Every finding on record at Ohio Valley Health Care

Based on observation and staff interviews, the facility failed to maintain an infection control program which limits the transmission of pathogens and helps prevent the spread of disease, as evidenced by; Not having the correct enhanced barrier protection (EBP) sign indicators for residents rooms. There were lift pads left out on wheelchairs and on lifts. In the laundry room there were no cleaning logs and the air vent was off during the washing/drying process. Finally, the water control / maintenance program was missing logs, diagrams and service checks for the entire system. These were random opportunities for discoveries during the Long Term Survey Process and have the ability to affect more than a limited number of residents. Facility Census: 62. Findings Include: a) Enhanced Barrier Protection (EBP)While conducting facility rounding on 03/16/26 at approximately 12:30 PM it was observed the Enhanced Barrier Protection (EBP) signs on rooms 104, 105, 106, 107, 108 and 109, were all missing the required indicators to signify what resident the EBP precautions pertained to. This facility uses an orange dot on the name plate of the resident to indicate what resident is under the EBP, these rooms were all missing the orange dot marker.During an interview with Staff member #63 they stated I know who they go to because I work with them daily, but not sure how you would tell otherwise.During a secondary interview with Staff #89 they stated It's the orange dots, we put them on the names of who the EBP goes with.b) Lift padsMultiple lift pads which are used to aid in the transition of residents from bed to wheelchair and back, were noted to be left out / stored on wheelchairs and patient lifts in the hallways. These pads are to be stored away in an area to keep them clean and sanitary and not to allow for cross contamination from other staff, residents and family in the facility. Lift pads are to be treated like all other laundered linen and kept in an area which is covered and clean and not out in the open. They can be used multiple times for the same resident if not visibly soiled, however, they need to be stored in a sanitary manner. On the 100 hall there were five (5) wheelchairs and one (1) lift which had lift pads left out on them. The 200 hall had two (2) wheelchairs and one (1) lift which had lift pads stored out on them, two of those lift pads were visibly soiled.During an interview with Staff #89 on 03/16/26 at approximately 1:15 PM, they confirmed the facility stores the lift pads on the wheelchairs and lifts. That way they are always available when we need them.c) Laundry roomDuring inspection of the laundry area on 3/17/26 at approximately 2:46 PM, the air control vent was observed to be off and not creating the required air control / separation of the clean and dirty sides of the area. There must either be a physical separator, ie. a door or plastic drape, or the use of ventilation air flow to prevent pathogens from traveling from the dirty area to the clean linens. With the ventilation system off, this separation was not maintained.During an interview with Staff #80 they confirmed, the vent was off. I'll make sure we keep that vent on when doing the laundry.d) Water maintenanceThe water maintenance program was only able to produce logs of weekly required water temperatures being done. The rest of the required logs / checks were not being completed or the facility did not have records available at the time of the survey process. The facility was missing the water flow diagram, water testing, dead leg tests ect.On 3/18/26 at approximately 9:30 AM in an interview with the Administrator they confirmed, they did not have any of those documents but are working to resolve this issue. We don't have a water plan yet and the water system flushes are not completed either. We are waiting on corporate facilities to get us all of that.

Based on observation, record review and staff interview, the facility failed to implement and develop a comprehensive person-centered care plan which includes the measurable side effects of medications treating psychosocial needs, use of a communication board, and a preference to keep the room door closed. This was found during the Annual Long Term Care Survey Process. This was true for (3) three of 19 records reviewed. Resident identifiers: #12, #26 and #42. Facility census: 62. Findings include: a) Resident #12 A review of Resident #12's Care plan found they receive antipsychotic medication related to psychosis with associated risks. The care plan read as follows: -- Problem start date of 09/15/22. Resident receives antipsychotic medication related to psychosis with associated risks. The care plan was void of any side effects nursing staff would need to monitor for. A review/revision was time stamped for 01/01/26 at 11:23AM. Further review of Resident #12's Care plan found they receive an antidepressant medication related to depression with associated risks. The problem statement related to this read as follows: -- Problem start date of 09/15/22. Resident receives antidepressant medication related to Depression with associated risks. The problem statement was void of any side effects nursing staff need to monitor for in the problem area. A review/revision was time stamped for 01/01/26 at 11:23AM. Diagnosis related to these care plans included: -- Unspecified psychosis not due to a substance or known physiological condition. -- Anxiety disorder, unspecified. -- Major depressive disorder, recurrent, unspecified.) Review of the Medication Administration Record (MAR) shows an order to monitor for side effects related to medication ordered :Anti-psychotic mediation every shift: Sedation, Drowsiness, Dry Mouth, Constipation, Blurred Vision, Extra Pyramidal Reaction, Weight Gain, Edema, Postural Hypotension, Sweating, Loss of Appetite, Urinary Retention. Review of the MAR shows an order to monitor for side effects related to medication ordered: Anti-depressant every shift: Sedation, Drowsiness, Dry Mouth, Blurred Vision, Urinary Retention, Tachycardia, Muscle Tremor, Agitation, Headache, Skin Rash, Photosensitivity (skin), Excess Weight Gain. Staff interview with the Minimum Data Set (MDS) Coordinator. On 03/18/26 at around 12:30PM the MDS Coordinator after his review of the care plan reported, this is usually how I write these, I did not add any side affects for the Certified Nursing Assistants (CNAs) to monitor for since they are in the Medication Administration Record (MAR). This surveyor questioned if the CNAs have access to the monitoring tool in the MAR which he replied no. I will review this and add the possible side affects so the CNAs have an understanding. b) Resident #28 During an interview on 03/16/26 at 12:23 PM the resident only responded by shaking her head yes/no, she did not verbally communicate. Resident #28's care plan was reviewed found the following problem statement: Problem: I am alert, I do have aphasia noted and I am unable to verbally communicate my needs. I am able to respond to yes/no questions, this is not always 100% accurate. I do not have capacity to make my own medical decisions, I have a responsible party to do so for me. I am here for rehab with the goal to return home if my spouse can safely meet my needs and manage my care at home. Further review of the care plan found no intervention related to a communication board. During an interview on 3/17/26 at 10:07 am with LPN #4 when asked how she communicates with Resident #28, she stated she shakes her head yes/no to questions and she also has a communication board but she refuses to use it. During an interview on 3/17/26 at 10:10 AM with Activity Director #91, when asked how she communicates with Resident #28 she stated, she answers yes/no questions. When asked about a communication board, she did not know about the board. She then went to get another staff member. Restorative Aide #63 said, Resident #28 has a communication board but refuses to use it. She also stated we just know her. An interview with Director of Nursing (DON) on 3/17/26 at 10:45 AM confirmed, there was no mention of a communication board in Resident #28's care plan. c) Resident #42 A review of Resident #42's care plan found the following intervention, I prefer to have my room's door shut for privacy. Please respect my preferences. Explain safety concerns while being courteous. During an observation and interview with Registered Nurse (RN) #81 on 3/18/26 at 8:30 AM it was confirmed Resident #42's door was opened, when asked why she stated she didn't know why it was open unless she just wanted it open at this time. When Resident #42 was asked if she wanted her door shut and she shook her head yes.

Based on record review and staff interview the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was true for five (5) out of five (5) employees reviewed during the long term care survey process. Employee identifiers #18, 62,52,46 and 36. Facility census: 62.Findings include: a) On the afternoon of 03/17/26 the competency reviews for Nurse Aide(NA)s #18, 62, 52, 46 and 62 were requested from the Nursing Home Administrator(NHA).On the afternoon of 03/18/26 the NHA confirmed the facility did not have any competency reviews for the NAs #18, 62, 52,46, and 62.

Based on record review and staff interview the facility assessment failed to state the break down of staffing needed to care for the residents based on their acuity levels. This failed practice had the potential to affect more than a limited number of residents. Facility census: 62. Findings include: a) A review of the facility assessment with a review date of 02/16/26 found no staffing levels were identified in regards to the number of direct care staff needed to care for the residents based on the acuity level of the residents housed at the facility. In fact the facility assessment contained no break down to reflect the acuity level of the residents housed in the facility to base staffing off of. During the Nursing Home Administrator (NHA) interview on 03/18/26 at 1:13 PM he verified there wass no break down of staff in the facility assessment as required.

Based on staff interview and record review the facility failed to provide the required training for two (2) out of five (5) employees reviewed for training during the long term care survey process. Nursing Aide (NA) identifiers #62 and 18. Facility census: 62. Findings include: a) NA #62 On the afternoon of 03/17/26 the training record for NA #62 was requested from the Nursing Home Administrator (NHA). On 03/18/26 at 12:54 PM the NHA provided the training record for NA #62. Upon review of the training record it was noted there was only ten (10) hours of training. The NHA confirmed NA #62 did not have the full 12 hours of training as required. b) NA #18 On the afternoon of 03/17/26 the training for NA #18 was requested from the NHA. On 03/18/26 at 12:54 PM the NHA provided the training record for NA #18. Upon review of the training record it was noted there was only six (6) hours of training. The NHA confirmed NA #18 did not have the full 12 hours of training as required.

Based on interviews and record reviews during a recertification survey, the facility did not ensure timely notification to the physician of Resident's significant weight loss. This is true for one (1) of three (3) Resident's reviewed for weight loss. Resident identifiers: Resident #5. Facility census: 62. Findings include:a) Resident #5An observation on 03/17/26 at 8:08 AM, found the resident was in her room struggling to feed herself. Her hand was shaky, and she was dropping food.A medical record review on 03/17/26 at 12:24 PM revealed a severe weight loss. Resident #5 weighed 114.6 pounds (LBS.) on 01/25/26 and weighed 101.4 LBS. on 02/22/26 equaling an 11.52% in weight loss. Resident #5s Weight log showed:03/08/2026 -Weight: 105.2 lbs / Body Mass Index (BMI): 16.9802/22/2026 -Weight: 101.4 lbs / BMI: 16.3601/25/2026 -Weight: 114.6 lbs / BMI: 18.4901/21/2026 -Weight: 113.0 lbs / BMI: 18.24Subsequent review of the resident's medical record showed it did not contain documentation of Resident #5's physician being notified of the significant weight loss.During an interview on 03/17/26 at approximately 1:32 PM the Director of Nursing (DON) stated, the facility does not document meal intakes. She also verified no residents receive supplements or scheduled snacks.During an interview on 03/18/26 at approximately 9:13 AM with the Director of Nursing (DON), she confirmed the physician was not notified of significant weight loss for Resident #5.A subsequent review of Resident #5s medical record revealed on 03/18/26 at 9:48 AM after surveyor intervention, the facility notified the Physician of the recent weight loss. The physician advised to add a diagnosis of unspecified protein-calorie malnutrition to the chart and begin dronabinol 2.5mg daily for appetite stimulation and an Order to check CMP on Friday.

Based on Interviews and record review, the facility failed to update the Minimum Data Set (MDS) with a Significant Change is status for Resident #9. No significant change in status assessment was completed within 14 days of a significant change in a resident's medical status as per regulations. This was discovered during the the Long Term Care Survey Process and was true for one (1) of 19 sampled residents. Resident Identifier: Resident #9. Facility Census: 62Findings Include: During an interview with Resident #9 and their roommate on 03/16/26 at approximately 12:51 PM, they stated they had a fall in their room on water on 1/20/26. It was unwitnessed by staff, but was seen by the roommate who alerted the staff Resident #9 had fallen and hit her head after slipping on some water Resident #9 had spilled. Notes in the chart about the incident show the facility followed all their protocols and notified the Medical Power of Attorney (MPOA), Medical Doctor (MD) and took vitals prior to sending the resident to the hospital on 1/20/26. The facility staff called emergency room (ER) department for an update on Resident #9's condition and were informed R#9 had a fracture of the cervical spine (neck) in the C2 area. Further testing was performed at the ER prior to the resident returning to the facility. It was noted the resident refused all care and treatment at the ER and this was cleared by their MPOA. Resident #9 was to wear a C-collar for spinal support during the healing process at all times as per the discharge notes. An Interdisciplinary Team (IDT) meeting was held to discuss the updates needed to Resident #9's care and healing process. The orders and care plan for the resident were updated to reflect these changes, but no Significant Change In Status Assessment MDS was completed after these changes were made. A Significant Change In Status Assessment is required per regulations if: Chapter 2 of the RAI Manual covers SCSA. A significant change is a major decline or improvement in a resident's status that:Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; Impacts more than one area of the resident's health status; and Requires interdisciplinary review and/or revision of the care plan.Additionally, the SOM states a Significant Change in Status Assessment (SCSA) is a comprehensive assessment that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline. A fall with major injury will trigger a need for a Significant Change In Status Assessment as it will lead to Significant Change in Status as well as the Self-Limiting aspect of an injury and time it will take to heal. Resident #9's neck fracture impacted all of her activities of daily living (ADLs) as well increased need for monitoring and medications. Record review of the MDSs on 3/17/26 found no Significant Change in Status Assessment completed within the required time frame of 14 days of the event. There were only the required annual and quarterly MDS assessments in the residents chart. Interviews were conducted on 3/17/26 at approximately 11:32 AM with the Administrator and MDS coordinator. The MDS coordinator stated I am not sure those [fall and fracture] would trigger a CIC change that needs to be done. I will look into that for you and see what the manual states. I will get back to you shortly, I'll be honest I didn't think those two events would qualify for CIC being completed.The Administrator later stated I do probably think that one was needed for the fall with injury,

Based on record review and staff interview, Resident #42 care plan was found to not be revised to address Resident #42 dental issues. This was true for one (1) of 19 sampled residents reviewed during the long term care survey process. Resident Identifier #42. Facility Census: 62. Findings include:During record review and resident interview it was found that resident #42 had a toothache from 12/02/25 to the present time. This was not addressed in Resident #42's care plan. This was confirmed to be true by the Director of Nursing (DON) on 03/18/26 at 9:27 AM.

Based on observations and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible. During a random opportunity for discovery, the following issues were identified: A treatment cart was left unlocked and unattended and oxygen tanks were stored improperly. These failed practices had the potential to effect more than a limited number of resident currently residing in the facility. Facility census: 62.Findings Include: a) Treatment Cart On 03/18/26 at 8:50 AM, an observation of an unlocked, unattended treatment cart was made. The cart was in a place easily accessible allowing access to these treatment supplies by residents, unauthorized persons, or visitors. At 8:56 AM, Licensed Practical Nurse (LPN) #4 confirmed during an interview the treatment cart was left unlocked and unattended. She stated she did not have a key for the cart and, at that time, asked LPN #23 if they possessed one. At 9:10 AM, the Director of Nursing confirmed while the treatment cart key is kept locked up, all nurses have access to it. b) Oxygen tank storage It was observed on 3/18/26 at approximately 8:45 AM three (3) oxygen tanks were being stored behind the nurses station between the 100 and 200 hallways. The tanks were in rolling carts without regulators and not in the proper metal cages. These pose an explosion / fire risk and must always be kept in a secure location in the facility. The area the tanks are normally stored in, the medication room did not have the proper signage and therefore was not able to be used according to Staff #4. [Life safety] told us we can't store them in the medication room anymore because we don't have the right sign for them. So they moved them out here for now. The Administrator confirmed, [Life Safety] said the sign was not the approved one and they will order the proper one today.

Based on observation, record review and staff interview the facility failed to ensure Resident #42 maintained acceptable parameters of nutritional status. Resident #42 suffered a severe weight loss and the facility failed to ensure the resident was reviewed by the licensed dietician and/or interventions were put into place to prevent further weight loss. This was true for one (1) of six (6) residents reviewed for the care area of nutrition during the long term care survey process. Resident Identifier: #42. Facility Census: 62.a) Resident #42 An observation of Resident #42 in her bed on 03/16/26 at approximately 1:30 PM, found her noon time meal was on her over the bed table and was untouched, The resident indicated she did not want to eat. A review of Resident #42's medical record found the following weights: -- 05/30/25 - 170.2 pounds (Lbs.) -- 07/18/25 - 169.5 Lbs. -- 09/16/25 - 171.5 Lbs. -- 12/26/25 - 166 Lbs. -- 02/20/26 - 148.8 Lbs. From 12/26/25 to 02/20/26 Resident #42 lost 10.36 percent of her body weight. This represents a severe weight loss. On the afternoon of 03/17/26 the Director of Nursing (DON) was asked were the facility tracks their meal percentages for each resident. She stated, We do not do that here. She further stated, we have a very liberalized eating program and we use quality ingredients. She further stated, we monitor there weights closely and offer substitutes if they do no eat. She indicated she works closely with the Dietician and the Physician and weight loss is not a problem here. Further review of the medical record found a physician's order which indicated the resident was to be weighed in the first and third week of each month. However after reviewing the weights it was found Resident #42 was not weighed twice a month as ordered. The medical record did contain nursing notes which indicated the resident often refused weights. When asked about interventions for Resident #42's weight loss the DON stated, the dietician did not see her when she was here last and she does not know why. When asked if she had notified the Dietician of Resident #42's severe weight loss she stated, I did not tell her but she should catch that on her own. The DON stated, the Dietician comes weekly on Thursdays and makes recommendations as needed for residents with nutritional concerns. Resident #42's weight loss was identified on 02/20/26 when she allowed them to weigh for the first time in two (2) months. The dietician was at the facility on 02/26/26, 03/05/26, and 03/12/26 and did not review and/or make recommendations for Resident #42. The DON on 03/18/26 in the afternoon stated, The dietician will see her tomorrow. A final review of the medical record on 03/18/26 found not interventions were put into place to address Resident #42's severe weight loss.

Based on record review and staff interview the facility failed to ensure nurse staff postings were correct. There were seven (7) out of 14 days of incorrect nurse staff postings. This failed practice had the potential to effect more than an isolated number of residents. Facility census: 62.The nurse staff posting was requested from the Nursing Home Administrator (NHA) on 03/17/26 for the timeframe of 02/08/26 to 02/22/26. On 03/18/26 the NHA provided the nurse staff posting and the hours per patient day (HPPD) report. This surveyor compared the staff posting to the HPPD report and found on the following days the nurse staff posting was incorrect: --02/08/26 the HPPD report indicated 125 nursing hours but the nurse staff posting indicated 131 nursing hours.--02/11/26 the nurse staff posting indicated only one (1) hour of RN coverage, however the time detail report provided by the NHA indicated there was eight (8) hours of RN coverage on this date. --02/12/26 the HPPD report indicated 208.75 nursing hours but the nurse staff posting indicated 193 nursing hours.--02/26/26 the HPPD report indicated 163.5 nursing hours but the nurse staff posting indicated 179 nursing hours.--02/17/26 the nurse staff posting indicated 5 hours of RN coverage and the time detail report indicated 4.75 hours of RN coverage.--02/20/26 the nurse staff posting indicated 5 hours of RN coverage and the time detail indicated 7.25 hours of RN coverage.--02/22/26 the HPPD report indicated 170 nursing hours but the nurse staff posting indicated 178 nursing hours.

Based on record review, resident interview and staff interview, the facility failed to ensure resident safety for medication administration. Resident Identifiers: #3 and #13. Facility Census: 42. The state agency notified the Nursing Home Administrator of the immediate jeopardy at 4:30 PM on 08/26/24. The facility submitted a plan of correction (POC) at 6:09 PM. At 6:25 PM, the POC was accepted by the state agency. The state agency verified the POC was implemented by conducting staff interviews and the immediate jeopardy was abated at 10:15 AM on 08/27/24. Findings Include: a) On 08/25/24 at approximately 11:25 AM, the resident was interviewed regarding receiving the wrong medication on 07/01/24. Resident #3 responded, I don't even know what medication I take, there is probably eight (8) or nine (9) of them. On 08/26/24 at 11:30 AM, a review of the facility's reportables regarding medication errors was completed. The review found two (2) events occurred for two (2) different residents on 07/01/24 and 08/20/24. Resident #3 was administered the following medications in error: Norco 7.5/325mg (opiate for pain), Xanax 0.25mg (anti-anxiety) and Metoprolol 37.5mg (hypertension). Resident #13 was administered Lyrica 150mg (anticonvulsant used for pain control). Neither Resident #3 nor Resident #13 were ordered the medications that were administered. On 08/26/24 at 11:50 AM, the Director of Nursing (DON) was interviewed regarding these events. The DON stated, The first event was a seasoned nurse, Registered Nurse (RN) #85 .the second event was LPN #94, who was on orientation with LPN #105. The DON stated, There really isn't an excuse for the mistake RN #85 made, and the reason the event happened with LPN #94 is the seasoned nurse (LPN #105) was not with LPN #94 when the medication was administered. On 08/26/24 at 12:20 PM, the DON stated, a disciplinary write-up and re-education regarding the rights of medication administration was provided to RN #85, at which time, the same education was provided to all nurses. LPN #94 was re-educated regarding the rights of medication administration as well. On 08/26/24 at 2:00 PM, the sign-in sheets dated for 07/05/24 and 07/23/24 were reviewed. Of the 25 nurses employed by the facility, only 18 signed the acknowledgement sheets of attendance. On 08/26/24 at 3:30 PM, Resident #13 was interviewed regarding the medication error. The resident stated, I knew something was wrong when they told me about taking my vitals all night. The nurse was scared, and she told me she was sorry for giving the wrong medication .I was afraid of what might happen to me .this has never happened before. The state agency notified the Nursing Home Administrator of the immediate jeopardy at 4:30 PM on 08/26/24. The facility submitted a plan of correction (POC) at 6:09 PM. At 6:25 PM, the POC was accepted by the state agency. The state agency verified the POC was implemented by conducting staff interviews and the immediate jeopardy was abated at 10:15 AM on 08/27/24. b) Facility's Plan of Correction IJ Abatement Plan 1. Resident #3 and Resident #13 were assessed by the Assistant Director of Nursing (ADON) on 8/26/2024 for any further possible adverse outcomes from the medication administration errors that occurred 07/01/24 and 08/20/24. Med Pass observation to be completed by the ADON/ Designee on all current license nurses working this shift beginning on 8/26/24 at 5:30pm. Licensed nurses not available during this timeframe will be completed on their next scheduled shift. 2. All current residents of the facility have the potential to be affected. 3. The Director of Nursing (DON) will immediately initiate re-education beginning on 8/26/24 at 5:15pm to all licensed nurses that are working and prior to his/her next scheduled shift regarding medication administration process to include the 6 rights of administration to be completed by 9/5/2024. Licensed nurses not available during this timeframe will be provided reeducation including posttest prior to the next scheduled shift by the DON/ designee. New Licensed nurses during orientation will receive education prior to completion of orientation. 4. Nurse Med Pass observation will be monitored for 5 residents by the DON/ Designee daily during all shifts x 14 days then monthly during all shifts x 3 months with on-going as indicated by audits and monitoring. The DON/ Designee will present results of medication admission audits or monitoring monthly to the Quality Improvement Committee for any additional follow up and/or in-serving .

Based on record review and staff interview, the facility failed to ensure annual performance reviews were completed for nursing staff. This was true for four (4) of five (5) staff members reviewed under the care area of sufficient and competent nurse staffing. Facility Census: 42. Findings Include: a) Annual Performance Reviews On 08/27/24 at 3:00 PM, a review of the staff employment files was completed. The review found the annual performance evaluations were not completed for the following nurse aides (NAs): -NA #71 -NA #50 -NA #72 -NA #14 On 08/28/24 at approximately 9:45 AM, the Administrator was notified of the missing evaluations. The Administrator stated, we will be working on this.

Based on record review and staff interview, the facility failed to monitor refrigerator temperatures in the medication room on the 300 hall. This was a random opportunity for discovery and has the potential to affect more than a limited numberof residents. Facility Census: 42. Findings Include: a) Medication Refrigerator On 08/26/24 at 8:10 AM, a tour of the medication room on the 300 hall was completed. The tour found the medication refrigerator temperatures were not monitored and documented on the following dates: --08/02/24 AM --08/02/24 PM --08/03/24 AM --08/04/24 AM --08/04/24 PM --08/05/24 PM --08/07/24 AM --08/08/24 AM --08/10/24 AM --08/11/24 AM --08/12/24 AM --08/13/24 AM --08/13/24 PM --08/15/24 AM --08/16/24 AM --08/17/24 AM --08/17/24 PM --08/18/24 AM --08/18/24 PM --08/19/24 PM --08/21/24 AM --08/22/24 AM On 08/26/24 at 8:18 AM, the Director of Nursing (DON) was notified. The DON stated, the nurse on the 300 hall let me know. b) Facility Policy On 08/26/24 at 8:30 AM, the facility policy entitled, Medication Storage was reviewed. The review found under Procedures #11 the following: Medications requiring refrigeration or temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit) are kept in a refrigerator with a thermometer to allow temperature monitoring.

Based on observation and staff interview the facility failed to provide a safe, clean, comfortable and homelike environment for Resident #21. This was a random opportunity for discovery. Resident Identifier: #21. Facility Census: 42. Findings included: a) Resident #21 An observation on 08/25/24 at 11:45 AM, of Resident # 21's room found the wallpaper had horizontal strips torn from it along the wall from the bathroom door to the window. During an interview on 08/27/24 at 9:20 AM, with Corporate [NAME] President (CVP) #107, CVP #107 confirmed the wallpaper was torn in Resident #21's room.

Based on record review and staff interview the facility failed to ensure all admitting diagnosis were reflected on the Preadmission Screening and Resident Review (PASRR). This was true on two (2) of four (4) PASRRs reviewed during the Long-Term Care Survey Process. Resident identifiers: #36 and #21. Facility Census: 42 Findings included: a) Resident #36 On 08/26/24 at 3:27 PM a record review found Resident #36 was admitted on [DATE] with an admitting diagnosis of: Unspecified Dementia with Psychotic disturbance, Psychosis and Major Depressive Disorder. Review of the PASRR which was submitted on 03/15/22 reflected Resident #36 had a diagnosis of Alzheimer's, multi-infarct, senile dementia but did not have a diagnosis of psychosis or major depressive disorder. This was confirmed during an interview on 08/26/24 at 3:30 PM with Social Worker #58 when she agreed the admitting diagnosis of psychosis and major depressive disorder should have been on the PASRR . b) Resident #21 On 08/27/24 a record review found Resident #21 had the following diagnoses: Unspecified Psychosis, Onset date 06/02/22 Unspecified Mood disorder, Onset date 06/02/22 Major Depressive Disorder, Onset date 05/31/22 Review of the PASSR dated 08/27/24 found the following medical diagnoses were not identified on the PASSR: Major Depressive Disorder The above information was confirmed with the Admissions Director (AD) on 08/28/24 at 11:41 AM. The AD agreed the additional medical diagnosis should have been on the PASRR. 50801

Based on record review and staff interview the facility failed to comply with the Medical Power of Attorneys' (MPOA) wishes regarding administration of immunizations. This was true for two (2) of six (6) immunizations reviewed during the long term care survey process. Resident identifiers: #35 and #36. Facility Census: 42 Findings included: a) Resident #35 On 08/26/24 at 1:27 PM, a record review found Resident #35 received a COVID vaccine without consent. Review of the Medication Administration Record shows Resident #35 received Comirnaty 2023-24 (12y up) (COVID vac 2023-24) Suspension; 30 mcg/0.3 ml, administered 0.3 ml intramuscular COVID vaccine on 02/02/24 by Registered Nurse (RN) #24. A progress note dated 01/05/24 at 5:52 PM states Spoke with the POA son (name) regarding upcoming vaccines. Consented to RSV, Prevnar 20 (pneumonia) and Shingrix (Shingles) but no COVID vaccines were to be given This progress note was initiated and signed by RN #24. The MPOA was notified of the administration of the COVID vaccine, as well as the Physician. According to the Incident Report and the reporting documentation to Office of Health Facility Licensure & Certification (OHFLAC) there were no adverse reactions. A new order was received from the Physician to monitor the resident for any changes in condition. The facility provided education to the nursing staff of ensuring consents were on record for any immunizations administered. The Vaccination Consent form was redesigned in April 2024 to reflect consent or declination of all vaccines offered on one page to simplify the review of the Resident or responsible parties wishes. This was addressed in the Quality Assurance Performance Improvement QAPI meeting as well. The above findings were confirmed with the Administrator and the Manager Quality RN #69 on 08/27/24 at 2:15 PM. b) Resident #36 On 08/26/24 at 1:26 PM, a record review found Resident #36 received a Shingrix (Shingles) vaccine on 07/22/24 by Manager Quality RN #69. Additional record review shows Resident #36's Medical Power of Attorney signed a declination of the Shingrix (Shingles) vaccine on 06/24/24. The MPOA was notified as well as the Physician. According to the review of the Incident Report and the reporting documentation to Office of Health Facility Licensure & Certification (OHFLAC) there were no adverse reactions. A new order was received from the Physician to monitor the resident for any changes in condition. The facility provided education to the nursing staff of ensuring the right resident prior to administering any medication. On 08/27/24 at 9:10 AM during an interview with the Director of Nursing she stated the nurse confused Resident #36 with another resident with a similar last name but residing on a different hall. It was confirmed at this time that the vaccine should not have been administered.

Based on observation and staff interview, the facility failed to maintain a safe and accident free environment as possible regarding the disposal of razors. This was a random opportunity for discovery and had the potential to affect no more than an isolated number of residents. Resident Identifier: #43. Facility Census: 42. Findings included: a) Resident #43 On 08/25/24 at 10:55 AM, an observation was made of two (2) used disposable razors laying in the soap dish in the shower in Resident #43's bathroom. On 08/25/24 at 10:58 AM, Nurse Aide (NA) # 35 was notified. NA #35 stated, let me get rid of those. On 08/25/24 at 11:16 AM, the Administrator was notified and confirmed the two (2) used disposable razors should not be left in the shower.

Based on record review and staff interview the facility failed to ensure Resident #5 maintained acceptable perimeters of nutrition by not implementing recommendations made by the registered dietician. This was true of one (1) of two (2) residents reviewed for the care area of nutrition during the long term care survey process. Resident identifier: #5. Facility Census: 42. Findings included: a) Resident #5 A review of Resident #5's medical record on 08/27/24 at 1:30 PM revealed a nutritional assessment dated [DATE] which included the following recommendation: .protein added to meals to encourage healing. Further review of the resident's record found the following care plan intervention: Encourage foods high in protein & offer protein supplements as ordered. This intervention was added to the care plan on 01/31/24. Further review of Resident #5's medical record found protein was not added to the resident's meals and no nutritional supplements to increase protein intake were added to the resident's physician orders. At 2:30 PM on 08/27/24 the Director of Nursing (DON) acknowledged orders for nutritional recommendations had not been implemented appropriately.

Based on record review and staff interview, the facility failed to monitor behaviors and/or side effects for residents prescribed psychotropic medications. This was true for three (3) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifiers: #43, #21 and #5. Facility Census: 42. Findings Include: a) Resident #43 On 08/27/24 at 12:35 PM, a record review was completed for Resident #43. The review found the resident had three psychiatric diagnoses; Unspecified Dementia, Bipolar Disorder and Depression. The resident was prescribed Risperdal (antipsychotic medication) 2mg (milligram) daily for bipolar disorder. The review also, found no documentation regarding the monitoring of behaviors for the resident who was receiving an antipsychotic medication. On 08/27/24 at 2:00 PM, the Director of Nursing (DON) was interviewed regarding the monitoring of behaviors. The DON stated, I don't have any documentation for behavior monitoring .I added it. b) Resident #21 A review of Resident #21's medical record found they were prescribed Celexa, an antidepressant medication , Wellbutrin an antidepressant medication and Zyprexa an antipsychotic medication. The medical record was void of any behavior monitoring related to the use psychotropic medications for Resident #21. In an interview with the Director of Nursing (DON) on 08/27/24 at 2:30 PM, she confirmed they have not been monitoring for behaviors for Resident #21. c) Resident #5 A review of Resident #5's medical record on 08/27/24 at 2:15 PM revealed, Trazodone was prescribed for an improper diagnosis of G47.00 : Insomnia, unspecified. There was no documentation of monitoring for side effects associated with this psychotropic medication. The medical record was also void of any behavioral monitoring related to the use of trazadone. On 08/27/24 at 2:15 PM, the Director of Nursing (DON) was notified of the issue. Upon their return at approximately 2:30 PM, the DON acknowledged the facility did not monitor for side-effects or behaviors related to the use of trazadone. 49466 50801

Based on resident interview, medical record review and staff interview, the facility failed to provide assistance and care in a dignified manner during toileting resulting in a delay in assistance causing Resident #3 to experience periods of incontinence on night shift (3rd) over the last 3-4 weeks. This was true for one (1) of three (3) residents reviewed for the care area of dignity during the Long Term Care Survey Process (LTCSP). This practice resulted in actual psychological harm, including degradation and humiliation for Resident #3. Resident identifier: #3 Facility census: 63. Findings included: a) Resident #3 The initial interview with Resident #3, on 08/13/18 at 1:47 PM, revealed the resident had been having episodes of incontinence in the last three (3) to four (4) weeks. She said, by the time the staff answers my call light I have wet the bed and then they get me up and then I freeze to death. This is embarrassing and degrading to me. On 08/14/18 at 11:33 AM, a review of the resident's last quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 08/07/18 found the resident assessed as having clear speech, as able to be understood, and able to understand others. Resident #3's Brief Interview for Mental Status (BIMS) score of twelve (12) identified the resident was mildly cognitively impairment. She also requires assist of one with transfers and toileting. Review of Resident #3's Activities of Daily Living (ADL) pertaining to bladder incontinence, found beginning on 07/25/18 the resident was documented as continent on 1st shift (6 AM to 2 PM) and 2nd shift (2PM to 10 PM). On 3rd shift (10 PM to 6 AM) Resident #3 was documented incontinent and this level of incontinence continue through 08/14/18 (date of review). Interview with the Director of Nursing (DON), on 08/15/18 at 2:05 pm, found the DON was not aware of the periods of incontinence on 3rd shift (10 PM to 6 AM). She said she would have to speak with the 3rd shift nurse. She then provided the nurses note written on 08/15/18 at 2:28 pm by the DON read, Spoke to night shift RN (registered nurse) resident experiencing recent episodes of incontinence, primarily on 10-6 shift. Nurse stated she had witnessed resident to beginning to void when staff assists her to walk to the bathroom. States that when resident uses her wheel chair, this normally does not occur. Nurse states the resident normally uses call light appropriately for toileting assistance. No further information provided. Interview with Resident #3, on 08/16/18 at 8:00 am, found the resident eating breakfast. She told me she was so happy it was the first night in a while she had not had an accident (incontinent of urine).

Based on resident interview, medical record review and staff interview, the facility failed to provide assistance and care in a dignified manner during toileting resulting in a delay in assistance causing Resident #3 to experience periods of incontinence on night shift (3rd) over the last 3-4 weeks. This was true for one (1) of three (3) residents reviewed for the care area of dignity during the Long Term Care Survey Process (LTCSP). This practice resulted in actual psychological harm, including degradation and humiliation for Resident #3. Resident identifier: #3 Facility census: 63. Findings included: a) Resident #3 The initial interview with Resident #3, on 08/13/18 at 1:47 PM, revealed the resident had been having episodes of incontinence in the last three (3) to four (4) weeks. She said, by the time the staff answers my call light I have wet the bed and then they get me up and then I freeze to death. This is embarrassing and degrading to me. On 08/14/18 at 11:33 AM, a review of the resident's last quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 08/07/18 found the resident assessed as having clear speech, as able to be understood, and able to understand others. Resident #3's Brief Interview for Mental Status (BIMS) score of twelve (12) identified the resident was mildly cognitively impairment. She also requires assist of one with transfers and toileting. Review of Resident #3's Activities of Daily Living (ADL) pertaining to bladder incontinence, found beginning on 07/25/18 the resident was documented as continent on 1st shift (6 AM to 2 PM) and 2nd shift (2PM to 10 PM). On 3rd shift (10 PM to 6 AM) Resident #3 was documented incontinent and this level of incontinence continue through 08/14/18 (date of review). Interview with the Director of Nursing (DON), on 08/15/18 at 2:05 pm, found the DON was not aware of the periods of incontinence on 3rd shift (10 PM to 6 AM). She said she would have to speak with the 3rd shift nurse. She then provided the nurses note written on 08/15/18 at 2:28 pm by the DON read, Spoke to night shift RN (registered nurse) resident experiencing recent episodes of incontinence, primarily on 10-6 shift. Nurse stated she had witnessed resident to beginning to void when staff assists her to walk to the bathroom. States that when resident uses her wheel chair, this normally does not occur. Nurse states the resident normally uses call light appropriately for toileting assistance. No further information provided. Interview with Resident #3, on 08/16/18 at 8:00 am, found the resident eating breakfast. She told me she was so happy it was the first night in a while she had not had an accident (incontinent of urine).

Based on observation, record review and staff interviews the facility failed to implement the care plans for nine (9) of eighteen (18) sampled residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #12 did not receive planned pain management, Resident # 21 did not receive planned nutritional intervention, Resident #60 did not receive planned activities utilizing a CD player, Resident #60 also did not receive planned treatment of [REDACTED].#30 did not receive planned transfer assistance, Resident #50 did not receive planned transfer assistance, Resident #6 did not receive planned diabetic management, Resident #17 did not receive planned weekly assessment including observation of wound, and Resident #43 did not receive planned splinting services to right hand. Resident identifiers: #12, #21, #60, #30, #50, #6, #17, and #43. Facility census: 58. Findings include: a) Resident #12 During the Stage 1 initial tour of the facility, on [DATE] at 11:52:23 a.m., while observing the resident, she cried out. There was no visible stimulus that might have caused her to cry out. As a result of this observation, the resident was selected for further review for the care area of pain during Stage 2 of the survey. An observation on [DATE] at 2:44 p.m. found Nurse Aide (NA) #55 providing passive manipulation of Resident #12's right hand. When the NA extended the fingers of the resident's right hand, the resident cried out. When NA #55 extended the fingers of the resident's left hand, she cried out again. In an interview on [DATE] at 2:50 p.m., NA #55 revealed that she reported residents' experiencing pain to the nurse. When asked whether the nurse did anything about it when she reported a resident was having pain to the nurse, the NA said she was sure the nurses took care of things that were reported to them, but did not provide further detail. When informed of the resident's vocalization of pain on [DATE] at 2:59 p.m., Registered Nurse (RN) #26 said, She always does that. I know her. The nurse acknowledged the resident received a new order for [MEDICATION NAME] sulfate 0.25 milliliter (ml) to be administered every hour or as needed on [DATE], but the resident had not received any doses. Review of the resident's Medication Administration Record [REDACTED]. A record review revealed pain assessment conducted each shift on [DATE] and [DATE] found all of the assessments indicated the resident had no pain. During an interview on [DATE] at 9:48 a.m., the resident's son said the facility had called him that morning to stop her medications because she could not swallow. On [DATE] at 9:56 a.m., during an interview with Restorative Nurse Aide (RNA) #55, when asked if she reported the expressions of crying out to the charge nurse, the RNA replied, I didn't report it to the nurse. We all are aware of the moaning. The RNA added it was not relayed to the nurse, because everyone knows. When asked how did everyone know, the response was, Everyone knows (Resident's first name) decline. When asked how do you know her pain needs are being met, the RNA repied, I'm sure the nurse and the DON (Director of Nursing) knows. Everyone is careful with her care. We tell the nurse if the resident doesn't eat. A review of the resident's medical record on [DATE] at 10:00 a.m. found the resident was actively dying. The resident's care plan revealed an intervention dated [DATE] of, My nurse will administer narcotic pain medication once every hour as needed and monitor for effectiveness or any side effects. The first dose of [MEDICATION NAME] sulfate was not administered until [DATE] around 11:44 p.m. During an interview on [DATE] at 10:16 a.m., the Assistant Director of Nursing (ADON) stated, I would have expected her to use the sublingual ([MEDICATION NAME]) because the resident has trouble swallowing, at the point when she is crying when she is provided care. I want her to be comfortable as well. I agree to a point that she has a history of yelling out, but she is at the end stage of life. I feel like she needs to be comfortable, I feel like she should have had the [MEDICATION NAME]. The resident expired on [DATE]. The resident's annual comprehensive minimum data set assessment with an assessment reference date of [DATE] included [DIAGNOSES REDACTED]. Staff attributed her crying out as a demonstration of the residents' historical mode of communication (i.e. 'I know her .') instead of considering the resident was actively dying and assessing the resident's comfort needs. Additionally, the resident was no longer able to swallow medications, eliminating even the use of Tylenol. The physician ordered [MEDICATION NAME] for the resident's pain on [DATE], but it was not administered until [DATE] at 11:44 p.m. These findings led to a determination of actual harm. b) Resident #21 On [DATE] at 3:50 p.m., a review of the resident's medical record revealed [REDACTED]. Dining room observations on [DATE] at 5:25 p.m. revealed Resident #21 had a dinner tray with only the dessert item eaten. Nurse Aide (NA) #36 offered to remove the dining tray, but did not offer the resident alternative meal choices. After helping reposition the resident, Registered Nurse (RN) #26 removed the resident's dinner tray at 5:28 p.m. on [DATE] and left the room without offering Resident #21 an alternative food choice or inquiring about meal intake. On [DATE] at 6:04 p.m., during an interview, NA #36 acknowledged that she had offered an alternative choice during meal selection only, but had not offered an alternative choice when the resident refused the selected items. On [DATE] at 11:10 a.m., an interview with Assistant Director of Nursing (ADON) #28 revealed that she expected staff to offer Resident #21 an alternative food choice and/or additional servings of a preferred food since the resident was a picky eater. c) Resident #60 1. Activities Review of the resident's care plan on [DATE] at 9:44 a.m. revealed Resident #60 had a care plan developed on [DATE] that included, I enjoy listening to music, I may find comfort in listening to quiet recorded music in my bedroom. A CD (compact disc) player can be provided from activities department. During an interview with Activity Director (AD) on [DATE] at 10:01 a.m. she stated, I don't know where there is a CD player. In addition, the AD was unware the resident's care plan included an intervention for the CD player. An interview with Nurse Aide #58 revealed Resident #60 had a CD player that was supplied by the facility; however, the resident's husband removed the CD player and put a fan it its place. How long the CD player had been missing and its current location were unknown. Review the activity record for [DATE] found no evidence of the CD player being used or that the resident had listened to music. 2. Pressure Ulcers During an observation of Resident #60 on [DATE] at 11:11 a.m. with Licensed Practical Nurse (LPN) #42, the LPN lilted the sheets and the resident's feet were observed wrapped in gauze. The resident's feet were not elevated off the bed. When asked why the resident's heels were not elevated, LPN #42 stated since the resident had received an air mattress her heels did not need elevated. Review of the resident's care plan on [DATE] at 11:30 a.m. revealed a problem of pressure ulcers with an approach established on [DATE] to, Elevate my heels off all surfaces q (every) shift. Maintain Allevyn heel protectors to bilateral heels q shift. Change 2 x (twice) a week on shower days Mondays and Thursdays. On [DATE] at 1:58 p.m., during an interview with the director of nursing, the observation of the resident's heels on [DATE] at 11:30 a.m. was discussed. The director of nursing was informed that the resident had a care plan that indicated her heels would be elevated off all surfaces and the observation revealed this had not occurred. The director of nursing was also informed that LPN #42 felt the resident's heels did not need elevated since she had received an air mattress. There was no reply or reaction from the DON, at that time. d) Resident #30 Observations at 8:37 p.m. on [DATE], noted Nurse Aide (NA) #68 going into Resident #30's room. NA #68 asked Resident #30 if he was ready to go to bed and the resident said he was. The NA shut the resident's door, and a few minutes later, he opened the door and pulled the total mechanical lift into the room. The resident was sitting in his power wheelchair at that time. NA #68 was the only staff member observed in Resident #30's room. At 8:46 p.m., Licensed Practical Nurse (LPN) #54 entered the room. When interviewed after she exited the room, she stated the resident was already in bed when she entered the room. She stated NA #68 had put him in bed with the mechanical lift and did a real good job. In an interview at 8:50 p.m. on [DATE], NA #68 stated he had put Resident #30 to bed using the mechanical lift to transfer the resident to bed. He said the proper procedure was to look at the care plan for direction on how to transfer the resident. NA #68 was asked to look at the care plan to determine how Resident #30 should have been transferred from his wheelchair to the bed. When he looked at the kiosk (a wall mounted computer NAs use to complete their documentation and to review the residents' care plans), he said the resident's care plan identified the resident as needing the assistance of two (2) for all transfers. He stated, I should have gotten someone to help me. A review of Resident #30's care plan at 9:00 p.m. on [DATE], found an intervention with a start date of [DATE] stating, I need total assistance of 2 (two) for transfers as of [DATE], I use a mechanical lift for transfers. I have an electrical chair to get around in. Further review of Resident #30's activities of daily living (ADL) flow sheets for [DATE] through present on [DATE] at 11:00 a.m. found Resident #30 was transferred with a mechanical lift with a the assistance of one (1) on the following occasions: -- Day Shift: [DATE], [DATE], [DATE], [DATE], and [DATE]. -- Evening Shift: [DATE] and [DATE]. -- Night Shift: [DATE] These findings were reviewed with the Director of Nursing (DON) on [DATE] at 9:10 a.m. and no further information was provided at the time of exit on [DATE] at 2:00 p.m. e) Resident #50 At 8:23 p.m. on [DATE], NA #36 was observed transferring Resident #50 from her chair to the bed. NA #36 moved the lift into the resident's room and when the surveyor entered the room and asked Resident #50 if she could observe her transfer NA #36 left the room and asked another staff member to come and assist her. NA #34 came into the room to assist NA #36 with Resident #50's transfer. At 8:25 p.m., while NA #36 was out of the room, when asked how the staff usually put her to bed, she pointed to the lift and stated, They use that thing because I cannot feel from the waist down. When asked how many staff members usually help to put her to bed she stated it was usually just one person. NA #36 and NA #34 reentered the room and transferred the resident to bed. Review of Resident #50's care plan found an intervention of, My activity level is out of bed to chair/wheelchair daily as tolerated. Transfer with total mechanical lift and assist of two. Over the bed trapeze for use with positioning. This intervention had a start date of [DATE]. Further review of Resident #50's activities of daily living (ADL) flow sheets for [DATE] through present on [DATE] at 12:00 p.m. found Resident #50 was transferred with a mechanical lift with a total assistance of one (1) on the following occasions: -- Day Shift: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. -- Evening Shift: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. These findings were reviewed with the Director of Nursing (DON) on [DATE] at 9:10 a.m. and no further information was provided at the time of exit on [DATE] at 2:00 p.m. f) Resident #6 A review of Resident #6's medical record at 11:49 a.m. on [DATE] found a physician's orders [REDACTED]. The sliding scale provided was: - Blood Sugar 1 - 50 give zero (0) (Give [MEDICATION NAME]); - 51- 70 give zero (0) units; - 71 - 100 give minus four (4) units, - 101 - 150 give minus two (2) units, - 151 - 200 give plus one (1) unit, - 201 - 250 give plus two (2) units, - 251 - 300 give plus three (3) units, - 301 - 350 give plus four (4) units, - greater than 350 give plus five (5) units. This sliding scale coverage was to be given before meals and in accordance with a scheduled dose of [MEDICATION NAME] that she also received before meals. The scheduled dose of [MEDICATION NAME] before meals order directed staff to administer four (4) units before breakfast and lunch and to administer 8 units before dinner. The dosage of this medication was to be adjusted according to the sliding scale order, which was dependent on her finger stick blood sugar. Resident #6's dosage of [MEDICATION NAME] was to be adjusted with positive (more) or negative (fewer) units as directed by the sliding scale order. The resident's care plan was reviewed and found a problem statement of, I have diabetes. This problem statement had a goal of, I will be free of signs and symptoms of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] thru this quarter. The interventions related to this goal included, I will have my insulin and oral anti - diabetic medications administered as ordered and monitored for effectiveness or side effects. This intervention was added to Resident #6's care plan on [DATE]. Review of Resident #6's medication administration records (MAR) from [DATE] through present found the following dates and times on which Resident #6 received the wrong dosage of [MEDICATION NAME] insulin: - On [DATE] at dinner Resident #6's blood sugar was 253 and she received 8 units of [MEDICATION NAME] when she should have received 12 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 207 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 159 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at breakfast Resident #6's blood sugar was 215 and she received four (4) units of [MEDICATION NAME] when she should have received 6 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 195 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at lunch Resident #6's blood sugar was 191 and she received 6 units of [MEDICATION NAME] when she should have received 5 units. - On [DATE] at dinner Resident #6's blood sugar was 162 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 206 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 201 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at lunch Resident #6's blood sugar was 307 and she received 5 units of [MEDICATION NAME] when she should have received 8 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 220 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 220 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 168 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 306 and she received 8 units of [MEDICATION NAME] when she should have received twelve 12 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 172 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 313 and she received 8 units of [MEDICATION NAME] when she should have received 12 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 184 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at breakfast Resident #6's blood sugar was 201 and she received zero (0) units of [MEDICATION NAME] when she should have received six (6) units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 227 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 187 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 200 and she received 6 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 195 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 185 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 250 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 178 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 230 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 222 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 176 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 175 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 100 and she received zero (0) units of [MEDICATION NAME] when she should have received 4 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 122 and she received 8 units of [MEDICATION NAME] when she should have received 6 units of [MEDICATION NAME]. - On [DATE] at lunch Resident #6's blood sugar was 141 and she received seven (7) units of [MEDICATION NAME] when she should have received 2 units. - On [DATE] at dinner Resident #6's blood sugar was 215 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at lunch Resident #6's blood sugar was 197 and she received 4 units of [MEDICATION NAME] when she should have received 5 units. - On [DATE] at dinner Resident #6's blood sugar was 205 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 124 and she received 8 units of [MEDICATION NAME] when she should have received 6 units of [MEDICATION NAME]. - On [DATE] at lunch Resident #6's blood sugar was 159 and she received 2 units of [MEDICATION NAME] when she should have received 5 units. - On [DATE] at dinner Resident #6's blood sugar was 222 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 219 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 199 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 164 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 155 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 182 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 157 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 101 and she received zero (0) units of [MEDICATION NAME] when she should have received 6 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 175 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 274 and she received 8 units of [MEDICATION NAME] when she should have received 12 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 147 and she received 8 units of [MEDICATION NAME] when she should have received 6 units of [MEDICATION NAME]. - On [DATE] at breakfast Resident #6's blood sugar was 162 and she received two (2) units of [MEDICATION NAME] when should have received 5 units. - On [DATE] at dinner Resident #6's blood sugar was 168 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 164 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 177 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 98 and she received zero (0) units of [MEDICATION NAME] when she should have received 4 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 183 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 209 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 213 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. Further review of the MARs found that beginning on [DATE] the facility stopped documenting on the MARs how many units of insulin Resident #6 received. This continued from [DATE] through present; therefore, it could not be determined whether Resident #6 received the correct dosage of insulin as ordered by the physician. These findings were reviewed with the Assistant Director of Nursing (ADON) at 2:48 p.m. on [DATE]. She was asked to review the information and these findings, and to please provide any additional information she had. At the time of exit on [DATE] at 2:00 p.m,. the ADON had provided no further information. g) Resident #17 1. A review of the resident's care plan on [DATE] at 1:15 p.m. revealed the care plan for pressure ulcers was not revised to address the Stage 2 pressure ulcer on the resident's the right heel until [DATE]. The care plan stated, My nurse will apply Allevyn foam heel to my right heel and wrap with Kling every day. [DATE] at 2:18 p.m., when asked about the care plan for the pressure ulcer on the resident's right heel, the Assistant Director of Nursing stated, The care plan was not implemented because no treatment can be done with Cam boot in place. 2. Review of the care plan dated [DATE] found it included, My nurse will perform weekly observations of my right heel wound on Tuesdays. There was no evidence in the resident's medical record to show a nurse did weekly observations of the right heel wound on Tuesdays. The only observation reports found regarding the resident's right heel were for [DATE], [DATE], [DATE], and [DATE]. No other observation reports for the right heel wound were available. [DATE] at 2:18 p.m., the Assistant Director of Nursing again stated, No treatment can be done with Cam boot in place. h) Resident #43 A review of the electronic medical record, on [DATE] at 8:38 a.m., revealed Resident #43 was admitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 8:41 a.m., a review of a physician's orders [REDACTED]. A concurrent review of the care plan revealed an intervention dated [DATE], I will receive restorative nursing for passive range of motion and right hand splint. An observation of Resident #43, on [DATE] at 9:53 a.m., found no splint on the resident's right hand. The hand splint was located on the resident's bedside stand. This observation also revealed the resident's right hand contracted in a grip-like position. On [DATE] at 10:16 a.m., an interview with Restorative Nursing Aide (RNA) #58 revealed she had no knowledge of an order for [REDACTED]. In an interview with the Assistant Director of Nursing (ADON) on [DATE] at 10:20 a.m., the ADON explained when a resident was discharged from therapy the orders were entered into the electronic medical record by the nurses and then the order was sent to the ADON for review and clarification. The ADON searched the therapy orders and failed to find an order for [REDACTED]. The ADON reviewed the resident's physician's orders [REDACTED].

Based on observation, record review and staff interview the facility failed to provide necessary care and services for four (4) of eighteen (18) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The facility failed to ensure effective management of pain for Resident #12, an actively dying resident, resulting in a determination of actual harm. The facility failed to follow a physician's orders [REDACTED].#43, failed to follow the physician's orders [REDACTED].#6, and failing to provide effective diabetic management for Resident #51. Resident identifiers: #12, #43, #6, and #51. Facility census: 58. Findings include: a) Resident #12 During the Stage 1 initial tour of the facility, on [DATE] at 11:52:23 a.m., while observing the resident, she cried out. There was no visible stimulus that might have caused her to cry out. As a result of this observation, the resident was selected for further review for the care area of pain during Stage 2 of the survey. An observation on [DATE] at 2:44 p.m. found Nurse Aide (NA) #55 providing passive manipulation of Resident #12's right hand. When the NA extended the fingers of the resident's right hand, the resident cried out. When NA #55 extended the fingers of the resident's left hand, she cried out again. In an interview on [DATE] at 2:50 p.m., NA #55 revealed that she reported residents' experiencing pain to the nurse. When asked whether the nurse did anything about it when she reported a resident was having pain to the nurse, the NA said she was sure the nurses took care of things that were reported to them, but did not provide further detail. When informed of the resident's vocalization of pain on [DATE] at 2:59 p.m., Registered Nurse (RN) #26 said, She always does that. I know her. The nurse acknowledged the resident received a new order for [MEDICATION NAME] sulfate 0.25 milliliter (ml) to be administered every hour or as needed on [DATE], but the resident had not received any doses. Review of the resident's Medication Administration Record [REDACTED]. A record review revealed pain assessment conducted each shift on [DATE] and [DATE] found all of the assessments indicated the resident had no pain. During an interview on [DATE] at 9:48 a.m., the resident's son said the facility had called him that morning to stop her medications because she could not swallow. On [DATE] at 9:56 a.m., during an interview with Restorative Nurse Aide (RNA) #55, when asked if she reported the expressions of crying out to the charge nurse, the RNA replied, I didn't report it to the nurse. We all are aware of the moaning. The RNA added it was not relayed to the nurse, because everyone knows. When asked how did everyone know, the response was, Everyone knows (Resident's first name) decline. When asked how do you know her pain needs are being met, the RNA repied, I'm sure the nurse and the DON (Director of Nursing) knows. Everyone is careful with her care. We tell the nurse if the resident doesn't eat. A review of the resident's medical record on [DATE] at 10:00 a.m. found the resident was actively dying. The resident's care plan revealed an intervention dated [DATE] of, My nurse will administer narcotic pain medication once every hour as needed and monitor for effectiveness or any side effects. The first dose of [MEDICATION NAME] sulfate was not administered until [DATE] around 11:44 p.m. During an interview on [DATE] at 10:16 a.m., the Assistant Director of Nursing (ADON) stated, I would have expected her to use the sublingual ([MEDICATION NAME]) because the resident has trouble swallowing, at the point when she is crying when she is provided care. I want her to be comfortable as well. I agree to a point that she has a history of yelling out, but she is at the end stage of life. I feel like she needs to be comfortable, I feel like she should have had the [MEDICATION NAME]. The resident expired on [DATE]. The resident's annual comprehensive minimum data set assessment with an assessment reference date of [DATE] included [DIAGNOSES REDACTED]. Staff attributed her crying out as a demonstration of the residents' historical mode of communication (i.e. 'I know her .') instead of considering the resident was actively dying and assessing the resident's comfort needs. Additionally, the resident was no longer able to swallow medications, eliminating even the use of Tylenol. The physician ordered [MEDICATION NAME] for the resident's pain on [DATE], but it was not administered until [DATE] at 11:44 p.m. These findings led to a determination of actual harm. b) Resident #43 A review of the electronic medical record on [DATE] at 8:38 a.m. revealed Resident #43, admitted on [DATE], had [DIAGNOSES REDACTED]. On [DATE] at 8:41 a.m., review of a physician's orders [REDACTED]. A concurrent review of the care plan revealed an intervention dated [DATE], I will receive restorative nursing for passive range of motion and right hand splint. An observation of Resident #43 on [DATE] at 9:53 a.m., found no splint on the resident's right hand. The resident's hand was in a grip-like position. The hand splint was located on the resident's bedside stand. On [DATE] at 10:16 a.m., an interview with Restorative Nurse Aide (RNA) #58, revealed she had no knowledge of an order for [REDACTED]. In an interview with the Assistant Director of Nursing (ADON) on [DATE] at 10:20 a.m., the ADON explained when a resident was discharged from therapy the orders were entered into the electronic medical record by the nurses and then the order was sent to the ADON for review and clarification. The ADON searched the therapy orders and failed to find an order for [REDACTED]. The ADON reviewed the resident's physician's orders [REDACTED]. c) Resident #6 A review of Resident #6's medical record at 11:49 a.m. on [DATE] found a physician's orders [REDACTED]. The sliding scale provided was: - Blood Sugar 1 - 50 give zero (0) (Give [MEDICATION NAME]); - 51- 70 give zero (0) units, - 71 - 100 give minus four (4) units, - 101 - 150 give minus two (2) units, - 151 - 200 give plus one (1) unit, - 201 - 250 give plus two (2) units, - 251 - 300 give plus three (3) units, - 301 - 350 give plus four (4) units, - greater than 350 give plus five (5) units. This sliding scale coverage was to be given before meals and in accordance with a scheduled dose of [MEDICATION NAME] that she also received before meals. The scheduled dose of [MEDICATION NAME] before meals order directed staff to administer four (4) units before breakfast and lunch and to administer eight (8) units before dinner. The dosage of this medication was to be adjusted according to the sliding scale order, which was dependent on her finger stick blood sugar. Review of Resident #6's medication administration records (MAR) from [DATE] through present found the following dates and times on which Resident #6 received the wrong dosage of [MEDICATION NAME] insulin: - On [DATE] at dinner Resident #6's blood sugar was 253 and she received 8 units of [MEDICATION NAME] when she should have received 12 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 207 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 159 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at breakfast Resident #6's blood sugar was 215 and she received four (4) units of [MEDICATION NAME] when she should have received 6 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 195 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at lunch Resident #6's blood sugar was 191 and she received 6 units of [MEDICATION NAME] when she should have received 5 units. - On [DATE] at dinner Resident #6's blood sugar was 162 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 206 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 201 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at lunch Resident #6's blood sugar was 307 and she received 5 units of [MEDICATION NAME] when she should have received 8 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 220 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 220 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 168 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 306 and she received 8 units of [MEDICATION NAME] when she should have received twelve 12 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 172 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 313 and she received 8 units of [MEDICATION NAME] when she should have received 12 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 184 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at breakfast Resident #6's blood sugar was 201 and she received zero (0) units of [MEDICATION NAME] when she should have received six (6) units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 227 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 187 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 200 and she received 6 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 195 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 185 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 250 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 178 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 230 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 222 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 176 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 175 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 100 and she received zero (0) units of [MEDICATION NAME] when she should have received 4 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 122 and she received 8 units of [MEDICATION NAME] when she should have received 6 units of [MEDICATION NAME]. - On [DATE] at lunch Resident #6's blood sugar was 141 and she received seven (7) units of [MEDICATION NAME] when she should have received 2 units. - On [DATE] at dinner Resident #6's blood sugar was 215 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at lunch Resident #6's blood sugar was 197 and she received 4 units of [MEDICATION NAME] when she should have received 5 units. - On [DATE] at dinner Resident #6's blood sugar was 205 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 124 and she received 8 units of [MEDICATION NAME] when she should have received 6 units of [MEDICATION NAME]. - On [DATE] at lunch Resident #6's blood sugar was 159 and she received 2 units of [MEDICATION NAME] when she should have received 5 units. - On [DATE] at dinner Resident #6's blood sugar was 222 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 219 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 199 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 164 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 155 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 182 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 157 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 101 and she received zero (0) units of [MEDICATION NAME] when she should have received 6 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 175 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 274 and she received 8 units of [MEDICATION NAME] when she should have received 12 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 147 and she received 8 units of [MEDICATION NAME] when she should have received 6 units of [MEDICATION NAME]. - On [DATE] at breakfast Resident #6's blood sugar was 162 and she received two (2) units of [MEDICATION NAME] when should have received 5 units. - On [DATE] at dinner Resident #6's blood sugar was 168 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 164 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 177 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 98 and she received zero (0) units of [MEDICATION NAME] when she should have received 4 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 183 and she received 8 units of [MEDICATION NAME] when she should have received 9 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 209 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. - On [DATE] at dinner Resident #6's blood sugar was 213 and she received 8 units of [MEDICATION NAME] when she should have received 10 units of [MEDICATION NAME]. Further review of the MARs found that beginning on [DATE] the facility stopped documenting on the MARs how many units of insulin Resident #6 received. This continued from [DATE] through present; therefore, it could not be determined whether Resident #6 received the correct dosage of insulin as ordered by the physician. These findings were reviewed with the Assistant Director of Nursing (ADON) at 2:48 p.m. on [DATE]. She was asked to review the information and these findings, and to please provide any additional information she had. At the time of exit on [DATE] at 2:00 p.m,. the ADON had provided no further information. d) Resident #51 The medical record review for Resident #51 on [DATE] at 2:40 p.m. revealed the resident had blood sugar readings that were beyond the acceptable range established by the physician for 19 of 30 days in [DATE]. On [DATE] at 8:05 p.m., the blood sugar was 321 mg/dl (milligrams per liter- a unit of measurement of mass concentration that shows how many grams of a certain substance are present in one liter of a usually liquid of [MEDICATION NAME] mixture. - [DATE] at 8:30 p.m. blood sugar reading was 308 mg/dl - [DATE] at 8:37 p.m. blood sugar reading was 376 mg/dl - [DATE] at 8:01 p.m. blood sugar reading was 305 mg/dl - [DATE] at 8:46 p.m. blood sugar reading was 422 mg/dl - [DATE] at 10:38 p.m. blood sugar reading was 400 mg/dl - [DATE] at 8:22 p.m. blood sugar reading was 383 mg/dl - [DATE] at 7:46 p.m. blood sugar reading was 297 mg/dl - [DATE] at 7:55 p.m. blood sugar reading was 349 mg/dl - [DATE] at 7:46 p.m. blood sugar reading was 324 mg/dl - [DATE] at 8:11 p.m. blood sugar reading was 329 mg/dl - [DATE] at 8:00 p.m. blood sugar reading was 290 mg/dl - [DATE] at 8:55 p.m. blood sugar reading was 305 mg/dl - [DATE] at 8:04 p.m. blood sugar reading was 429 mg/dl - [DATE] at 9:10 p.m. blood sugar reading was 360 mg/dl - [DATE] at 4:17 p.m. blood sugar reading was 372 mg/dl - [DATE] at 8:03 p.m. blood sugar reading was 295 mg/dl - [DATE] at 3:56 p.m. blood sugar reading was 283 mg/dl - [DATE] at 8:02 p.m. blood sugar reading was 310 mg/dl - [DATE] at 8:05 p.m. blood sugar reading was 321 mg/dl Progress note review: A review of the resident's progress notes on [DATE] at 3:00 p.m. revealed: -[DATE] at 10:39 p.m. (typed as written) Rechecked fs of 400 from 422 earlier. relayed to nite nurse. - [DATE] at 12:12 p.m. (typed as written) (physician) visited reviewed f/s from past evening no new orders. - [DATE] at 8:31 p.m. - 8:05p faxed to the dr (doctor) of fs of 429 w/ 10 units of [MEDICATION NAME] given as scheduled. awaiting response. will check later. monitor. - [DATE] at 9:01 p.m. - (typed as written) Noted by (physician name) of bs (blood sugar) w (with)/ no order. checked fs (finger stick) of 360 mg/dl at 9:10 p.m notice res (resident) taking off her top and put back. awake at this time. - [DATE] - (typed as written) New order received from (Nurse Practitioner) to give 5 units [MEDICATION NAME] before evening meal everyday. POA (power of attorney) notified of new order. The resident had a care plan established on [DATE] for diabetes mellitus. The care plan goal with a target date of [DATE] stated, I will be free of signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] thru (through) this quarter. On [DATE] at 4:29 p.m., an interview with the director of nursing (DON) revealed the physician had established ,[DATE] mg/dl as an acceptable range for blood sugars for Resident #51. The DON said the physician had reviewed the resident's finger sticks on [DATE]. On [DATE] he reviewed the finger stick from [DATE]. On [DATE] a new order was written for the resident to receive 5 units of [MEDICATION NAME] before the evening meal everyday. The DON did not have any further information to provide for the additional days where the resident's blood sugar was outside the physician established acceptable parameters.

Based on review of the electronic medical record (EMR), observation, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for pressure ulcers during Stage 2 of Quality Indicator Survey (QIS) did not develop an avoidable pressure ulcer. The facility failed to implement care plan interventions to prevent an in-house acquired pressure ulcer on the right lateral heel for Resident #60 resulting in actual harm. In addition, the facility failed to promote the healing of a pressure ulcer for Resident #21 by not performing the dressing change as ordered by the physician and directed by the care plan. This was true for one (1) of three (3) residents reviewed for pressure ulcers during Stage 2 of the survey. Resident identifiers: #60 and #21. Facility census: 58. Findings include: a) Resident #60 On 08/02/16 at 8:12 a.m., an EMR review revealed Resident #60, admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. A concurrent review of the admission minimum data set (MDS), with an assessment reference date (ARD) of 11/03/15, revealed Resident #60 had a suspected deep tissue injury (SDTI) to the right heel and a reddened area to the coccyx when admitted . Review of the resident's care plan found interventions dated 10/27/15, to elevate the resident's heels off surfaces every shift and to maintain Allevyn heel protectors to bilateral heels every shift and change twice a week on shower days of Mondays and Thursdays. During an observation of Resident #60 on 08/02/16 at 11:11 a.m., with Licensed Practical Nurse (LPN) #42, the LPN lifted the sheets to observe the resident's feet, which were wrapped in gauze. The resident's feet were not elevated off the bed. When LPN asked why the resident's heels were not elevated, LPN #42 stated since this resident had received an air mattress on 05/06/16, her heels did not need to be elevated. In an interview with LPN #42 on 07/28/16 at 12:39 p.m., regarding a nurse's note she wrote at 07/28/16 at 6:00 a.m., she stated that after the resident was given a shower, two (2) small reddened areas were noted to the right outer aspect of the resident's right heel. Allevyn heel protectors were reapplied as per orders. An additional dressing change observation, on 08/02/16 at 1:44 p.m., revealed both feet wrapped with Kling (gauze dressing) with Allevyn heel protectors on both heels and the heels were not positioned off the bed. The Kling and Allevyn was removed without difficulty, however a 4x4 gauze was adhered to the outer aspect of the right heel. Upon removal of the 4x4, a scant amount of tan drainage was observed. LPN #42 stated, It's healed, it's just dry skin and scabbed. However, LPN #42 agreed there were four (4) small open areas on the outer aspect of the right heel with a scant amount of brown drainage on the 4x4. On 08/02/16 at 1:58 p.m., during an interview with the Director of Nursing (DON), the observation of Resident #60's heels made on 08/02/16 at 11:30 a.m. was discussed. The DON was informed this resident had a care plan that indicated her heels would be elevated off all surfaces and two (2) observations revealed this had not occurred. The DON was also informed that LPN #42 stated since the air mattress had been applied, the resident's heels did not need elevated. The DON had no comment at that time regarding this information. In addition, when informed of the additional breakdown with drainage on the outer aspect of the resident's right heel, the DON had no comment. A request was made of the DON for any additional information regarding the development of an avoidable pressure ulcer on the outer aspect of the right heel. She stated all information had been provided, but she would look for additional evidence. No additional evidence was provided prior to exiting the facility on 08/04/16. The development of new pressure ulcers for a resident known to be at risk combined with the failure to implement established care plan interventions resulted in a determination of actual harm. b) Resident #21 On 07/26/16 at 3:50 p.m. a review of the medical record reveals a care plan with a planned approach dated 07/20/16 that read: My nurse will cleanse my sacral, right and left buttocks with normal saline solution and pack these areas with [MEDICATION NAME] AG and cover with Dermadress every day and as needed. On 07/27/16 at 9:20 p.m. observation of wound care for Resident #21 revealed a wound to the buttock area with exposed packing and dressing partially intact. Registered Nurse (RN) #26 removed soiled dressing, did not cleanse wound and applied new dressing covering the wound. On 07/27/16 at 9:40 p.m. an interview with RN #26 revealed her acknowledgement that she did not clean the wound. RN #26 stated, I was told I didn't have to do that, day shift cleans it. But It was not yucky. On 07/28/16 at 10:15 a.m. an interview with the Assistant Director of Nursing (ADON) included the notification of the observation of treatment change for Resident #21 that occurred on 07/27/16 at 9:40 p.m. performed by RN #26. The ADON was asked to explain the facilitys' expectation of providing Resident #21's wound care. The ADON stated, I expect that if a treatment is soiled, I expect them to apply the whole treatment, including cleaning the wound as ordered.

Based on observations, staff interviews, and a review of the Centers for Medicare and Medicaid (CMS) State Operations Manual, the facility failed to ensure the resident environment was as free as possible of accident hazards, over which it had control. Hot water temperatures were too high in resident rooms and common areas, creating a potential for serious injury to residents. The facility was not routinely checking water temperatures, and staff stated they had no means to do so. Affected areas included rooms #113, #114, and #206, and shower rooms on the 100 and 200 hallways. This resulted in a determination of immediate jeopardy (IJ). The facility was also observed with unlocked soiled utility closets which contained chemicals and other potentially hazardous items. The medication room was observed propped open and unattended, creating yet another accident hazard due to the various potentially hazardous supplies in that room. These practices had the potential to affect more than an isolated number of residents. At the time of the discovery, the facility's census was 64 residents. On [DATE] at 3:00 p.m., the hot water temperature in Room #113 was checked and registered 127 degrees Fahrenheit (F). At 3:05 p.m. the hot water temperature in Room #114 was 124 degrees (F). In the 100 hall shower room sink the hot water temperature registered 124.6 degrees (F) at 3:10 p.m., and the 200 hall shower room sink had a temperature of 120.4 degrees (F). At 3:55 p.m. the temperature of the hot water in the sink of Room #206 registered 125 degrees (F). When informed the water temperatures felt hot, Maintenance Employee #9 said he could not find anything to test the water, and asked to borrow one of the surveyor's thermometers. It was learned he did not have a thermometer to test the water temperatures, and had not tested water temperatures for "about 3 weeks." On [DATE] at 4:00 p.m., the Administrator was notified of an immediate jeopardy (IJ) due to hot water temperatures with no method to monitor water temperatures in resident areas. Corrective action was immediately implemented. Maintenance Employee #9 began draining the water out of the lines, at 4:00 p.m. on [DATE], by allowing the water in the showers to run. Employee #9 also adjusted the mixing valve. This allowed water to start circulating through a valve at a reduced temperature. The administrator assisted in this process and monitored temperatures to determine if they were going down. The Administrator provided an acceptable plan of correction on [DATE] at 6:40 p.m. The plan indicated the facility would do the following: "Maintenance personnel will monitor for water temperatures on a weekly basis at 2:00 p.m. to ensure water temperature is maintained at ,[DATE] degrees. The water temperatures will be monitored daily for the next two weeks then weekly thereafter. Water temperature will be checked on each hallway in random resident rooms. The room number and water temperature will then be documented on the Maintenance Log and initialed by the maintenance personnel completing the check. If the temperature does exceed 110 degrees the hot water will be adjusted immediately, the valves will be turned off and the water temperature will be checked at 30 minute intervals until it reaches an acceptable level. The nursing department will be notified if the temperature exceeds 110 degrees so that resident safety can be monitored until water temperatures are at 110 degrees or below. All staff will be inserviced within the next 24 hours on the location of thermometers available to check water temperatures as well as the policy and procedure regarding water temperature monitoring. The administrator will ensure that the logs are completed and water temperatures are within acceptable limits." The water temperatures were found within acceptable limits on [DATE] at 5:28 p.m. The facility provided evidence of the existence of thermometers. Evidence was also provided that all maintenance personnel were in-serviced, on [DATE] between 4:00 p.m. and 6:00 p.m., regarding the procedures to ensure safe hot water temperatures for residents. Surveyors continually monitored water temperatures as the facility worked toward getting the temperatures lowered and maintained at safe levels. Facility nursing personnel, who were present when the IJ was identified, were in-serviced on the need to monitor hot water and the location of a thermometer with which to measure the water temperatures. Observation revealed a communication form at the nurses' station regarding monitoring of hot water. The facility had a plan in place to provide the necessary information to all other nursing personnel as they came on shift, until all staff were educated on ensuring acceptable hot water temperatures. On [DATE] at 6:40 p.m., the immediacy of this deficient practice was abated. No deficient practice remained relative to the hot water; however, a deficient practice still remained relative to unsecured access to utility rooms and a medication room which contained potentially hazardous items. The scope and severity was reduced from a "K" to an "E." Findings include: a) Hot Water 1. On [DATE] at 3:00 p.m. the temperature of the hot water in the sink of Room #113 registered 127 degrees F. At 3:05 p.m. the temperature of the hot water in the sink of Room #114 was 124.9 degrees F. At 3:10 p.m. the 100 hall shower room sink had a hot water temperature of 124.6 degrees F and the 200 hall shower room sink had a hot water temperature of 120.4 degrees F. At 3:30 p.m., Room #114 had a hot water temperature of 125.2 degrees F and Room #206 had a hot water temperature of 125 degrees F. 2. According to Table 1 in the Guidance to Surveyors related to comfortable/safe water temperatures, in Appendix PP of the CMS State Operations Manual, a third (3rd) degree burn can occur at 120 degrees F with exposure of five (5) minutes. A third degree burn can occur at 124 degrees F with an exposure of three (3) minutes. A third degree burn can occur at 127 degrees F with an exposure time of one (1) minute. Burns can occur even at water temperatures below that level depending on the exposed individual's condition and the length of exposure. 3. At 3:30 p.m. on [DATE], Maintenance Employee #9 said he did not have a thermometer to take water temperatures. He said he could not find the thermometer that he used to take water temperatures. Employee #9 said he had not taken water temperatures in resident rooms in "about three (3) weeks." Employee #9 said he looked at the valves on the water heaters to determine the water temperature. 4. The administrator provided a copy of the logs used by maintenance staff. The logs were provided for a six (6) month period. The logs contained a section which allowed the maintenance staff to check a box if the weekly water temperature was below 110 degrees. The log did not require the maintenance staff to record the actual water temperature nor did it specify water temperatures be taken in resident rooms. On [DATE] at 3:30 p.m., the administrator said he thought maintenance personnel were recording actual temperatures in resident rooms. He said that was the procedure he expected them to follow. The administrator said maintenance personnel had never informed him they did not have a thermometer to take water temperatures. 5. On [DATE] at 10:10 a.m. an observation at the nursing desk on ,[DATE] hall revealed a sign which told the nursing staff that thermometers to test water temperatures were located in the medication room. Employee #24 (licensed practical nurse) said she did not know anything about a thermometer to check water temperatures. The medication room was checked by Employee #24 and the administrator and a thermometer was not located. The assistant director of nursing located the thermometer on a piece of paper at the desk at 10:20 a.m. . b) Other Potential Accident Hazards 1. The initial tour of the facility on [DATE] at 11:00 a.m., revealed the soiled utility closets on the 100 and 200 Hallways were unlocked. The clean utility closet on the 200 Hallway was also unlocked. All three (3) closets contained cleansing wipes and sanitary cleaning solution. The two soiled utility closets contained soiled linens, used sharps containers, and trash. In an interview on [DATE] at 11:05 a.m., Employee #79 (registered nurse-RN) stated the soiled and clean utility closets were to be locked at all times. The RN stated he would ensure the closets were locked and remained that way. 2. A random observation, on [DATE] at 11:45 a.m., revealed the door to the 300 Hallway medication room was propped open. The room contained medications, chemical cleansing wipes, Drug Buster solution (a solution used for disposing of unused or expired pharmaceuticals), and an unlocked treatment cart. The treatment cart contained multiple treatment creams and wound care supplies. There were no staff members in sight during this observation. An interview with Employee #66 (licensed practical nurse-LPN), on [DATE] at 11:50 a.m., revealed the medication room was to be locked at all times. The LPN stated the treatment cart was also to be locked at all times. .