Every finding on record at Old Brownlee Community Care Center

Based on record review, observation and interviews, the facility failed to ensure the resident's environment remained free of accident hazards by failing to ensure a quarterly Safe Smoking Assessment had been completed for 1 (#37) of 1 (#37) resident reviewed for smoking with severe cognitive impairment. Findings: Review of the facility's Smoking Policy dated 10/25/2022 revealed in part: 1.1 Purpose: To establish guidelines for safe smoking practices for residents, visitors, and employees. 1.5 Policy: ______ facility buildings are smoke-free. Smoking, including use of any tobacco products, such as vaping and/or electronic cigarettes are permitted only in outdoor designated smoking areas. Visitors and residents are not permitted to give or leave smoking paraphernalia with any resident. All smokers, including those who use e-cigarettes, will be assessed for risk factors that could determine a resident as an unsafe smoker and desire for smoking cessation on admission, quarterly, with significant change in status, and as needed by the IDT (Interdisciplinary Team). The IDT shall identify unsafe smoking practices and implement intervention(s) specific to the resident. The IDT will document the unsafe practices and interventions on the care plan. Unsafe smokers are not allowed in designated smoking areas without the determined supervision by the IDT. Smoking materials will be maintained by the nursing staff or other designated personnel for all unsafe smokers. 4. Assess the resident's ability to smoke safely by completing the Assessment for Safe Smoking UDA (User Defined Assessments) located in the electronic health record on each assessment and on each new onset. The assessment shall cover the resident's safety awareness, judgment, cognitive ability, and manual dexterity. 5. Identify an Unsafe Smoker in the electronic health record. 8. For all smokers who are on oxygen (O2) therapy, remove oxygen (tank or concentrator) at least 10 feet from the designated smoking are. 9. Staff will label all smoking materials belonging to the unsafe smoker and keep at the nurses station/team rooms. Return smoking materials to proper storage location following supervised smoking. Resident #37 was admitted to the facility on [DATE] with a re-entry date of 04/21/2025 and had diagnoses including, but not limited to vascular dementia, unspecified severity, without behavioral disturbance and Alzheimer's disease. Review of Resident #37's quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed in part, Resident #37 had a BIMS (Brief Interview for Mental Status) score of 05 indicating severely impaired cognition. Further review of Resident #37's quarterly MDS revealed Resident #37 received oxygen therapy. Review of Resident #37's medical record failed to reveal a quarterly Assessment for Safe Smoking was completed on 04/27/2025 at the time of Resident #37's MDS assessment. Review of Resident #37's medical record revealed a nursing note dated 05/02/2025 which read in part, Resident #37 requesting to smoke . reported by floor nurse that daughter took Resident #37's cigarettes home with her and instructed staff not to give Resident #37 cigarettes. An observation on 07/07/2025 at 9:30 a.m. revealed Resident #37 asleep in bed with O2 infusing at 2L (liter) per nasal cannula. Further observation revealed a pack of cigarettes and a lighter sitting on Resident #37's over bed table adjacent to Resident #37. During an interview on 07/07/2025 at 9:40 a.m. S5CNA (Certified Nursing Assistant) reported residents on oxygen should not have smoking materials in their room. During an interview on 07/07/2025 at 9:45 a.m., S4LPN (Licensed Practical Nurse) confirmed Resident #37's cigarettes and lighter were on his over bed table and Resident #37 was currently receiving oxygen therapy. S4LPN reported Resident #37 was an unsafe smoker due to a recent decline and needed to be reassessed for smoking safety. S4LPN reported Resident #37's cigarettes and lighter should not have been left at his bedside with oxygen therapy in use. During an interview on 07/08/2025 at 2:45 p.m., S3MDS Coordinator reported a Safe Smoking Assessment should be performed on admission, quarterly, annually, and with any significant change. S3MDS Coordinator acknowledged Resident #37 did not have a quarterly Safe Smoking Assessment in April of 2025 and the assessment should have been performed on 04/27/2025 with the quarterly MDS. During an interview on 07/09/2025 at 8:30 a.m., S3MDS Coordinator acknowledged Resident #37 had a BIMS score of 05 on the 04/27/2025 MDS assessment and had severe cognitive impairment. S3MDS Coordinator reported residents with severe cognitive impairment would be an unsafe smoker and need supervision. During a telephone interview on 07/09/2025 at 8:50 a.m., Resident #37's RP (Responsible Party) reported when Resident #37 returned from the hospital in April of 2025 she informed the staff, she did not want Resident #37's smoking materials stored in his room because of his dementia.

Based on record review, observations and interviews, the facility failed to ensure a resident had a physician's order in place and had been care planned for the use of side rails for 1 (#30) of 2 (#30 and #34) residents reviewed for bed rails. Findings: Review of the facility's Bed/Side Rails policy dated 11/28/2017 revealed in part: Policy: Even when bed rails are compatible with the bed and mattress, are properly designed to reduce the risk of entrapment or falls, and are used appropriately, they still can be hazardous for certain individuals, particularly to people with physical limitations or altered mental status, such as dementia or delirium. Side rails should only be used to improve a person's functional abilities, such as repositioning and to aid in getting out of bed . Bed rails requires a physician order and the order must state the reason for bed rail use. The use of bed rails must be added to the plan of care and reviewed at least quarterly and with significant change by the IDT (Interdisciplinary Team). The plan of care shall be consistent with the resident's specific conditions, risks, needs, behaviors, preferences, current professional standards of practice, and included measurable objectives and timetables, with specific interventions/services for use of the bed rails. Resident #30 was admitted to the facility on [DATE] with a re-entry date of 03/21/2025 and had diagnoses including, but not limited to, peripheral vascular disease and heart failure. Review of Resident #30's quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed in part, Resident #30 had a BIMS (Brief Interview for Mental Status) score of 12, indicating moderately impaired cognition. Review of Resident #30's quarterly Restraint Safety Device Elimination assessment dated [DATE] revealed Resident #30 utilized side rails for turning and repositioning while in bed. Review of Resident #30's medical record failed to reveal a physician's order for the use of side rails. Review of Resident #30's comprehensive care plan failed to revealed Resident #30 had been care planned for the use of side rails. An observation on 07/07/2025 at 9:30 a.m. revealed Resident #30 sitting in bed with upper quarter side rails in use bilaterally. An observation on 07/08/2025 at 8:00 a.m. revealed Resident #30 awake in bed with upper quarter side rails in use bilaterally. During an interview on 07/08/2025 at 8:00 a.m., Resident #30 reported he uses the upper side rails to position in bed. During an interview on 07/08/2025 at 4:00 p.m., S8CNA (Certified Nursing Assistant) acknowledged Resident #30 had upper quarter side rails in use and reported Resident #30 used the side rails for mobility. During an interview on 07/08/2025 at 4:15 p.m., S9LPN (Licensed Practical Nurse) acknowledged Resident #30 did not have a physician's order for the use of upper side rails and had not been care planned for the use of side rails. During an interview on 07/08/2025 at 4:20 p.m., S3MDS Coordinator, acknowledged Resident #30 had not been care planned for the use of bed rails and should have been. During an interview on 07/08/2025 at 4:30 p.m., S2DON (Director of Nursing) acknowledged Resident #30 did not have a physician's order in place for the use of side rails.

Based on observation, record review, and interview the facility failed to ensure an infection prevention and control program was maintained to help prevent the development and transmission of communicable diseases and infections for 1 (#53) of 1 (#53) resident observed for wound care. Findings: Review of the facility's Wound Care policy dated 01/09/2022 revealed in part: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. A clean technique is used for routine pressure ulcer dressing changes, unless otherwise ordered by the physician. Review of Resident #53's medical record revealed an admission date of 03/02/2022 with diagnoses that included, in part, Stage 3 sacrococcygeal pressure wound, unpecified protein-calorie malnutrition, nutritional anemia, heart failure, and Alzheimer's disease. Review of Resident #53's medical record revealed a physician order dated 06/15/2025: Cleanse Stage 3 pressure ulcer to coccyx with wound cleanser. Pat dry. Apply skin prep to periwound. Allow to dry. Apply Triad hydrophilic wound drg (dressing) to periwound. Apply Medihoney to wound bed. Cover with Medihoney and calcium alginate ag+ (silver) and wound drg daily until resolved - one time a day. Review of Resident #53's medical record revealed a care plan for Stage 3 pressure ulcer to sacrococcygeal with interventions that included, in part, follow facility policies/protocols for the prevention/treatment of skin breakdown. Observation of Resident #53's wound care to sacrococcygeal wound on 07/09/2025 at 8:50 a.m. revealed S6 Treatment Nurse adjusted her face mask with her right hand and failed to change her gloves prior to applying skin prep and prior to using fingers of the same hand to apply Triad cream to the periwound. During an interview on 07/09/2025 at 11:50 a.m. S6 Treatment Nurse reported she did not remember touching her mask and continuing wound care with the same gloves during Resident #53's wound care. S6 Treatment Nurse further reported gloves should have been changed after touching her mask during wound care.

Based on record review, observation and interviews, the facility failed to provide services that met professional standards for 1 (#387) of 31 sampled residents. The facility failed to ensure safe medication administration practices by leaving medication at the bedside. Findings: Review of the facility's Self-Administration of Medications policy with a revision date of November 2014 revealed in part: Residents that request to self-administer have the right to do so if the interdisciplinary team has determined self-administration is clinically safe and appropriate Policy Interpretation and Implementation 5. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them. 6. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. Review of the facility's Storage of Medications policy with a revision date of November 2020 revealed in part: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 5. Hazardous drugs are clearly marked and stored separately from other medications 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Review of Resident #387's medical record revealed an admission date of 07/02/2025 with diagnoses which included, in part, acute on chronic systolic (congestive) heart failure, acute and chronic respiratory failure with hypoxia, unspecified urinary incontinence, other idiopathic peripheral autonomic neuropathy, and other chronic pain. Review of Resident #387's medical record revealed an order dated 07/03/2025 for Lidocaine external cream 4%, apply to both knees and back topically as needed for pain. Further review of Resident #387's record failed to reveal a physician's order for self-administering medication Review of Resident #387's progress note by social services dated 07/02/2025 revealed a BIMS (Brief Interview for Mental Status) score of 13, indicating intact cognition. An observation on 07/07/2025 at 8:20 a.m. revealed 4% Lidocaine External cream on the bedside table in Resident #387's room. During an interview on 07/07/2025 at 8:20 a.m. Resident #387 reported Lidocaine medication cream (4% Lidocaine with Lavender essential oil) had been on her bedside table since yesterday. During an interview on 07/07/2025 at 9:25 a.m. S7 LPN (Licensed Practical Nurse) confirmed Resident #387 had an order for 4% Lidocaine cream, as needed for pain, but not an order to self-administer. S7 LPN confirmed the lidocaine cream should have been locked in the medication cabinet.

Based on record review, observation, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection by failing to ensure staff donned proper Personal Protective Equipment (PPE) when performing high-contact resident care for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents with Enhanced Barrier Precautions (EBPs) in place. Findings: Review of the facility's Enhanced Barrier Precautions policy with a revision date of April 2024 revealed in part: Policy Statement: Enhanced barrier precautions are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation: 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room). 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: h. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and chronic venous stasis ulcers. Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses including, in part, unspecified fracture of the thoracic 11-12 vertebra, type 2 diabetes, and depression. Review of Resident #2's Physician orders revealed in part: 01/20/2025 Enhanced Barrier Precautions. 02/11/2025 Calcium Alginate-Silver External Pad 6 (Calcium Alginate-Silver) Apply to spine (surgical) topically every day shift, every Monday, Wednesday, Friday for wound healing, clean surgical site with wound cleaner and pat dry, skin prep and allow to dry, apply gel fiber silver to wound bed, cover with gauze, secure with super absorbent dressing. Observation of wound care for Resident #2 on 04/02/2025 at 10:00 a.m. by S3Treatment Nurse and assisted by S4CNA (Certified Nursing Assistant) revealed in part, S3Treatment Nurse and S4CNA failed to don a ppe gown in preparation for wound care. S3Treatment Nurse removed the dressing from the surgical site of the spine and applied wound cleanser prior to donning a ppe gown. Further observation revealed S4CNA assisted S3Treament Nurse by holding a clean dressing in place, while not wearing a ppe gown. During an interview on 04/02/2025 at 10:05 am. S3Treatment Nurse acknowledged she and S4CNA had not donned a ppe gown prior to wound care and should have. During an interview on 04/03/2025 at 3:30 p.m., S2DON (Director of Nursing) acknowledged a ppe gown should be worn during wound care.

Based on record review and interviews, the facility failed to protect 5 (#1, #2, #3, #4, #5) of 5 sampled residents investigated for abuse from the potential of further abuse during the investigation process of an allegation of physical abuse. The facility failed to remove S6 CNA (Certified Nursing Assistant) from duties involving resident care after Resident #1 alleged S6 CNA had hit him. This deficient practice had the potential to affect all of the residents in the building. Findings: Abuse Components Plan Elder Justice Act and Affordable Care Act (Original effective date 09/11/2018, Revision #5 effective date 10/24/2022) in part: The Administrator or designee will immediately ensure that any further potential abuse, neglect, exploitation or mistreatment is prevented. If the alleged perpetrator is an employee or staff member, the individual is immediately reassigned to duties that do not involve resident contact or are suspended until the findings of the investigation have been reviewed by the Administrator or their designee. Immediately means as soon as possible, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Review of Resident #1's record revealed an admitted [DATE] and diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, generalized weakness, unspecified anxiety disorder, major depressive disorder, contracture left shoulder, left forearm, left hand, and left knee. Review of Resident #1's Significant Change MDS (Minimum Data Set) assessments with ARD (Assessment Reference Date) of 04/01/2024 revealed the resident had a BIMS score (Brief Interview for Mental Status) of 5 out of 15 indicating severe cognitive impairment. Further review of Resident #1's functional status revealed the resident was totally dependent on staff for activities of bed mobility, transfers, and toileting, with functional limitations in range of motion on one side for upper and lower extremities. Review of incident report for Resident #1 dated 04/10/2024 at 00:20 a.m. by S4 LPN (Licensed Practical Nurse) revealed in part: Writer was about to enter another resident room. Heard S6CNA come out Resident #1's room yelling I'm not scared of him he not going to swing on me. Writer asked what happened and she said you better go talk to him. I'm not S8 CNA. Writer entered room noticed Resident #1's right nostril bleeding with two abrasion above upper lip. When asking resident what happened he stated she beat me up and I don't want her in my room Writer ask what happened he stated she jumped me and beat me up I want to speak with S3 ADON (Assistant Director of Nursing) she can't come in here no more Writer advised S6 CNA not to go in room. Immediate Action Taken: S6 CNA notified to not enter resident room anymore until situation is cleared. Review of Resident #1's Nursing Note by S7 Hospice RN (Registered Nurse) revealed in part: S3 ADON (Assistant Director of Nursing) reported to hospice RN that there was an allegation of abuse with this patient which occurred the night of 04/09/2023, and it was reported that a CNA had hit patient and caused patient to have a bloody nose and scratches on his face. During an interview on 04/22/2024 at 9:52 a.m. Resident #1 was asked if any staff members were mean to him or had hurt him making his nose bleed. Resident #1 replied I don't know anything about that, the nurses know. During a repeat interview on 04/23/2024 at 11:38 a.m. Resident #1 said he remembered telling this surveyor yesterday that he didn't know anything about anyone hitting him. He then smiled and laughed and said S6 CNA stood on my right side then moved to my left side and started hitting me in the nose and it bled. During an interview on 04/23/2024 at 6:21 a.m. S4 LPN indicated she did not send S6 CNA home after Resident #1 alleged she hit him on 04/09/2024 because she didn't know she should have. S4 LPN further reported she just told S6 CNA not to go back in Resident #1's room, and she swapped assignments with another CNA. During an interview on 04/23/2024 at 6:41 a.m. S5 LPN indicated she was working with S4 LPN on the night of 04/09/2024. S5 LPN indicated S4 LPN had asked her to witness her assessment of Resident #1 after he alleged S6 CNA had hit him and made his nose bleed. S5 LPN reported when she entered Resident #1's room on 04/09/2024 at around midnight his nose was bleeding and he told her the bitch jumped on me and punched me in the face, and S6 CNA was immediately told not to go back in the room. S5 LPN reported she and S4 LPN were told by S2 DON during a phone call on 04/10/2024 at around 6:30 a.m. that they should have immediately suspended S6 CNA and sent her home as soon as they learned of Resident #1's allegations. S5 LPN reported they did not know they should have sent S6 CNA home, and had only removed her from working with Resident #1. During an interview on 04/23/2024 at 8:05 a.m. S6 CNA reported when she went in to check on Resident #1 on 04/09/2024 a little before midnight he was wet, but when I told him I needed to change him he started swinging his right arm all over the place. I went ahead and changed him and then left the room to tell the nurse he was swinging at me and she needed to check on him, and then I went to check on another resident. S4 LPN came back out and told me Resident #1's nose was bleeding, and he said I had hit him. She told me not to go back in his room, then she went and got S5 LPN from the other hall. S6 CNA confirmed she swapped care of Resident #1 with another CNA and continued to work with other residents until she was suspended at around 7:00 a.m. on 04/10/2024. During an interview on 04/22/2024 at 11:21 a.m. S2 DON (Director of Nursing) Indicated S4 LPN (Licensed Practical Nurse) tried to call her on 04/10/2024 at 1:01 a.m., but she was asleep and did not answer the call. When she woke up the morning of 04/10/2024 and saw she had a missed call, she called the nurse back at 6:32 a.m. S4 LPN told her S6 CNA came out of Resident #1's room at around midnight saying he's not gonna talk to me like I'm S8 CNA. S4 LPN conveyed to her she went into Resident #1's room and his nose was bleeding and he was saying S6 CNA had hit him. S4 LPN reported she told S6 CNA not to go back into Resident #1's room. I asked her if she had contacted S1 Administrator when she couldn't reach me, and she had not, so we added S1 Administrator to the call and explained to her what was going on. I told them S6 CNA needed to go home, and she was suspended pending investigation. S2 DON further confirmed S6 CNA had been allowed to continue her shift with resident care and should not have been. S1 DON indicated S6 CNA should have been suspended immediately pending the outcome of the investigation. During an interview on 04/22/2024 at 3:15 p.m. S1 Administrator confirmed S6 CNA should have been suspended immediately after staff was notified of Resident #1's allegation of abuse and was not. S1 Administrator further confirmed S6 CNA was allowed to continue working with residents for the remainder of her shift and should not have been.

Based on record reviews, policy reviews, and interviews, the facility failed to ensure an allegation of physical abuse was reported to the State Agency within the required timeframe for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents. Findings: Review of the facility's Abuse Components Plan Elder Justice Act and Affordable Care Act (Original effective date 09/11/2018, Revision #5 effective date 10/24/2022) policy revealed in part: All alleged violations involving abuse will be reported by the Administrator or designee to the Statewide Incident Tracking System (SIMS) (required) .All alleged violations involving abuse will be reported immediately, but no later than Two (2) hours if the alleged violation involves abuse. Immediately means as soon as possible, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Review of Resident #1's record revealed an admitted [DATE] and diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, generalized weakness, unspecified anxiety disorder, major depressive disorder, contracture left shoulder, left forearm, left hand, and left knee. Review of Resident #1's Significant Change MDS (Minimum Data Set) assessments with ARD (Assessment Reference Date) of 04/01/2024 revealed the resident had a BIMS score (Brief Interview for Mental Status) of 5 out of 15 indicating severe cognitive impairment. Further review of Resident #1's functional status revealed the resident was totally dependent on staff for activities of bed mobility, transfers, and toileting, with functional limitations in range of motion on one side for upper and lower extremities. Review of incident report for Resident #1 dated 04/10/2024 at 00:20 a.m. by S4 LPN (Licensed Practical Nurse) revealed in part: Writer was about to enter another resident room. Heard S6 CNA come out Resident #1's room yelling I'm not scared of him he not going to swing on me. Writer asked what happened and she said you better go talk to him. I'm not S8 CNA. Writer entered room noticed Resident #1's right nostril bleeding with two abrasion above upper lip. When asking resident what happened he stated she beat me up and I don't want her in my room Writer ask what happened he stated she jumped me and beat me up I want to speak with S3 ADON she can't come in here no more Writer advised S6 CNA not to go in room. Review of Resident #1's Nursing Note by S7 Hospice RN (Registered Nurse) revealed in part: S3 ADON (Assistant Director of Nursing) reported to hospice RN that there was an allegation of abuse with this patient which occurred the night of 04/09/2023, and it was reported that a CNA had hit patient and caused patient to have a bloody nose and scratches on his face. Review of the Statewide Incident Tracking System report revealed the allegation was not reported to the State Agency until 04/10/2024 at 7:35 a.m. During an interview on 04/22/2024 at 9:52 a.m. Resident #1 was asked if any staff members were mean to him or had hurt him, making his nose bleed. Resident #1 replied I don't know anything about that, the nurses know. During a repeat interview on 04/23/2024 at 11:38 a.m. Resident #1 said he remembered telling this surveyor yesterday that he didn't know anything about anyone hitting him. He then smiled and laughed and said S6 CNA stood on my right side then moved to my left side and started hitting me in the nose and it bled. During an interview on 04/22/2024 at 3:15 p.m. S1 Administrator indicated the State Agency was not notified via the SIMS system of Resident #1's allegation of abuse until 04/10/2024 at 7:35 a.m. S1 Administrator confirmed the State Agency should have been notified within 2 hours of staff becoming aware of the allegation of abuse and was not.

Based on observations, record reviews, and interviews the facility failed to maintain a medication error rate of less than 5% for 2 (#21, #48) residents out of 4 (#21, #48, #16, #70) residents observed during the medication administration. A total of 26 opportunities were observed which included 2 medication errors with Residents #21 and #48, for a medication error rate of 7.69%. Findings: Observation of medication administration on 07/17/2023 at 4:15 p.m. revealed S1 LPN (licensed practical nurse) retrieved a bottle of house stock Calcium 600 mg (milligrams)/ Vitamin D 10 mcg (microgram) from medication cart and administered Resident #21 Calcium 600 mg (milligrams)/ Vitamin D 10 mcg. Review of Resident #21's July 2023 Physician Orders revealed an ordered dated 04/04/2023 for Calcium 600mg/ Vitamin D 200 mg. Observation of medication administration on 07/18/2023 at 8:15 a.m. revealed S2 LPN retrieved a bottle of house stock Calcium 600 mg/ Vitamin D 10 mcg from medication cart and administered Resident #48 Calcium 600 mg/ Vitamin D 10 mcg. Review of Resident #48's July 2023 Physician Orders revealed an order dated 05/18/2021 and revised on 12/16/2022 for Calcium 600 mg/ Vitamin D 200 mg. During an interview on 07/18/2023 at 11:15 a.m. S2 LPN observed medication cart (1) and medication room (1) and confirmed house stock available was Calcium 600 mg/ Vitamin D 10 mcg. During an interview on 07/18/2023 at 11:30 a.m. S3 LPN reviewed Resident #21 and Resident #48's July 2023 Physician Orders for Calcium 600mg/ Vitamin D 200 mg, then observed medication cart (1) and medication cart (2) and found Calcium 600 mg/ Vitamin D 10mcg. S3 LPN confirmed correct dosage of Calcium/ Vitamin D supplement was not available on medication cart or medication storage therefore medication administered was incorrect.

Based on observations, record reviews and interviews the facility failed to provide the necessary care and services in accordance with accepted professional standards of practice for 4 (#3, #20, #52, #192) out of 5 (#3, #20, #52, #192, #193) residents reviewed for respiratory care. The facility failed to ensure: 1. Humidification bottles and oxygen tubing were changed, dated, and initialed weekly for Residents #3, #20 and #52. 2. Oxygen tubing was changed, dated, and initialed weekly for Resident #192. Findings: Review of the facility's Departmental (Respiratory Therapy) - Prevention of Infection policy revealed in part: Purpose - The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment . Steps in Procedure - . 3. Mark bottle with date and initials upon opening . 7. Change the oxygen cannulae and tubing every seven (7) days, or as needed. Resident #3: Review of Resident #3's medical record revealed an admitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - an order dated 6/24/2022 which read: Clean filters, change, date and initial on tubing every Sunday. - an order dated 6/1/2022 which read: Change out sterile water and O2 (oxygen) tubing every Sunday night. - an order dated 4/26/2021 which read: Oxygen at 2 liters (L) per nasal cannula continuous. Observation on 6/27/22 at 2:25 pm revealed Resident #3's humidification bottle was dated 06/19/2022. Further observation revealed resident #3's O2 tubing was not labeled with a date or initialed. During an interview on 6/27/2022 at 2:25 pm S3 LPN (Licensed Practical Nurse) acknowledged Resident #3's humidification bottle was outdated and should have been changed on Sunday, 6/26/2022 and had not been. S3 LPN further acknowledged Resident #3's O2 tubing had not been labeled with date or initialed and should have been. Resident #20: Review of Resident #20's medical record revealed an admitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - an order dated 6/24/2022 which read: Clean filters, change, date and initial on tubing every Sunday. - an order dated 6/1/2022 which read: Change out sterile water and O2 tubing every Sunday night. - an order dated 1/20/2022 which read: Continuous oxygen at 2L per nasal cannula. Observation on 6/27/22 at 10:05 am revealed Resident #20's humidification bottle was dated 6/19/2022. Further observation revealed Resident #20's O2 tubing was not labeled with date or initialed. During an interview on 6/27/2022 at 10:05 am S3 LPN acknowledged Resident #20's humidification bottle was outdated and should have been changed on Sunday, 6/26/2022 and had not been. S3 LPN further acknowledged Resident #20's O2 tubing had not been labeled with date or initialed and should have been. Resident #52: Review of Resident #52's medical record revealed an admitted [DATE] and a readmitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #52's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - an order dated 6/16/2022 which read: Clean filter, change, date and initial on tubing every Sunday. - an order dated 6/6/2022 which read: Oxygen at 2L per nasal cannula for SOB (shortness of breath) and/or saturation below 92%. - an order dated 6/1/2022 which read: Change out sterile water and O2 tubing every Sunday night. Observation on 6/27/22 at 9:00 am revealed Resident #52's humidification bottle was dated 6/15/2022. Further observation revealed Resident #52's O2 tubing had not been dated or initialed. During an interview on 6/27/2022 at 9:00 am S3 LPN reported residents' O2 tubing and sterile water humidifier bottles were to be changed every Sunday. S3 LPN acknowledged Resident #52's humidification bottle had not been changed since 6/15/2022 and should have been. S3 LPN further acknowledged Resident #52's O2 tubing had not been dated or initialed and should have been. Resident #192: Review of Resident #192's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 6/27/2022 at 1:45 pm revealed oxygen in use by resident #192 per nasal cannulae. Further observation revealed the nasal cannulae tubing was not dated or initialed. Observation on 6/29/2022 at 8:00 am revealed oxygen in use by resident #192 per nasal cannulae. Further observation revealed the nasal cannulae tubing was not dated or initialed. During and observation and interview on 6/29/2022 at 9:12 am S7 LPN acknowledged resident #192's oxygen tubing was not dated or initialed per policy and should have been, During an interview on 6/29/2022 at 9:15 am S9 Treatment Nurse acknowledged the oxygen equipment should be changed weekly, and labeled with the date and initials according to facility policy.

FACILITY Based on record reviews and interview, the facility failed to ensure each resident's MDS (Minimum Data Set) assessment was transmitted within 7 days of completion for 1 (#1) of 2 (#1, #8) residents reviewed for MDS transmission. Findings: Review of Resident #1's electronic health record revealed a discharge MDS with a completion date of 4/4/2022. Further review of Resident #1's discharge MDS failed to reveal a transmission date. During an interview on 6/29/2022 at 3:05 PM, S6 MDS Nurse confirmed a discharge MDS was completed for Resident #1 on 4/4/2022. S6 MDS Nurse further confirmed Resident #1's discharge MDS had not been transmitted and should have been.

Based on interviews, observations, and record review, the facility failed to ensure a comprehensive person-centered care plan was developed and implemented for 1 (#192) of 32 sampled residents care plans reviewed as evidenced by the failure to develop and implement a plan of care for a resident with oxygen in use. Findings: Record review for resident #192 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #192's June 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #192's care plan failed to reveal problems and approaches related to the care and use of oxygen. Observation on 06/27/2022 at 1:45 pm revealed oxygen in use by resident #192 per nasal cannula. Observation on 6/29/2022 at 8:00 am revealed oxygen in use by resident #192 per nasal cannula. During an interview on 6/29/2022 at 11:10 am S8 (ADON) Assistant Director of Nursing and S2 (DON) Director of Nursing, confirmed resident #192 had been on continuous oxygen at 2 liters/minute per nasal cannula since 6/10/2022. S8 ADON and S2 DON further confirmed resident #192's care plan had not been updated to include the use of oxygen and should have been. During an interview on 6/29/2022 at 11:25 am S6 Minimum Data Set Nurse confirmed resident #192's care plan should have been updated to include oxygen but was not.

Based on observation and interview the facility failed to provide appropriate treatment and services for 1 (#52) of 3 residents identified as receiving tube feedings per the Resident Census and Conditions of Residents form, dated 6/28/2022. The facility failed to ensure the formula bag was labeled correctly. Review of facility's Enteral Tube Feeding via Continuous Pump revealed in part: . Initiate Feeding- .On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. Review of Resident #52's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (hour) and may have a 2 hour break in the middle of the day . Observation on 6/27/2022 at 9:00 am revealed Resident #52's formula bag of [MEDICATION(S)] had not been labeled with resident's name, the date and time feeding was initiated or initialed by the nurse. During an interview on 6/27/2022 at 9:00 am S3 LPN acknowledged Resident #52's formula bag had not been labeled with resident's name, the date and time the tube feeding had been initiated or initialed by the nurse and should have been.

Based on record review, observation, and interviews, the facility failed to ensure staff practices were consistent with current infection control principles and practices by failing to ensure proper infection control techniques were practiced during perineal care for 1 (#79) of 1 (#79) residents observed for perineal care out of a total of 41 residents who were occasionally or frequently incontinent of bladder as identified on the Resident Census and Conditions of Residents Report dated 6/28/2022. Findings: Record review of facility's Perineal Care Policy revealed steps in procedures in part: #2- Wash and dry hands thoroughly, #7- Put on gloves, #10- Remove gloves and discard in designated container, and #11-Wash and dry your hands thoroughly. Observation on 6/27/2022 at 2:20 pm of perineal care performed on Resident #79 by S4 Care Partner and assisted by S5 Care Partner revealed staff failed to perform handwashing or use of sanitizer prior to donning gloves. Following perineal care, S4 Care Partner continued to use dirty gloves while assisting Resident #79 with changing gown, adjusting linen, providing activities of daily living and turning on water faucet. Further observation revealed S4 Care Partner and S5 Care Partner removed their gloves and failed to wash their hands upon exiting the room. During an interview on 6/27/2022 at 2:25 pm S4 Care Partner acknowledged she did not wash her hands prior to donning gloves or after removal of gloves following perineal care for Resident #79. During an interview on 6/27/2022 at 2:27 pm S5 Care Partner acknowledged she did not wash her hands prior to donning gloves or after removal of gloves while assisting with Resident #79's perineal care.

Based on record reviews, observations and interviews the facility failed to ensure residents' plan of care was implemented for 2 (#12, #73) of 26 total sampled residents reviewed. The facility failed to ensure the correct intravenous fluids were administered to Resident #12 and failed to ensure vital signs were monitored for Resident #73 as ordered by the physician. Resident #12 Observation on 6/21/2021 at 10:00 AM revealed [MEDICATION(S)] 0.45% infusing to Resident #12's left arm at 100ml (milliliter)/hr (hour). Observation on 6/22/2021 at 9:00 AM revealed [MEDICATION(S)] 0.45% infusing to Resident #12's left arm at 100ml/hr. Review of Resident #12's verbal order dated 6/14/2021 revealed [MEDICATION(S)] 0.9% Use 100 ml (milliliters)/hour intravenously for 24 hours related to dementia for 7 days 100 ml/hour (1 bag daily for 7 days). Review of Resident #12's Progress Notes revealed the following: 6/14/2021 at 21:23 PM revealed new order for [MEDICATION(S)] solution 0.9% use 100 ml/hr intravenously for 24 hours for 7 days 100 ml/hr (1 bag daily x 7 days) first bag was started at 5pm --S4 LPN (Licensed Practical Nurse) 6/14/2021 at 3:49 PM new orders per S5 NP (Nurse Practicioner) to give [MEDICATION(S)] 0.45% 100ml/hr 1 bag daily for 7 days due to low blood pressure, lethargic and amber color urine. Review of June 2021 MAR (Medication Administration Record) from June 14, 2021 through June 22, 2021 revealed Resident # 12 received [MEDICATION(S)] 0.9%. Use 100ml/hr intravenously x 24 hours related to dementia in other diseases classified elsewhere with behavioral disturbances for 7 days 100ml/hr (1 bag daily for 7 days) During an interview on 6/21/2021 at 11:30 AM S5 RN (Registered Nurse) Clinical Coordinator confirmed Resident # 12 was receiving [MEDICATION(S)] 0.45% and the order was for [MEDICATION(S)] 0.9%. S5 RN Clinical Manager stated she accepted the verbal order from nurse practitioner and enter the order for [MEDICATION(S)] was entered incorrectly. During an interview on 6/24/2021 at 2:45 S1 DON (Direcor of Nurses) stated verbal orders are entered electronically by the physician, nurse practitioner, or nurse. The physician and nurse practitioner can sign their orders electronically and by signing electronically they are verifying the orders have been reviewed. Review of Verbal order [MEDICATION(S)] 0.9% Use 100ml (milliliters)/hour intravenously x 24 hours related to dementia for 7 days 100 ml/hour (1 bag daily for 7 days) revealed S8 Medical Director signed and dated the order on 6/22/2021 at 10:56 PM. Resident #73 Review of Resident # 73's Medical Records revealed admitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #73's June 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 6/16/2021 - [MEDICATION(S)] tablet 1mg (milligram) give 1 tablet by mouth one time a day for [CONDITION(S)] (hypertension) 6/14/2021 - [MEDICATION(S)] tablet 3.125mg give 1 tablet by mouth two times a day; hold if SBP (systolic blood pressure) 110; hold if HR(heart rate) <60 6/14/2021 - [MEDICATION(S)] tablet 24-26mg give 1 tablet by mouth two times a day; hold if SBP <110 r/t (related to) CHF 6/05/2021 - Oxygen at 2 liter per nasal cannula continuous. May remove for brief periods, bathing/showers every shift 6/05/2021 - Perform blood pressure, pulse, respiration, temperature and oxygen saturation every shift and as needed Review of Resident 73's May and June 2021 MARs (medication administration record) and electronic health record failed to reveal vital signs were monitored every shift on the following days: May - 27, 28 and 31 on the 1600 shift - no blood pressure, pulse, respiration, temperature and oxygen saturation June - 1, 3, 4, 7, 8, 12, 15, 18, 21 - 1600 shift - no blood pressure, pulse, respiration, temperature and oxygen saturation June 6th - 0800 and 1600 shifts - no blood pressure, pulse, respiration, temperature and oxygen saturation June 11th - 0000 and 1600 shifts - no blood pressure, pulse, respiration, temperature and oxygen saturation June 20th - 0800 shift - no blood pressure, pulse, respiration, temperature and oxygen saturation June 10th - 1600 shift - no blood pressure, respiration, oxygen saturation During an interview on 06/24/2021 at 12:30 PM S1 DON (Director of Nursing) acknowledged Resident #73's vital signs were not monitored for May and June 2021 every shift as ordered and should have been.

Based on record reviews and an interview, the facility failed to ensure residents were free from unnecessary medications for 2 (#30, #73) of 26 total sampled residents reviewed. The facility failed to ensure Resident #30 and Resident #73 were monitored for antidepressant side effects while receiving an antidepressant. Findings: Resident #30 Review of Resident #30's Medical Records revealed admitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 30's June 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 6/23/2021 - Monitor for sign and symptoms of antidepressant side effects:0=none, 1=dry mouth, 2=drowsiness, 3=disorientation, 4=delirium, 5=agitation, 6= tremor, 7=irregular heartbeat, 8=headache, 9=insomnia, 10=GI (gastrointestinal) distress, 11=weight gain/loss, 12=skin rash, 13=sweating, 15=diarrhea, 16=slurred speech, 17=dizziness, 18=impulsive behavior, 19-decrease libido, 20=other, see nurses notes; every shift document the number that corresponds with antidepressant side effect presented. 5/4/2021 - [MEDICATION(S)] capsule delayed release particles 30mg (milligram) give 1 capsule by mouth one time a day for [CONDITION(S)] Review of Resident #30's May and June 2021 MARs (medication administration record) failed to reveal monitoring of antidepressant medication side effects for May and June 1-22nd. During an interview on 06/24/2021 at 12:30 PM S1 DON (director of nursing) acknowledged Resident #30 has not been monitored for antidepressant side effects for May and June 1-22nd and should have been. Resident #73 Review of Resident #73's Medical Records revealed admitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #73's June 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 6/23/2021 - Monitor for sign and symptoms of antidepressant side effects: 0=none, 1=dry mouth, 2=drowsiness, 3=disorientation, 4=delirium, 5=agitation, 6=tremor, 7=irregular heartbeat, 8=headache, 9=insomnia, 10=GI distress/nausea, 11=weight gain/loss, 12=skin rash, 13=sweating, 15=diarrhea, 16-slurred speech, 17=dizziness, 18=impulsive behavior, 19=decrease libido, 20=other/nurses notes every shift 5/26/2021 - [MEDICATION(S)] tablet 50mg give 1 tablet by mouth one time a day for depression Review of Resident #73's May and June 2021 MARs failed to reveal monitoring of antidepressant medication side effects for May and June 1-22nd. During an interview on 06/24/2021 at 12:30 PM S1 DON (director of nursing) acknowledged Resident #73 has not been monitored for antidepressant side effects for May and June 1-22nd and should have been.

Based on record reviews and interviews the facility failed to ensure a resident who was unable to complete (ADL) activities of daily living received the necessary services in a timely manner for 1 (#8) of 2 residents (#8, #16) reviewed for ADLs. Findings: Review of quarterly MDS (Minimum Data Sets) dated 3/16/2021 revealed Section C. Cognitive status: BIMS (Brief Interview of Mental Status) of 14. Review of Care Plan revealed a problem: ADL (Activities of daily living) self-care performance deficit related to history of right humerus fracture, impaired mobility with bathing/ showering with approaches to require limited assistance by (1) staff with bathing/ showering, personal hygiene/ oral care: require set-up assistance by (1) staff with personal hygiene and oral care Review of Resident #8's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 6/22/2021 at 11:00 AM Resident #8's family member stated since Resident #8 returned from the hospital she has been a little weak and required more staff assistance with ADL's. During an interview on 6/24/2021 at 12:00 PM Resident # 8 reported waiting 3 hours for assistance after having a bowel movement on 6/23/2021. During an interview on 6/24/2021 at 12:10 PM S9 LPN (Licensed Practical Nurse) confirmed on 6/23/2021 around 5:00 PM Resident #8 asked for assistance to be cleaned. S9 LPN further confirmed observing S10 CNA (Certified Nurse Assistant)/ Care Partner enter Resident #8 room, turn off the call light, and exit the room. During a telephone interview on 6/24/2021 at 12:30 PM resident family member reported Resident #8 called on 6/23/2021 around 5:00 PM and reported she had called for assistance after having a bowel movement and was waiting to be cleaned. During a telephone interview on 6/24/2021 at 12:35 PM S11 CNA confirmed she came in early for 7:00 PM shift and cleaned up Resident #8. During an interview on 6/24/2021 at 12:45 PM S12 House Coordinator reported between 4:00 PM to 5:30 PM staff is serving dinner and staff do not stop to clean resident. S12 House Coordinator further reported it may not be the right thing to do but that's what happened. During an interview on 6/24/2021 at 3:30 PM S10 CNA/Care Partner confirmed Resident #8 called for assistance around 4:30 PM. S10 CNA/Care Partner confirmed Resident # 8 required another 2 staff members for ADL assistance. S10 CNA/Care Partner further confirmed she did not return to provide ADL assistance for Resident #8 until around 7:00 PM.

Based on observations and interviews the facility failed to ensure the nurse staffing data was posted daily. The facility failed to ensure the nurse staffing data was readily accessible to residents and visitors. The facility had a total census of 84 residents. Findings: Observation on 06/22/2021 at 8:40 am of the household units with S5 Clinical Coordinator failed to reveal nurse staffing data postings. During an interview on 06/22/2021 at 8:50 am the S6 House Coordinator and S5 Clinical Coordinator confirmed there was no nurse staffing data post at the facility. S5 Clinical Coordinator reported there is a nurse and CNA (certified nursing assistant) schedule in the nurse's station but she was not aware nurse staffing data had be posted readily accessible to anyone. S6 House Coordinator reported she was not aware nurse staffing data had to be posted.

Based on an observation and interview the facility failed to ensure Resident #30's accommodation of needs were met by ensuring the call bell was within reach. Findings: Review of Resident #30's Medical Records revealed admitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's Comprehensive Care Plan revealed: At risk for falls - call light within reach. Observation on 06/22/2021 at 9:50 AM revealed Resident #30 yelling out for staff. Further observation revealed call bell on bed out of resident's reach. During an interview and observation on 06/22/2021 at 10:00 AM S2 Household Coordinator confirmed Resident #30's call bell was out of reach and should not have been. During an interview on 06/24/2021 at 12:48 PM S3 LPN (licensed practical nurse) verified Resident #30 is able to use the call bell.

Based on an observation and interviews the facility failed to ensure 2 (#28, #18) of 4 (#41, #62, #28, #18) residents reviewed for accidents were provided a hazard free environment. The facility failed to ensure the grab bar and baseboard was secure in the resident's shared bathroom. Findings: Observation on 8/6/19 at 9:39 AM of Resident #28 and #18's shared bathroom revealed when the grab bar next to the toilet was pulled, the wall paneling pulled away from the wall. Further observation revealed a rubber baseboard trim pulled away from the wall and was lying by the front of the toilet. During an interview on 8/6/19 at 9:39 AM S9 Maintenance stated the wall, grab bar, and rubber baseboard should not be that way and were not safe. During an interview on 8/6/19 at 9:41 S6 LPN (Licensed Practical Nurse) stated Resident #28 and #18 were able to go to the bathroom by themselves.

Based on observations, record reviews and interviews the facility failed to develop and/or implement residents' plan of care for 2 (#28, #34) out of 28 total sampled residents reviewed. The facility failed to: 1. Develop a care plan for incontinence for Resident #28 2. Provide a fall mat for Resident #34 Findings: Resident #28 Review of Resident #28's record revealed a [DIAGNOSES REDACTED]. Review of Resident #28's (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #28's Progress Notes revealed the following: 8/5/19 Nursing - .continues to dribble urine when walking to bathroom . 8/1/19 Nursing - dribbles urine when she goes to the bathroom - does not let staff know when floor or she is wet still has trouble holding when she gets up . During an interview on 8/8/19 at 11:15 AM S8 CNA stated Resident #28 is incontinent at times During an interview on 8/8/19 at 11:21 AM S5 MDS RN (Minimum Data Set/Registered Nurse) stated Resident #28 is not care planned for urinary incontinence and should be. Resident #34 Review of Resident #34's Comprehensive Care Plan revealed the following problem and approach: Problem: Moderate risk for falls; Approaches: need a fall mat. Observation on 8/6/19 at 2:24 PM failed to reveal a fall mat bedside Resident #34's bed. Observation on 8/7/19 at 12:20 PM revealed Resident #34 sitting up in geri-chair with no fall mat at bedside. Observation on 8/8/19 at 10:16 AM failed to reveal a fall mat bedside Resident #34's bed. During an interview on 8/8/19 at 10:16 AM S7 CNA (Certified Nursing Assistant) stated Resident #34 is transferred using a lift and has never seen a fall mat at his bedside. During an interview on 8/8/19 at 10:16 AM S4 LPN (Licensed Practical Nurse) stated Resident #34 does not have a fall mat and should have one.