NAs). Both nurses and NAs had electronic access to this resource. When asked, the ADON stated she would expect nursing staff to be following a resident ' s care plan.

Based on record review and staff interviews, the facility failed to prevent a significant medication error when a medication aide failed to identify residents which resulted in 2 residents receiving the other one's medications (Residents #97 and #64) resulting in medication induced shock for Resident #97 requiring hospitalization and intravenous medications and fluids for 2 of 5 sampled residents reviewed for medication administration (Residents #97 and #64). Immediate jeopardy began on 5/22/21 when, during medication administration on the 400 hall, Medication Aide #1 administered Resident #97's medications to Resident #64 and Resident #64's medications to Resident #97 and was removed on 6/10/21 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated potential for actual harm that is not immediate jeopardy) to ensure monitoring systems in place are effective. The findings included: 1a. Resident #97 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set assessment dated [DATE] revealed Resident #97 had severe cognitive impairment. A nurse's note dated 5/22/21 at 10:50 PM revealed Resident #97 was sent out to the hospital for evaluation due to rapid decline in blood pressure. The on-call physician's assistant was notified at 10:10 PM and family was also notified. Resident #97's blood pressure was 68/36 and he was alert and talking prior to leaving the facility with emergency medical services. A medication error report dated 5/22/21 revealed Medication Aide #1 failed to properly identify Resident #97 and gave him Resident #64's evening medications to include [MEDICATION(S)] 500 milligrams (a mood stabilizer) and the following medications used to treat high blood pressure: [MEDICATION(S)] 50 milligrams, [MEDICATION(S)] 200 milligrams, [MEDICATION(S)] 0.3 milligrams, [MEDICATION(S)] 40 milligrams and [MEDICATION(S)] 20 milligrams. b. Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS dated [DATE] revealed Resident #64 had severely impaired cognition. The medication error report dated 5/22/21 further revealed Medication Aide #1 failed to properly identify Resident #64 and gave him Resident #97's medications which included [MEDICATION(S)] 25 milligrams (a medication used to treat behaviors), [MEDICATION(S)] 5 milligrams (a medication used to lower blood pressure) and [MEDICATION(S)] 5 milligrams (a medication used to treat anxiety). Review of Resident #97's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #64's MAR for May 2021 indicated his evening medication was documented as administered on 5/22/21. A telephone statement by Medication Aide #1 taken by the Director of Nursing (DON) on 5/24/21 was reviewed. The statement revealed she was administering medications to Residents #64 and #97 and Nurse #1 was the charge nurse. She proceeded to prepare the medications for the residents. Both residents' medications were put in individual cups and crushed. No markings were put on the cups. Medication Aide #1 entered the room with both cups in hand and she noted both residents' door tags were labeled A. Medication Aide #1 stated she knew which cup belonged to which resident, but she got the cups switched up. Medication Aide #1 stated she went and got Nurse #1 after 5 minutes after she realized she made a mistake. Medication Aide #1 was educated that evening by Nurse #1 on the appropriate identifiers for residents and the 6 rights of medication administration which include identifying the correct resident, drug, route for administration, dose, time, assessing for pain and ensuring the documentation is accurate. She verbalized understanding on the night of 5/22/21. During the phone statement, she was remorseful of the mistake she made. The DON educated her on the importance of only administering one person's medications at a time to prevent these kinds of errors. She verbalized she knew that was not the proper way to administer medications. An interview was conducted on 6/8/21 at 2:28 PM with Medication Aide #1. She stated she worked the 7:00 PM - 7:00 AM shift on 5/22/21 and administered medications to Residents #64 and 97. She stated both residents were in the same room and both had A on their door tags, indicating they were both in the A bed. She added she never worked the hall before but thought she knew one of the residents. She stated she didn ' t ask either one of their names and should have. When she checked Resident #64's blood sugar and it was normal, she realized her error because his blood sugar was normal, and she did not expect it to be so she immediately notified Nurse #1. Nurse #1 immediately assessed both residents while she obtained vital signs. Resident #97's blood pressure dropped to 74/53. She stayed with Resident #97 until the ambulance arrived and he remained alert. She stated she was immediately educated by Nurse #1 on the 6 medication rights. She was also checking Resident #64's vital signs and they remained normal. A statement by Nurse #1 dated 5/23/21 revealed on the night of 5/22/21, Medication Aide #1 was working on 400 hall and she was assigned to cover her hall. At approximately 9:45 PM, she came to her and informed her of a medication error that just occurred. She explained that 411 A and 411 B were given each other ' s medications as when she pulled the medication for A bed and looked at the card on the door it showed A bed to be Resident #64's so when she pulled the meds for B bed she brought them to the roommate Resident #97. Medication Aide #1 stated when looking at pictures on the computer, they looked similar and did not realize they were not the right residents. Nurse #1 assessed both residents' level of consciousness and while Medication Aide #1 obtained vitals for both residents, she looked over the medications that had been given in error. Nurse #1 assessed Resident #97's heart sounds which were faint, and no radial pulses were palpated. Manual blood pressure on left arm was 78/56 and right arm was 74/53. Nurse #1 checked Resident #97's chart and identified no code status. 911 was called due to blood pressure dropping to 60/30's. Medication Aide #1 stayed at the bedside while she notified the physician and family. The on-call physician's assistant gave an order to hold Resident #64's medications until the next administration and obtain vital signs every hour x 4 hours and then every 2 hours x 8 hours if remained stable. She also notified the DON and Assistant Director of Nursing and educated Medication Aide #1 on the medication rights. The emergency room physician called and stated the resident was stable and would be monitored with the hopes of returning to the facility by morning. At 4:00 AM, Nurse #1 called the hospital to ask when they could expect Resident #97 back and was informed that he would be admitted due to a heart rate in the 20 ' s and he would need to be started on a medication drip. An interview with Nurse #1 was conducted on 6/9/21 at 9:30 AM. She stated she worked the 7:00 PM - 7:00 AM on 5/22/21. She was assigned to C-100 hall and was the RN for the C-200 medication aide (Med Aide #1). She stated Med Aide #1 came to her and told her that she thought she made a mistake and that she gave the residents in room [ROOM NUMBER] each other's medications. Med Aide #1 stated she looked at both residents' pictures and they looked similar, but she went by their facial hair which wasn ' t the same as it was in the pictures because they weren't current. Nurse #1 stated she immediately went to room [ROOM NUMBER] to assess both residents. She also looked at both residents' medications and noted several blood pressure medications. Med Aide #1 began checking vital signs and Resident #97's blood pressure was in the 70's/40's range. She checked the chart and found Do not resuscitate status, called physician and 911 to send resident to emergency department. Last blood pressure checked was in the 60's over 30's range. She educated Medication Aide #1. She stated that Monday, on 5/24/21, she got a text message from the Assistant Director of Nursing (ADON) regarding medication administration and it included making sure to pull only one resident's medications at a time. Nurse #1 stated Medication Aide #1 did not tell her at that time that she prepared both residents' medications at the same time. A review of the hospital history and physical for Resident #97 dated 5/22/21 read, the resident presented from the facility after the resident developed [CONDITION(S)] at the facility after inappropriately receiving wrong medication due to staff error. Upon arrival to Emergency Department, resident ' s blood pressure was in the 90/50 ' s and heart rate as low as 20 ' s. A review of the hospital discharge summary dated 5/28/21 read active hospital problem: diagnosis [CONDITION(S)] due to medication. Hospital course: resolved medication-induced shock. Patient required extended course on [MEDICATION(S)] infusion (used to treat life threatening low blood pressure) on 5/23/21 due to persistent [CONDITION(S)] (low heart rate) and [CONDITION(S)]. Resident was discharged in stable condition on 5/28/21 to another skilled nursing facility with no follow up required. On 6/9/21 at 10:00 AM, the Administrator was interviewed. He stated he was informed of the medication error involving Residents #97 and #64 and that Resident #997 was transferred to the hospital. He recalled Medication Aide #1 reported she thought the residents looked alike. He stated he didn't agree, and Medication Aide #1 should still have followed the 6 rights of medication administration. She was immediately asked not to return to facility. On 6/9/21 at 10:25 AM, the ADON was interviewed. She stated she got a call from Nurse #1 and was informed Medication Aide #1 made a medication error. Medication Aide #1 administered Resident #64 & 97's medications to each other. Nurse #1 told her she immediately assessed both residents and Resident #97's blood pressure was dropping so she sent him to the emergency department, and he was admitted . They met with the family on 5/24/21 to let them know what they were going to put into place to prevent further errors. She stated she found out after the DON interviewed Med Aide #1 that she poured both residents ' medications at the same time, but she was unaware of that at the time. Education was immediately provided to Medication Aide #1. The Director of Nursing provided education to all nurses and medications aides on 5/24/21 on the 6 medication rights and the DON also did an audit of door tags to ensure they were accurate. The Administrator, Assistant Administrator and Corporate Nurse Consultant were notified of the immediate jeopardy on 6/10/21 at 11:05 AM. The facility provided the following credible allegation of immediate jeopardy removal: Resident # 97 received the incorrect medications on 5/22/2021. The resident was sent to the hospital for evaluation and was notified to have a blood pressure of 68/36. The resident was alert and verbal at the time of transfer. Medication Aide #1's failure to properly identify Resident #97 resulted in him being transferred to the hospital emergency department and subsequently admitted for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 64 received the incorrect medications on 5/22/2021. Resident # 64 did not have any changes in vital signs. No other residents were impacted by the medication error. On 5/23/2021 the Director of nursing audited all current resident ' door name plates and compared to the electronic health record to ensure that the name plates matched the current resident and their bed/room assignments. On 5/23/21, the risk management nurse also reviewed all current residents in the electronic health record ensure that photos were uploaded. On 5/23/2021, the nurse managers conducted a root cause analysis and determined that the root cause of the error was that the medication aide did not validate the resident identify prior to administering the medications. She also had poured two residents' medications at one time. All Full Time and Part Time and as needed (PRN) Nursing (Registered Nurses, Licensed Practical Nurses) and Medication aides will be educated on the following by the Director of Nursing, Nurse Managers and Staff Development Nurse. Education began on 5/23/2021. Director of Nursing, and /or Assistant Director of Nursing and/or Unit Managers and /or Nurse Managers will complete a Medication observation of med pass using a Medication observation tool, on 12 staff nurses {Registered nurse and Licensed Practical Nurse} and 3 medication aides). This was completed on 6/10/2021. In-service topics included preventing medication errors (including validating identity by using door plates, pictures and verbal identification), the 6 rights of medication administration, and following medication safety practices (such as only pouring one resident's medications at a time). Those that did not receive the in-service training by 5/26/2021 will not be allowed to work until the training is complete. This training was incorporated into the general orientation program and provided by the Staff Development Nurse. The Interdisciplinary Team ( Administrator, Director of Nursing, Nurse Managers, Mini Data Set Coordinators, Unit Manager, Support nurse, Therapy, Health Information Management, Dietary Manager, Medical Director, Wound Nurse, Pharmacist), were notified of the medication error by 5/23/2021 and were involved in the removal plan. Immediate Jeopardy Removal date: 6/10/21. The credible allegation for immediate jeopardy removal was validated on 6/14/21 which removed the immediate jeopardy on 6/10/21 as evidenced by staff interviews, in-service record reviews and medication audit record reviews. The in-service included information on types of medication errors, preventing medication errors by following the 6 rights of medication administration, preparing medications for only one resident at a time and other safe practices to incorporate into the daily medication pass routine such as: minimizing distractions.

Based on observations, record review, staff interviews, nurse practitioner (NP) interview, and review of the facility's COVID19 policies and Centers for Disease Control and Prevention (CDC) COVID 19 guidelines the facility failed to develop a policy to address aerosolized treatments and failed to implement their COVID policies and CDC guidelines when staff did not ensure a resident on enhanced droplet precautions was quarantined and remained on enhanced droplet precautions for 14 days after being readmitted to the facility following a hospitalization , staff failed to post precaution signage on the resident's door, failed to wear required personal protective equipment (PPE) when providing care or while in the resident's room, and failed to disinfect a face shield after providing suctioning for 1 of 1 resident (Resident #3) reviewed for enhanced droplet precautions. These failures occurred during the COVID-19 pandemic. A total of 16 residents tested positive for the COVID-19 virus on October 27, 2020. Additionally, five more residents tested positive for the [MEDICAL CONDITION] on 10/28/2020. Immediate Jeopardy began on 10/25/20 when the facility moved Resident #3, who was on enhanced droplet precautions, to a general population unit which was not a quarantine unit and failed to continue the resident's enhanced droplet precautions after he completed only 8 of the 14 days that were ordered by the physician. Additionally, the facility did not have a policy that addressed aerosolized treatments and a Respiratory Therapist suctioned Resident #3 without wearing a gown and failed to disinfect her face shield after she suctioned Resident #3 and a medication aide failed to cover her nose while in the resident's room. Immediate jeopardy was removed on 11/3/20 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. Findings included: The facility's COVID 19 guidelines titled American Healthcare Association guidance for new admissions, personal protective equipment, and Dedicated Areas were dated effective April 2, 2020. These guidelines stated that all residents being admitted or being readmitted from an emergency room visit, should be placed on quarantined and on enhanced contact precautions for 14 days. The PPE requirements for the health care professionals included disposable gowns, N95 or KN95 mask, goggles or face shields. Centers for Disease Control and Prevention (CDC) Preparing for COVID-19 in Nursing Homes dated June 25, 2020 revealed that CDC guidance stated for managing new admissions and readmissions whose COVID-19 status is unknown, healthcare personnel should wear an KN95 or higher-level respirator, eye protection (googles or face shield that covers the front and sides of the face), gloves and gown when caring for these residents. In the CDC guidelines for Isolation dated 6/25/2020: During procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions, especially suctioning, endotracheal intubation. During aerosol-generating procedures on patients with suspected or proven infections transmitted by respiratory aerosols wear a fit-tested N95 or higher respirator in addition to gloves, gown and face/eye protection. In addition, the guidelines state that While wearing gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe. Then, carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution. In the CDC guidance 3/27/2020 Recommended Guidance for Extended Use and Limited Reuse of N95s they state to: Discard N95 respirators following use during aerosol generating procedures. Resident #3 was admitted to the facility on [DATE] with the following pertinent Diagnoses: [REDACTED].#3 was hospitalized [DATE]-10/16/20. Resident #3 was readmitted to the facility on [DATE] following a hospitalization for pneumonia. He was admitted to the ventilator unit (C300 hall) into a private room upon arrival. Review of physician order [REDACTED]. Nursing note revealed that on 10/25/20, Resident #3 no longer required mechanical ventilation and was moved to a semiprivate room on the [MEDICAL CONDITION] unit (C200 hall) which was not a quarantine hall. On 10/27/20 from 10:00 a.m. to 10:30 a.m., tour of the building it was noted to have a ventilator hall (C300), a [MEDICAL CONDITION] hall (C200), a quarantine hall (C100), and a Covid-19 hall (C400). On 10/28/20 at 9:40 a.m. an observation was made of a Respiratory Therapist (RT) who performed [MEDICAL CONDITION] care and suctioning on Resident #3 in the resident's semiprivate room on the C200 hall. There was no enhanced droplet precaution signage observed posted on resident's door. While providing the care the RT wore a KN95 mask, gloves, and a face shield. The RT did not wear a gown or an N95 mask when providing Resident #3's [MEDICAL CONDITION] care and suctioning. She performed hand hygiene upon exiting the room but did not disinfect her face shield when she exited the resident's room and left the unit. Interview with RT on 10/30/20 at 12:05 p.m. revealed that Resident #3 was on enhanced precautions while on the ventilator unit. She stated that she did not recall seeing an enhanced droplet precaution sign on Resident #3's door since he was moved from the ventilator unit to his current room. She stated that while he was on enhanced precautions while on the ventilator unit, she had worn a KN95 mask, gloves, gown, and face shield which was disinfected after care. RT stated that on 10/28/20 she left the unit after providing [MEDICAL CONDITION] care to Resident #3. RT did not wear a gown and a N95 mask when she suctioned/trach care Resident #3 who was on enhanced droplet precautions because she did not know he was still on enhanced droplet precautions. An observation on 10/29/20 at 6:08 AM of the C-200 hall, revealed Medication Aide #1 was exiting Resident #3's room with her mask under her nose. On 10/29/20 at 6:10 AM, an interview was conducted with Medication Aide #1. She stated she knew the mask was supposed to cover her nose, but it kept sliding down. She added she had received training on PPE. On 10/29/20 at 10:05 a.m. Resident #3's room, which was a semi-private room, located on C200 hall, was observed. The resident's room did not have an enhanced droplet precaution sign posted on the door and there was no personal protective equipment outside or just inside of the resident's room. 10/29/20 at 10:10 am, Nurse #5 was observed entering Resident #3's room wearing only a mask and face shield. Nurse #5 did not don gloves or a gown prior to entering Resident #3's room. While in the room Nurse #5 was observed to administer medications and adjusted the resident's bed covers. At 10:15 a.m. Nurse #5 exited Resident #3's room, performed hand hygiene and entered another resident room on the C200 hallway which was not a quarantine room. Prior to entering this room, Nurse #5 did not change her mask or face shield. She was not wearing gloves or a gown. While in this room Nurse #5 administered medications to both residents who resided in this room. Interview with Nurse #5 10/29/20 at 10:20 a.m. stated that she had been off for several days and was unsure if Resident #3 should be on enhanced precautions or not. She did state that it was facility policy that residents returning to the facility be placed on enhanced droplet precautions for 14 days. She also stated DON and ADON were responsible for assessing new admits and readmits and making sure staff were aware they were on 14-day quarantine. Interview with ADON/Infection Preventionist and DON 10/29/20 at 10:45 am --she stated that Resident #3 had physician's orders [REDACTED]. But, staff mistakenly discontinued Resident #3's enhanced droplet precautions from 10/25/20 to 10/30/20 and staff failed to post enhanced droplet precaution signage on the door of his current room during this time period. The ADON explained enhanced droplet precaution signage was displayed while the resident was on the ventilator unit, but that it was not posted on the resident's room door when he was moved to his current room on 10/25/20. The ADON stated the staff did not know who had moved Resident #3 or why he was not moved to the quarantine hallway on 10/25/20. Both the ADON and DON stated that the facility liked to keep all [MEDICAL CONDITION] together on the same hall, but they can put a resident on enhanced precautions regardless of what hall they are on. The DON stated they are following the CDC guidelines laid out in their Covid-19 book. When asked if the facility's previous Administrator, who left in late May/early June, put the Covid-19 book together, she stated yes. Interview with Nurse Practitioner 10/29/20 at 11:55 a.m. stated when asked about the risk involved with not displaying enhanced droplet precaution signage and not wearing PPE, she replied she felt like everyone was at risk whether the sign was displayed or not. She did acknowledge that everyone should be wearing a mask and eyewear throughout the building except the Covid-19 unit which should be wearing full PPE and they should be following CDC guidelines for 14-day quarantine residents even as they are moved from room to room in the facility. Interview with Administrator on 10/29/20 at 1:10 p.m. revealed that he relied on his director and assistant director of nursing to identify residents who should be on quarantine and to provide the staff with any updates to CDC guidelines and the training necessary. He stated that the DON and ADON have gone through every resident to ensure they had identified all residents who should still be on enhanced droplet precautions. A phone interview was conducted on 10/31/20 at 10:45 a.m. with the Administrator informing him that Immediate Jeopardy was identified at tag F-880. The facility's credible allegation of immediate jeopardy removal for F-880 INFECTION PREVENTION AND CONTROL included the following: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident # 3 was readmitted to Oak(NAME)Health and Rehabilitation on 10/16/20 after an admission to the Hospital. Upon return, resident # 3 was placed in isolation, to include Enhanced Droplet Precautions, based on Centers for Disease Control and Prevention (CDC) recommendations. On 10/25/20, 5 days prior to his scheduled date of isolation discontinuation, resident # 3 was moved to a non-isolated room, with another roommate. This decision was made without the acknowledgement or approval of the Administrator or Director of Nursing. On 10/29/20, this action was brought to the attention of the Administrator. Immediately upon acknowledgement, the appropriate Enhanced Droplet Precautions Infection Control signage was placed on the resident door and appropriate personal protective equipment (PPE) was placed for access to staff for resident care by the LPN Unit Coordinator. The Resident #3 and roommate were both tested for COVID-19 utilizing the BD Veritor Plus Point of Care testing device by the ADON on 10/29/2020, and results were negative. Staff that had any entrance to the room of the resident and roommate were identified and were tested for COVID-19 on 10/29/2020 using the BD Veritor Plus Point of Care testing device by the ADON and the DON. Of the 10 staff identified and at risk, 0 were found to be positive for COVID-19. Both resident #3 and roommate were placed on enhanced droplet precautions through 11/8/2020. On 10/29/20, all admissions and readmissions to Oak(NAME)Health and Rehabilitation during the previous two weeks, were identified and audited for appropriate isolation procedures to include appropriate Enhanced Droplet Precautions, to include masks, gloves, gowns and googles or face shields by the DON. Of the 12 admissions and readmissions, 0 residents were found to have been moved out of isolation procedures prior to the 14-day monitoring requirements. Respiratory therapist #1 provided [MEDICAL CONDITION] care to resident # 3 on 10-28-20 at approximately 0940 per surveyor observation. Respiratory therapist #1, wore mask, gloves and face shield during [MEDICAL CONDITION] care. Per surveyor reported observation, Respiratory therapist #1 did not wear a gown, and did not disinfect face shield after use. The facility does have a policy for [MEDICAL CONDITION] care and suctioning related to PPE requirements with an addendum attached to follow CDC guidelines dated 4/2020, in regards to PPE conservation due to COVID-19. A clarification of cleaning or disinfecting the face shield was added to the policy related to aerosol generating procedures on 11-3-20. The residents with the same care team (nurse and respiratory therapist) as resident #3 and the roommate continue to be monitored for signs or symptoms of COVID-19. Residents have temperature, heart rate and oxygen saturation monitored twice a day and are assessed for new cough or change in cough, sore throat, or shortness of breath. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete In-Service was provided to the Administrator and the Director of Nursing on the correct procedures of isolation and 14-day monitoring by the Regional Clinical Manager on 10/29/2020. Also, on 10/29/2020 all departments, including contract therapy and respiratory therapist were in-serviced on the appropriate readmission and admission isolation procedures and the Enhanced Droplet Precautions signage and use of PPE. This in-service was provided by the DON and was completed in person and via telephone. Staff was in-serviced that no room changes can be made without the approval of the Administrator or the DON. No staff members will be able to work beyond 10/29/20 unless appropriate in-servicing occurs. All new admissions and re admissions beginning 10/29/2020 will be tracked daily by the Administrator, and Director of Nursing to ensure the appropriate 14 days of isolation is followed and that all Enhanced Droplet Precaution signage has been placed with the availability of PPE. Prior to discontinuing isolation and moving a resident out of Enhanced Droplet Precautions, the Administrator and/ or Director of Nursing will validate date of admission, and date of discontinuation of isolation. The Administrator will maintain a daily tracking log of admissions and readmissions to include start date of isolation and discontinuation of isolation based on CDC recommendations. Face shields will continue to be cleaned and disinfected when visibly soiled between residents throughout the facility including the [MEDICAL CONDITION] unit. All staff were in-serviced on use of PPE including proper disinfecting of soiled face shields on 10/29/2020 by the DON. Additional in service was provided to all licensed nurses and respiratory therapists on CDC guidelines to disinfect face shields after aerosolized treatment prior to re-use on 11-3-20 by the Director of Nursing. A policy was put in place in April 2020 regarding quarantining new admits and readmissions. Policy follows CDC and CMS recommendations. The facility put the extended use of eye protection in to place in April 2020 per the CDC recommendation for conservation of PPE. Eye protection should be removed and reprocessed if it becomes visibly soiled or difficult to see through. All facility staff were educated in April 2020 with on-going education taken place including 10/29/20 with the education on new admits, readmits and PPE. This in service was provided by the Director of Nursing. We continue to monitor PPE and have a standard delivery of masks and face shields delivered monthly to the facility. In addition, the supply clerk continues to order and received additional PPE from outside suppliers. PPE supplies and availability are monitored weekly using a burn rate calculator. Random daily surveillance of staff, to include respiratory therapist, by assigned team members, to include Administrator, Director of Nursing and nurse managers for proper enhanced droplet isolation protocols and cleaning of protective eyewear was put into place on 10-29-20 IJ removal date: 11/3/20 On 11/5/2020 the facility's Immediate Jeopardy removal plan and date of Immediate Jeopardy removal of 11/3/2020 was validated by the following: Resident #3 and roommate had an enhanced droplet precaution sign on door and a large yellow cart with PPE in drawers. Nurse, housekeeping and nurse assistant interviewed on the hall verbalized the reason for the quarantine and stated they had an in-service regarding proper mask, gloves, gowns and face shield/google use. Record review showed Resident #3 and roommate continue to test negative for Covid-19, as well as, immediate staff who cared for him. All residents who were currently on enhanced droplet precautions were reviewed. All resident rooms had appropriate signage on doors, door was closed to each room and PPE located outside of room door. Verified credible allegation of compliance through observations of signage and PPE carts, observation of staff entering and exiting resident rooms with appropriate PPE and performing hand hygiene. Review of in-service training records revealed staff from all shifts and disciplines had been in-serviced. Interviews with multiple staff, review of facility policies, review of staff surveillance and review of in-service records. Reviewed in-service titled, Infection Control/PPE , and 14-day Isolation for Admissions/Readmissions, dated 10/29/20 and 11/3/20. Inservice information included proper disinfecting of soiled face shields. All staff were educated on policies/procedures. A review of the facility tracking log of all new admission/readmissions and noted dates of admission and dates of isolation discontinued date revealed no concerns. Reviewed facility policy of use of eye protection, dated 3/18/20. Updated information added 11/3/20 regarding disinfecting goggles/face shields during aerosolized procedures.

Based on record reviews, family member, van driver, home health staff and facility staff interview the facility failed to address Resident #1's care needs (medications, activities of daily living, and pressure sore management), the type of caregiver support and the logistics of assuring that the resident had the equipment and support required. The facility did not have a comprehensive care plan that addressed discharge. The facility discharged Resident #1 to home despite failing to address and acknowledge family members' voiced concerns of being unable to care for Resident #1 at home. This was evident in 1 of 4 residents reviewed for discharge planning (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] after a recent hospital course for a left hip hemiarthroplasty (replacement of half of the hip joint) due to a fall at home that resulted in a left femoral fracture. The resident's cumulative [DIAGNOSES REDACTED]. Review of a 48-hour interim care plan for Resident #1 dated 8/28/18 revealed a goal that resident would have a smooth transition to home/assisted living facility. Approaches included to initiate discharge planning, provided resident/representative with information regarding community resources and educate resident/representative on services provided in the facility. Review of the 14-day Minimum Data Set ((MDS) dated [DATE] coded the resident with severely impaired cognition. The MDS indicated Resident #1 required extensive assistance of 2 people for bed mobility, total assistance of 2 people for transfer, and required extensive assistance of one person for dressing, eating, toilet use, personal hygiene and bathing. The MDS indicated Resident #1 was incontinent of bowel and bladder. The resident's balance was coded as steady only when stabilized with staff assistance and her mobility device was a wheelchair. Resident #1 was coded as expected discharge to the community. A review of the comprehensive care plan dated 9/12/18 did not include a care plan for discharge planning. A review of the treatment progress note dated 9/17/18 revealed Resident #1 had a newly acquired inhouse identified unstageable pressure sore to the left buttock. An unstageable pressure sore has full thickness tissue loss in which the base of sore is covered by slough and/or eschar in the wound bed. Review of the wound assessment report dated 9/17/18 and 9/24/18 revealed this an inhouse pressure sore to the left buttock measured 1.2 centimeters (cm) in length by 1.5 cm in width, no measurable depth with 100% slough tissue. There was no further assessment of the pressure sore prior to discharge. Review of a Discharge Planner (DP) note dated 9/21/18 for Resident #1 stated the Social Worker (SW) had informed the responsible party (RP) that Resident #1 last day of Medicare coverage was 9/28/18. The SW explained the non-coverage letter, advanced beneficiary notice letter and appeal process and rights to the resident. Review of a departmental note dated 9/28/18 revealed Resident #1 was scheduled to be discharged home on[DATE] with her family. Home health had been arranged, no equipment was determined to be needed and the family was to arrange for a follow up visit with her primary care physician. A review of discharge paper work dated 9/28/18 for Resident #1 revealed no documentation related to treatment of [REDACTED]. Review of a departmental note authored by the DP dated 10/3/18 at 4:53pm stated Called (family) and left message that I (DP) needed to speak with family as soon as possible that the patient was not picked up on discharge date and that we will be transporting patient home soon, so they needed to call my personal cell #/am. Review of the nurse progress notes dated 10/3/18 and 10/4/18 revealed resident took medications crushed and placed in pudding. An interview on 2/6/19 at 11:56 am with the Treatment Nurse (TN) stated I do not know the status of the wound (referring to the pressure sore) when she was discharged and did not educate the family about how to care for the wound. The incision site also had drainage. Further interview revealed the home health agency would perform the dressing changes. Interview on 2/6/19 at 12:40 pm with the Administrator revealed no facility staff accompanied resident home and it was his expectation that staff follow the regulations (was not specific) for discharging residents home. Interview on 2/6/19 at 1:21 PM with the DP who stated the Medicare non-coverage for Resident #1 was in effect on 9/28/18. The RP stated to her that they could not afford private pay so Resident was to be discharged to her home on 9/28/18. Further interview revealed the family had at home a handicap van, hospital bed and wheelchair. DP stated no one called and no one came to pick Resident #1 up on 9/28/18. On 10/1/18 she spoke with a family member on 10/4/18 who requested transportation and she refer them to a private van service. I then called them (referring to the van service) to transport the resident on 10/4/18. DP stated she was unaware of the teaching/preparation of the discharge. Home Health Agency #1 was the agency that approved Resident #1's admission for home care. An interview on 2/6/19 at 2:20 PM with Nurse #10 indicated she administered the resident's medications crushed and mixed with pudding, required total care and was fragile. Nurse #10 stated I gave no instructions because the resident went home with home health services. Nurse #10 indicated she had completed the discharge paper work on 10/4/18 for Resident #1. She stated she discharged the resident to no one and was told to complete the paper work (did not identify who gave her instructions). Nurse #10 stated she never saw a medication list or prescriptions to send home with the resident. She added home health was scheduled to be in the home the next day. Further interview with Nurse #10 indicated 10/4/18 was the only day she had worked with this resident and she really didn't know much about her. She stated normally when she discharged a resident there was a family member present and she would review all of the medications and appointments with them. Nurse #10 added she didn't see any treatment orders for Resident #1's pressure sore. She stated this was not the normal process for discharging a resident. An interview via the phone on 2/6/19 at 7:14 PM with a family member indicated she had informed the facility that they (referring to the family) had no means to take care of Resident #1. She stated on 10/4/18 the facility called again and the next thing we knew Resident #1 was dropped off by a van. This family member indicated they had no medications except insulin for the resident and they had no knowledge that the resident had a pressure sore on her buttock. The family member stated the facility just dumped Resident #1 off without any instructions on how to take care of her. She added the resident was placed in another nursing home. Continued interview revealed I received only one sheet of paper. The family member continued to indicate the family did not have all the medications to administer and had told the facility that they could not take care of her at home due to inability to lift and move Resident #1. Further interview revealed the home care nurse called the pharmacy to get the medications and she Tried talking to (DP) who was rude and told us we had no choice but to bring her home. An interview on 2/6/19 at 2:30 pm with Nursing Assistant (NA) #11 stated resident required total care for all activities of daily living, fed herself finger foods but staff needed to feed her. Resident was incontinent of urine and stool and would require 2 people to transfer her to the toilet. She needed staff to turn her at least every 2-3 hours and position her with pillows on her right side due to leaning. An interview on 2/6/19 at 3:30 pm with Home Health Agency (HHA) Nurse #1 and HHA Nurse #2 (nurse who conducted the initial evaluation on 10/5/18) was conducted via the phone. HHA Nurse #2 stated on arrival on 10/5/18 at 1:06 pm to the resident's home, Resident #1's brief, clothing and bed sheets were soaked with urine. She also experienced an incontinent episode of bowels. HHA Nurse #2 stated Resident #1 expressed to her that she was hungry and had not eaten all day. A family member then brought Resident#1 a pop tart and walked into and out of the room. There was no set up date for a follow-up with the physician nor were there any medications. HHA Nurse #2 stated she called the pharmacy for medication to be delivered and set up an appointment to the MD office. Additionally, there was no glucometer or strips to test the resident's blood glucose level. HHA Nurse #2 indicated by 10/24/18 Resident #1 was transferred to another skilled facility. An interview on 2/7/19 at 12:23 PM with the Transportation company (TC) van driver indicated a family member (No name provided) was present when he arrived at the home. The van driver stated he brought the Resident's personal belongings and a discharge packet. TC van driver stated no facility staff accompanied the resident and a family member transferred the resident to bed so that he could return the facility's wheelchair. Interview on 2/8/19 at 9 AM with the Physical Therapist (PT) revealed on the initial screening resident was maximal assist for bed mobility and did not have good body awareness due to previous stroke and limited motor skills. An inquiry was made about home visits and the PT therapist indicated that the rehab department does not conduct home visits and rely on the home health physical therapist to assess. The PT indicated the resident did not achieve her goals and needed maximal to moderate assistance from staff. The facility implemented the following corrective action: Resident # 1 was admitted to Oak Forest Health and Rehabilitation on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. Upon admission to facility, resident #1 was identified with Impaired Skin Integrity. A 48-hour interim care plan was completed on (MONTH) 28, (YEAR) including discharge planning with goal of a smooth transition to home. Resident #1 received physician order [REDACTED]. On (MONTH) 17, (YEAR) the facility Treatment Nurse discovered a pressure ulcer to Resident #1's left buttock. The Treatment Nurse completed the appropriate documentation for the pressure ulcer and notified resident's attending physician and Medical Director. New orders were received from the physician on (MONTH) 18, (YEAR) for the treatment of [REDACTED]. The discharge planning of Resident #1 included a referral for Home Health services to include PT, OT evaluation and treatment and nursing for treatment of [REDACTED]. PT and OT services were discontinued on (MONTH) 25, (YEAR) and ST services were discontinued on (MONTH) 27, (YEAR). At this time resident had reached her maximum potential and an order on (MONTH) 25, (YEAR) was received from the Medical Director to discharge resident home with family on (MONTH) 28, (YEAR). On (MONTH) 21, (YEAR) the discharge planner issued a Notice of Non-Coverage and discussed with Resident's Representative via phone call at 1:59 pm. Resident's Representative was notified of last covered day of skilled services to be on (MONTH) 27, (YEAR). Resident's Representative verbalized understanding and confirmed the plan for resident to return home on (MONTH) 28, (YEAR). Resident's Representative did not arrive to facility on (MONTH) 28, (YEAR) to pick up Resident#1 as planned. At approximately 7pm, the charge nurse on duty notified the facility Administrator that the family had not picked resident up. The administrator instructed that facility would hold off on discharge and revisit issue on Monday, (MONTH) 1, (YEAR). On (MONTH) 1, (YEAR), the facility Social Worker attempted to contact Resident Representative and was unable to reach him. Social Worker then contacted second family member and left messages to return call. The second family member called Social Worker back on (MONTH) 4, (YEAR) and requested for facility to transport Resident #1 home. Transportation was notified and agreed to transport resident and bill family for cost of transport. Resident was picked up at facility on (MONTH) 4, (YEAR) and taken home and received by Resident Representative. Resident's discharge instructions including information regarding Home Health agency was given to Resident Representative at time of transport. The facility failed to provide and document sufficient preparation and orientation to resident representative to ensure safe and orderly discharge from the facility. The family representative did not have knowledge of the resident's wound and treatment for [REDACTED]. The nurse failed to provide and review a medication list and medication prescriptions with family representative. Family training and documentation was not completed. On (MONTH) 4, (YEAR), the facility failed to train a family representative of Resident #1's medical condition including; wound care treatment/surgical incision drainage, medication listing review, and medication prescriptions, type of diet resident needed, level of supervision and ADL assistance needed prior to Resident #1's discharge home. The discharge planning of Resident #1 did include a referral for Home Health services to include PT, OT evaluation and treatment and nursing for treatment of [REDACTED]. Corrective action accomplished for those residents found to have been affected by the deficient practice. Resident #1 was discharged from the facility on (MONTH) 4, (YEAR). At the time of this compliance, Resident #1 is residing in another skilled nursing facility. Address how corrective action will be accomplished for those residents having the potential to be affected by the same deficient practice. Starting (MONTH) 13, (YEAR), the facility completed a 100% audit of all residents discharged within the last two weeks prior to the start of the original plan of correction regarding Resident #1. This audit included sixteen residents and no negative findings were found. This audit was completed on 12/14/18 and was to ensure the facility implemented an effective orientation, preparation, and transition to post-discharge care including education of medications and residents' medical treatment needs. By failing to provide a family representative with a review of Resident #1's wound treatment, medication listing, and medication prescriptions, this is considered neglect according to regulation. The discharge planner and nurse involved with Resident #1's discharge was educated on (MONTH) 6, (YEAR) by the Administrator and Director of Nursing. The in-servicing included, but was not limited to; notification of changes, development, preparation, and implementation of a comprehensive care plan for discharge, as well as a preparation and implementation of the discharge planning process. The Director of Nursing, Assistant Director of Nursing, assistant administrator gave an in-service to all staff, including but not limited to the discharge planner, social worker and nurses starting (MONTH) 2, 2019 and completed by (MONTH) 4, 2019. The in-service included Abuse and Neglect education. A 100% audit was completed utilizing a comprehensive care plan tool starting on 12/19/18 and completed on 12/20/18 of all current residents residing in the facility to ensure each resident had a discharge care plan. This audit was completed by Discharge Planner and Director of Nursing. Discharge Planner and Director of Nursing ensured the current care plan matched the discharge plan for each resident. Measures will be put into place or what systematic changes will be made to ensure that the deficient practice will not occur. Upon admission, the discharge plan process is initiated. The interim care plan is initiated on admission by the admitting nurse and completed by the RN Unit Manager, Assistant Director of Nursing, and Director of Nursing. All nurses were educated by the Director of Nursing on (MONTH) 17, (YEAR) about the requirement of the facility to develop and implement a care plan for each resident including the discharge plan. The interim care plan includes the discharge plan of whether to remain in the facility or desire to discharge back to the community. The discharge plan of any upcoming potential discharges for the next seven days will be reviewed by the Discharge planner weekly and discussed in the Medicare/Medicaid meeting by the administrator, Discharge Planner, Therapy manager, assistant administrator, Director of Nursing, Social Worker and the MDS coordinator. In the Medicare/Medicaid meeting, upcoming or potential discharges through the next seven days are discussed and care plans are updated at this time. The potential discharges discussed are evaluated the interdisciplinary team including but not limited to; home health, primary care physician, durable medical equipment needs, any services needed from the community, education for medication management, treatments, food and dietary needs, care needs of activities of daily living and level of supervision needed. During the Medicare/Medicaid meetings, the interdisciplinary team reviews the progression of each resident and projected discharge date based upon safety and resident goals. The Director of Nursing or Assistant Director of Nursing brings information for any residents with a change in condition according to information gathered from Unit Managers and Charge Nurses. These residents are reviewed at this time for any significant changes that may affect an upcoming discharge. Any change of condition including discharge information is communicated to the resident or resident representative and provider by the Discharge Planner, nurse and/or Unit Manager. The interdisciplinary team consists of at least the Director of Nursing, Social Worker, Dietician, Therapy Director, and Nursing MDS Coordinator. The Director of Nursing communicates any potential discharge residents to the Unit Coordinator/Manager to initiate training/teaching to resident or resident representative when applicable. This includes but is not limited to; blood sugar checks, insulin administration, wound care, tube feedings, oxygen therapy, and medication management. The providers are also included in the discussions of potential discharges and address safety and medical needs. The Social Worker and/or Discharge Planner are responsible for communicating with the resident and family representative on discharge needs including community resources for potential discharges. The Dietician is responsible for education on dietary needs related to their diagnosis. The Therapy Director is responsible for the oversight of the treating therapist, to ensure resident meets goals for safe discharge and any barriers to discharge are communicated to the team for follow up. If a home visit is applicable based on discharge needs, the Therapy Director will be responsible for coordination. The Therapy Director will also coordinate caregiver training where applicable and ensure completion. The Nursing MDS Coordinator reviews each resident for clinical needs at the facility and also ensuring the resident has appropriate follow up based on medical needs for discharge. Resident and family representatives are then notified by the Discharge Planner of future discharge date and will assist with discharge follow up needs. The discharge planner updates the discharge care plan as needed. The nursing staff will document the discharge instructions given to the resident and/or resident representative upon discharge. This process will be reviewed prior to discharge by the Director of Nursing as noted with the discharge audit. The provider will complete a discharge summary after visiting resident to include discharge plan for resident and ensure medical needs are met prior to discharge. On (MONTH) 30, (YEAR), the Regional Vice President of Operations for the contracted therapy company educated all facility Rehab Directors via telephone regarding the importance of home visits when needed to determine a resident's safety or additional safety needs post discharge from the facility. The discharge planner and/or therapy manager is responsible for determining the need of a home visit for all discharged residents and assigning the staff member that will go out to the home. When a home visit is deemed necessary for resident safety, it is completed prior to the discharge home. Beginning (MONTH) 2, 2019, the Assistant Administrator, Director of Nursing, and Assistant Director of Nursing provided in-servicing for all staff, including the discharge planner and discharging nurse, regarding abuse and neglect of residents. This was completed by (MONTH) 4, 2019. Beginning (MONTH) 14, (YEAR), a resident's discharge planning will begin at the time of admission. The discharge planner, and/or therapy director will speak with the resident and/or representative within 72 hours of admission to determine discharge needs. The needs determined will include discharge disposition, needs of the home such as stairs or other impediments, follow up physician needs, pharmacy preferences, home health preferences, and care needs. These needs will continue to be discussed amongst the social worker, discharge planner, therapy director, and nurse management throughout the stay and leading up to discharge at least weekly and with change in condition. Resident and/or representatives will be notified of any changes that take place by the Discharge Planner from the initial discharge plans or if a home visit is needed to assess safety. The Director of Nursing educated all nurses, including the treatment nurse, dietary manager, therapy manager, activity director, and social workers on (MONTH) 17, (YEAR) and completed by (MONTH) 28, (YEAR). This in-service included; family representative training to ensure understanding of discharge instructions, notification of change in condition, including but not limited to, newly acquired wounds or change in condition of a resident's skin, development and implementation of a care plan, and discharge planning process. The nurses and social workers were educated to document all discharge planning including training given prior to discharge. Any nursing staff and/or social worker that did not receive this in-servicing on (MONTH) 17, (YEAR) were not allowed to work until in-servicing was completed. This in-service was 100% complete on (MONTH) 28, (YEAR). In-servicing for Abuse and Neglect policies will be included in the new staff orientation and also in annual training of existing staff. This in-servicing will be provided by the Administrator, Assistant Administrator, Director of Nursing and/or Staff Development Coordinator; including but not limited to education/training regarding unsafe discharges. The facility plans to monitor its performance to make sure that solutions are sustained. Beginning (MONTH) 18, (YEAR), the Director of Nursing began completion of a daily discharge audit tool. This tool is used to ensure proper documentation post discharge including, but not limited to; resident's comorbidities, mental status, education of treatments, destination, and disposition of resident's personal properties upon discharge. This tool will be completed weekly for a minimum of three months and then a minimum of monthly for one year. Results of these audit tools will be presented to the QAPI committee by the Director of Nursing for any changes or outcome resolutions. On (MONTH) 14, (YEAR), the Assistant Administrator began a discharge planning audit tool. This tool involves reviewing the medical record prior to discharge to ensure the discharge planner documented discharge needs and involvement of caregivers and interdisciplinary team in conducting a safe discharge plan. It allows the facility to ensure all agencies required for post discharge are ordered timely and are documented in the resident's record. This tool was completed daily x 4 weeks and will continue to be completed weekly for a minimum of three months and then a minimum of monthly for one year. The assistant administrator calls each newly discharged resident and/or representative to ensure all discharges were properly prepared and implemented to include; review of medication listings, transportation method was appropriate, home health initiation occurred, wounds treatment education if applicable was provided, and any other education needed related to residents' medical needs was provided. Reassurance is made of no concerns or issues at the time and ensures resident or caregiver has a call back number if needed. Results of these audit tools will be presented to the QAPI committee by the Assistant Administrator for any changes or outcome resolutions. The assistant administrator will monitor that each resident has a discharge plan on admission and ensure that the plan is reviewed and revised as needed. The Director of Nursing and/or Assistant Director of Nursing will bring a list of all new admissions along with the medical record of each to the daily stand up meeting. The residents' records will be reviewed by the DON/ADON to ensure that all new admissions are reviewed to ensure the Interim Care plan including but not limited to the discharge plan, is completed. All projected plans for a discharge in the next 7 days, will be reviewed and revised by the IDT team weekly in the Medicare/Medicaid meeting. Completion date: 1/4/19 The credible allegation was verified via staff interviews and record reviews on 2/8/19 and as evidenced by the following: verification of re-education for discharge planner, social worker and licensed nurses. Staff training and in-services Review of audits. All staff interviewed (nursing and non-nursing staff, administrative staff) as appropriate stated new processes for discharge and abuse/neglect Review of documentation for resident discharge of a resident including stand-up meeting, assessment, discharge began at admission, discharge summary, medication release form and discharge instructions, validated staff reviewed resident discharges daily to verify needed equipment, medication, nursing assessment, documentation and services were arranged at the time of discharge. Based on the verification the facility compliance was achieved on 1/4/19.

Based on record reviews, interviews with the facility staff, home health agency staff, van driver and family member the facility failed to provide a safe discharge planning process that included discharge goals, needs and caregiver support for 1 of 4 residents reviewed for discharge (Resident #1). The facility failed to ensure a safe place to go to after being discharged from the facility. The facility failed to assess Resident #1's medical condition to identify possible barriers for a safe discharge home. The findings included: Resident #1 was admitted to the facility on [DATE] after a recent hospital course for a left hip hemiarthroplasty (replacement of half of the hip joint) due to a fall at home that resulted in a left femoral fracture. The resident's cumulative [DIAGNOSES REDACTED]. Review of a 48-hour interim care plan for Resident #1 dated 8/28/18 revealed a goal that resident would have a smooth transition to home/assisted living facility. Approaches included to initiate discharge planning, provided resident/representative with information regarding community resources and educate resident/representative on services provided in the facility. Review of the 14-day Minimum Data Set ((MDS) dated [DATE] coded Resident #1 with severely impaired cognition. The MDS indicated Resident #1 required extensive assistance of 2 people for bed mobility, total assistance of 2 people for transfer, and required extensive assistance of one person for dressing, eating, toilet use, personal hygiene and bathing. The MDS indicated Resident #1 was incontinent of bowel and bladder. The resident's balance was coded as steady only when stabilized with staff assistance and her mobility device was a wheelchair. Resident #1 was also coded as expected discharge to the community. A review of the comprehensive care plan dated 9/12/18 did not include a care plan for discharge planning. A review of the treatment progress note dated 9/17/18 revealed Resident #1 had a newly acquired in-house identified unstageable pressure sore to the left buttock. An unstageable pressure sore has full thickness tissue loss in which the base of sore is covered by slough and/or eschar in the wound bed. Review of the wound assessment report dated 9/17/18 and 9/24/18 revealed this an in-house pressure sore to the left buttock measured 1.2 centimeters (cm) in length by 1.5 cm in width, no measurable depth with 100% slough tissue. There was no further assessment of the pressure sore or the draining incision site prior to discharge. Review of the (MONTH) (YEAR) physician orders [REDACTED].> [MEDICATION NAME] 5 milligrams (mg) by mouth (po) every day (qd) for hypertension. [MEDICATION NAME] 60 mg po qd for [MEDICAL CONDITION]. Aspirin 81 mg po qd for [MEDICAL CONDITION]. [MEDICATION NAME] 1 scoop three times a day as a protein supplement for wound healing. Bydureon 0.65 milliliter (2 mg) subcutaneous once a day on Mondays for diabetes. Carvedilol 25 mg twice a day for hypertension. [MEDICATION NAME] 40 mg po qd for depression. [MEDICATION NAME] 1 mg po qd a steroid to treat pituitary [DIAGNOSES REDACTED] Eliquis 5 mg po twice a day. An anticoagulant. Humalog U-100 insulin per a sliding scale three times a day before meals for diabetic control. [MEDICATION NAME] U-100 insulin per sliding scale at 8 pm for diabetic control. [MEDICATION NAME] 40 mg po qd for high cholesterol [MEDICATION NAME] 1,000 mg po twice a day for high cholesterol. Potassium Chloride extended release 10 milliequivalent once a day for potassium replacement. Vitamin C 500 mg po twice a day for wound healing. MVI with minerals 1 qd po for wound healing. Vitamin D3 5,000-units qd po as a supplement. Zinc sulfate 220 mg po qd for wound healing. Donepezil 10 mg po at bedtime for memory enhancement. Cleanse sacral wound (pressure sore) with saline apply nickel thick sized Santyl ointment (enzymatic [MEDICATION NAME] ointment) and cover with calcium alginate (absorbent wound dressing) with a dry dressing daily. A review of discharge paper work dated 9/28/18 for Resident #1 revealed no documentation related to treatment of [REDACTED]. Record review revealed Resident #1 was discharged home on[DATE] via a transportation van service without facility staff. An interview on 2/6/19 at 11:56 AM with the Treatment Nurse (TN) stated she did not educate the family about how to care for the pressure sore or the surgical incision site. Further interview revealed the home health agency would perform the dressing changes. Interview on 2/6/19 at 1:21 PM with the Discharge Planner (DP) who stated the Medicare non-coverage for Resident #1 was in effect on 9/28/18. She stated the Responsible Party (RP) informed her they could not afford private pay so the Resident was to be discharged to her home on 9/28/18. Further interview revealed the family had at home a handicap van, hospital bed and wheelchair. The DP stated no one called and no one came to pick Resident #1 up on 9/28/18. The DP stated on 10/1/18 she received a phone call from Resident #1's RP who requested transportation to Resident's home and she referred them to a private van service. She stated she called the van service and made the transportation appointment for Resident #1. The DP stated she was unaware of the teaching/preparation of the discharge. She stated Home Health Agency #1 was the agency that approved Resident #1 admission for home care. An interview on 2/6/19 at 2:20 PM with Nurse #10 indicated she administered the resident's medications crushed and mixed with pudding and required total care and was fragile. I gave no instructions because the resident went home with home health services. Additionally, Nurse #10 stated she discharged the resident to no one and was told to complete the paper work. Nurse #10 stated she never saw a medication list or prescriptions to send home with the resident. She added home health was scheduled to be in the home the next day. Nurse #10 indicated 10/4/18 was the only day she had worked with this resident and she really didn't know much about her. She stated normally when she discharged a resident there was a family member present and she would review all of the medications and appointments with them. Nurse #10 added she didn't see any treatment orders for Resident #1's pressure sore. She stated this was not the normal process for discharging a resident. An interview via the phone on 2/6/19 at 7:14 PM with Resident #1's RP revealed DP requested that they pick up the resident on 9/28/18. Resident #1's RP indicated that during that call she had informed the facility that they had no means to take care of Resident #1. She stated on 10/4/18 the facility called again and the next thing we knew Resident #1 was dropped off at home by a van. Resident #1's RP indicated they had no medications except insulin for the resident and they had no knowledge that the resident had a pressure sore on her buttocks. Resident #1's RP stated the facility just dumped Resident #1 off without any instructions on how to take care of her. She added the resident was placed in another nursing home. Continued interview revealed I received only one sheet of paper. The RP continued to indicate the family did not have all the medications to administer and had told the facility that we could not take care of her at home due to inability to lift and move Resident #1. The home care nurse called the pharmacy to get the medications. The RP indicated she Tried talking to DP who was rude and told us we had no choice but to bring her home. An interview on 2/6/19 at 2:30 pm with Nursing Assistant (NA) #11 stated resident required total care for all activities of daily living, fed herself finger foods but staff needed to feed her. Resident was incontinent of urine and stool and would require 2 people to transfer her to the toilet. She needed staff to turn her at least every 2-3 hours and position her with pillows on her right side due to leaning. An interview on 2/6/19 at 3:30 pm with Home Health Nurse #1 and Home Health Nurse #2 (HHA) #1 and HHA Nurse #2 (nurse who conducted the initial evaluation on 10/5/18) was conducted via the phone. HHA Nurse #2 stated on arrival on 10/5/18 at 1:06 pm to Resident #1's home. Resident #1's brief, clothing and bed sheets were soaked with urine and incontinent episode of bowels. HHA Nurse #2 stated Resident #1 expressed to her that she was hungry and had not eaten all day. A family member then brought Resident#1 a pop tart and walked into and out of the room. There was no set up date for a follow-up with the physician nor were there any medications. HHA Nurse #2 stated she called the pharmacy for medication to be delivered and set up an appointment to the MD office. Additionally, there was no glucometer or strips to test the resident's blood glucose level. HHA Nurse #2 indicated by 10/24/18 the resident was transferred to another skilled facility. An interview on 2/7/19 at 12:23 PM with the Transportation (TC) van driver indicated a family member was present when he arrived at the home. The van driver stated he brought Resident #1's personal belongings and a discharge packet to Resident #1's home. TC van driver stated no facility staff accompanied the resident where and a family member transferred the resident to bed so that he could return the facility's wheelchair. Interview on 2/8/19 at 9 am with the Physical Therapist(Pt) revealed on the initial screening resident was maximal assist for bed mobility and did not have good body awareness due to previous stroke and limited motor skills. An inquiry was made about home visits and the PT therapist indicated that the rehab department does not conduct home visits and rely on the home health physical therapist to assess. The PT indicated the resident did not achieve her goals and needed maximal to moderate assistance from staff. Interview on 2/6/19 at 12:40 pm with the Administrator revealed no facility staff accompanied resident home and was his expectation that staff follow the regulations (was not specific) for discharging residents home. The facility implemented the following corrective action: Resident # 1 was admitted to Oak Forest Health and Rehabilitation on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. Upon admission to facility, resident #1 was identified with Impaired Skin Integrity. A 48-hour interim care plan was completed on (MONTH) 28, (YEAR) including discharge planning with goal of a smooth transition to home. Resident #1 received physician order [REDACTED]. On (MONTH) 17, (YEAR) the facility Treatment Nurse discovered a pressure ulcer to Resident #1's left buttock. The Treatment Nurse completed the appropriate documentation for the pressure ulcer and notified resident's attending physician and Medical Director. New orders were received from the physician on (MONTH) 18, (YEAR) for the treatment of [REDACTED]. The discharge planning of Resident #1 included a referral for Home Health services to include PT, OT evaluation and treatment and nursing for treatment of [REDACTED]. PT and OT services were discontinued on (MONTH) 25, (YEAR) and ST services were discontinued on (MONTH) 27, (YEAR). At this time resident had reached her maximum potential and an order on (MONTH) 25, (YEAR) was received from the Medical Director to discharge resident home with family on (MONTH) 28, (YEAR). On (MONTH) 21, (YEAR) the discharge planner issued a Notice of Non-Coverage and discussed with Resident's Representative via phone call at 1:59 pm. Resident's Representative was notified of last covered day of skilled services to be on (MONTH) 27, (YEAR). Resident's Representative verbalized understanding and confirmed the plan for resident to return home on (MONTH) 28, (YEAR). Resident's Representative did not arrive to facility on (MONTH) 28, (YEAR) to pick up Resident#1 as planned. At approximately 7pm, the charge nurse on duty notified the facility Administrator that the family had not picked resident up. The administrator instructed that facility would hold off on discharge and revisit issue on Monday, (MONTH) 1, (YEAR). On (MONTH) 1, (YEAR), the facility Social Worker attempted to contact Resident Representative and was unable to reach him. Social Worker then contacted second family member and left messages to return call. The second family member called Social Worker back on (MONTH) 4, (YEAR) and requested for facility to transport Resident #1 home. Apollo Transportation was notified and agreed to transport resident and bill family for cost of transport. Resident was picked up at facility on (MONTH) 4, (YEAR) and taken home and received by Resident Representative. Resident's discharge instructions including information regarding Yadkin Home Health agency was given to Resident Representative at time of transport. The facility failed to provide and document sufficient preparation and orientation to resident representative to ensure safe and orderly discharge from the facility. The family representative did not have knowledge of the resident's wound and treatment for [REDACTED]. The nurse failed to provide and review a medication list and medication prescriptions with family representative. Family training and documentation was not completed. On (MONTH) 4, (YEAR), the facility failed to train a family representative of Resident #1's medical condition including; wound care treatment/surgical incision drainage, medication listing review, and medication prescriptions, type of diet resident needed, level of supervision and ADL assistance needed prior to Resident #1's discharge home. The discharge planning of Resident #1 did include a referral for Home Health services to include PT, OT evaluation and treatment and nursing for treatment of [REDACTED]. Corrective action accomplished for those residents found to have been affected by the deficient practice. Resident #1 was discharged from the facility on (MONTH) 4, (YEAR). At the time of this compliance, Resident #1 is residing in another skilled nursing facility. Address how corrective action will be accomplished for those residents having the potential to be affected by the same deficient practice. Starting (MONTH) 13, (YEAR), the facility completed a 100% audit of all residents discharged within the last two weeks prior to the start of the original plan of correction regarding Resident #1. This audit included sixteen residents and no negative findings were found. This audit was completed on 12/14/18 and was to ensure the facility implemented an effective orientation, preparation, and transition to post-discharge care including education of medications and residents' medical treatment needs. By failing to provide a family representative with a review of Resident #1's wound treatment, medication listing, and medication prescriptions, this is considered neglect according to regulation. The discharge planner and nurse involved with Resident #1's discharge was educated on (MONTH) 6, (YEAR) by the Administrator and Director of Nursing. The in-servicing included, but was not limited to; notification of changes, development, preparation, and implementation of a comprehensive care plan for discharge, as well as a preparation and implementation of the discharge planning process. The Director of Nursing, Assistant Director of Nursing, assistant administrator gave an in-service to all staff, including but not limited to the discharge planner, social worker and nurses starting (MONTH) 2, 2019 and completed by (MONTH) 4, 2019. The in-service included Abuse and Neglect education. A 100% audit was completed utilizing a comprehensive care plan tool starting on 12/19/18 and completed on 12/20/18 of all current residents residing in the facility to ensure each resident had a discharge care plan. This audit was completed by Discharge Planner and Director of Nursing. Discharge Planner and Director of Nursing ensured the current care plan matched the discharge plan for each resident. Measures will be put into place or what systematic changes will be made to ensure that the deficient practice will not occur. Upon admission, the discharge plan process is initiated. The interim care plan is initiated on admission by the admitting nurse and completed by the RN Unit Manager, Assistant Director of Nursing, and Director of Nursing. All nurses were educated by the Director of Nursing on (MONTH) 17, (YEAR) about the requirement of the facility to develop and implement a care plan for each resident including the discharge plan. The interim care plan includes the discharge plan of whether to remain in the facility or desire to discharge back to the community. The discharge plan of any upcoming potential discharges for the next seven days will be reviewed by the Discharge planner weekly and discussed in the Medicare/Medicaid meeting by the administrator, Discharge Planner, Therapy manager, assistant administrator, Director of Nursing, Social Worker and the MDS coordinator. In the Medicare/Medicaid meeting, upcoming or potential discharges through the next seven days are discussed and care plans are updated at this time. The potential discharges discussed are evaluated the interdisciplinary team including but not limited to; home health, primary care physician, durable medical equipment needs, any services needed from the community, education for medication management, treatments, food and dietary needs, care needs of activities of daily living and level of supervision needed. During the Medicare/Medicaid meetings, the interdisciplinary team reviews the progression of each resident and projected discharge date based upon safety and resident goals. The Director of Nursing or Assistant Director of Nursing brings information for any residents with a change in condition according to information gathered from Unit Managers and Charge Nurses. These residents are reviewed at this time for any significant changes that may affect an upcoming discharge. Any change of condition including discharge information is communicated to the resident or resident representative and provider by the Discharge Planner, nurse and/or Unit Manager. The interdisciplinary team consists of at least the Director of Nursing, Social Worker, Dietician, Therapy Director, and Nursing MDS Coordinator. The Director of Nursing communicates any potential discharge residents to the Unit Coordinator/Manager to initiate training/teaching to resident or resident representative when applicable. This includes but is not limited to; blood sugar checks, insulin administration, wound care, tube feedings, oxygen therapy, and medication management. The providers are also included in the discussions of potential discharges and address safety and medical needs. The Social Worker and/or Discharge Planner are responsible for communicating with the resident and family representative on discharge needs including community resources for potential discharges. The Dietician is responsible for education on dietary needs related to their diagnosis. The Therapy Director is responsible for the oversight of the treating therapist, to ensure resident meets goals for safe discharge and any barriers to discharge are communicated to the team for follow up. If a home visit is applicable based on discharge needs, the Therapy Director will be responsible for coordination. The Therapy Director will also coordinate caregiver training where applicable and ensure completion. The Nursing MDS Coordinator reviews each resident for clinical needs at the facility and also ensuring the resident has appropriate follow up based on medical needs for discharge. Resident and family representatives are then notified by the Discharge Planner of future discharge date and will assist with discharge follow up needs. The discharge planner updates the discharge care plan as needed. The nursing staff will document the discharge instructions given to the resident and/or resident representative upon discharge. This process will be reviewed prior to discharge by the Director of Nursing as noted with the discharge audit. The provider will complete a discharge summary after visiting resident to include discharge plan for resident and ensure medical needs are met prior to discharge. On (MONTH) 30, (YEAR), the Regional Vice President of Operations for the contracted therapy company educated all facility Rehab Directors via telephone regarding the importance of home visits when needed to determine a resident's safety or additional safety needs post discharge from the facility. The discharge planner and/or therapy manager is responsible for determining the need of a home visit for all discharged residents and assigning the staff member that will go out to the home. When a home visit is deemed necessary for resident safety, it is completed prior to the discharge home. Beginning (MONTH) 2, 2019, the Assistant Administrator, Director of Nursing, and Assistant Director of Nursing provided in-servicing for all staff, including the discharge planner and discharging nurse, regarding abuse and neglect of residents. This was completed by (MONTH) 4, 2019. Beginning (MONTH) 14, (YEAR), a resident's discharge planning will begin at the time of admission. The discharge planner, and/or therapy director will speak with the resident and/or representative within 72 hours of admission to determine discharge needs. The needs determined will include discharge disposition, needs of the home such as stairs or other impediments, follow up physician needs, pharmacy preferences, home health preferences, and care needs. These needs will continue to be discussed amongst the social worker, discharge planner, therapy director, and nurse management throughout the stay and leading up to discharge at least weekly and with change in condition. Resident and/or representatives will be notified of any changes that take place by the Discharge Planner from the initial discharge plans or if a home visit is needed to assess safety. The Director of Nursing educated all nurses, including the treatment nurse, dietary manager, therapy manager, activity director, and social workers on (MONTH) 17, (YEAR) and completed by (MONTH) 28, (YEAR). This in-service included; family representative training to ensure understanding of discharge instructions, notification of change in condition, including but not limited to, newly acquired wounds or change in condition of a resident's skin, development and implementation of a care plan, and discharge planning process. The nurses and social workers were educated to document all discharge planning including training given prior to discharge. Any nursing staff and/or social worker that did not receive this in-servicing on (MONTH) 17, (YEAR) were not allowed to work until in-servicing was completed. This in-service was 100% complete on (MONTH) 28, (YEAR). In-servicing for Abuse and Neglect policies will be included in the new staff orientation and also in annual training of existing staff. This in-servicing will be provided by the Administrator, Assistant Administrator, Director of Nursing and/or Staff Development Coordinator; including but not limited to education/training regarding unsafe discharges. The facility plans to monitor its performance to make sure that solutions are sustained. Beginning (MONTH) 18, (YEAR), the Director of Nursing began completion of a daily discharge audit tool. This tool is used to ensure proper documentation post discharge including, but not limited to; resident's comorbidities, mental status, education of treatments, destination, and disposition of resident's personal properties upon discharge. This tool will be completed weekly for a minimum of three months and then a minimum of monthly for one year. Results of these audit tools will be presented to the QAPI committee by the Director of Nursing for any changes or outcome resolutions. On (MONTH) 14, (YEAR), the Assistant Administrator began a discharge planning audit tool. This tool involves reviewing the medical record prior to discharge to ensure the discharge planner documented discharge needs and involvement of caregivers and interdisciplinary team in conducting a safe discharge plan. It allows the facility to ensure all agencies required for post discharge are ordered timely and are documented in the resident's record. This tool was completed daily x 4 weeks and will continue to be completed weekly for a minimum of three months and then a minimum of monthly for one year. The assistant administrator calls each newly discharged resident and/or representative to ensure all discharges were properly prepared and implemented to include; review of medication listings, transportation method was appropriate, home health initiation occurred, wounds treatment education if applicable was provided, and any other education needed related to residents' medical needs was provided. Reassurance is made of no concerns or issues at the time and ensures resident or caregiver has a call back number if needed. Results of these audit tools will be presented to the QAPI committee by the Assistant Administrator for any changes or outcome resolutions. The assistant administrator will monitor that each resident has a discharge plan on admission and ensure that the plan is reviewed and revised as needed. Compliance date was 1/4/19 The credible allegation was verified via staff interviews and record reviews on 2/8/19 and as evidenced by the following: verification of re-education for discharge planner, social worker and licensed nurses. All staff interviewed (nursing and non-nursing staff, administrative staff) as appropriate stated new processes for discharge and abuse/neglect Staff training and in-services. Review of audits. Review of documentation for resident discharge of a resident including stand-up meeting, assessment, discharge began at admission, discharge summary, medication release form and discharge instructions, validated staff reviewed resident discharges daily to verify needed equipment, medication, nursing assessment, documentation and services were arranged at the time of discharge. The facility's compliance date was verified as 1/4/19.