Every finding on record at Opus Post Acute Rehabilitation

Based on observation, record review, interview, and review of facility policy, the facility neglected the needs of Resident (R)1 by failing to ensure the resident had access to their call light, after a Certified Nursing Assistant (CNA) removed the call light from the resident's reach for 1 of 1 resident reviewed.Findings include: Review of the facility policy titled Prevention of and Prohibition Against Abuse, with a revision date of 12/2023, indicated the facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, muscle weakness, cognitive communication deficit, hypertension, lack of coordination, need for assistance with personal care, and abnormalities of gait and mobility. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/12/25 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 09 out of 15, indicating R1 was moderately cognitively impaired.Review of R1's Care Plan with an initiated date of 03/27/2025 revealed a problem area: [R1] has activities of daily living (ADL), self care performance deficit related to muscle weakness, respiratory failure, guillian-barre syndrome, and parkinson's. Interventions directed staff to: TOILET USE: Requires staff assistance with toileting needs. Date Initiated: 03/27/2025 Revision on: 03/29/2025 TRANSFER: Requires assistance with transfers. Date Initiated: 03/27/2025 Revision on: 03/29/2025 BED MOBILITY: Requires assistance with bed mobility. Date Initiated: 03/27/2025 Revision on: 03/28/2025 BATHING: Requires assistance with bathing needs. Date Initiated: 03/27/2025 Revision on: 03/29/2025 PERSONAL HYGIENE ROUTINE: Requires assistance with personal hygiene. Date Initiated: 03/27/2025 Revision on: 03/28/2025 DRESSING: Requires assistance with dressing. Date Initiated: 03/27/2025 Revision on: 03/28/2025 EATING: Requires assistance with eating. Date Initiated: 03/27/2025 Revision on: 03/29/2025. Further review of R1's Care Plan revealed a problem area; Dependent on staff for activities, cognitive stimulation, social interaction r/t Immobility, Physical Limitations . During an interview on 12/04/25 at 11:30 AM, R1 revealed that he remembers the incident and the alleged perpetrator, CNA, but he has not seen the alleged perpetrator, CNA, since the incident. R1 stated that the current CNAs help him with his Activities of Daily Living (ADLs) and revealed that all the other staff members treat him nicely. R1 does not feel unsafe, and staff members are not unprofessional towards him. R1 stated that they feel safe living in the facility and believe that he is protected from harm.An attempted interview on 12/04/25 at 11:33 AM with the alleged CNA was unsuccessful.An attempted interview on 12/04/25 at 11:40 AM with R1's representative (son) was unsuccessful. During an interview on 12/04/25 at 11:55 AM, the Director of Nursing (DON) stated that the alleged perpetrator CNA admitted to taking his call light and putting it out of reach, and that's why she was terminated. There were no negative or adverse outcomes during the period when R1 did not have his call light, but the facility still fired the alleged perpetrator because removing the call light is unacceptable and should not have happened.

Based on observation, interview, and review of facility policy, the facility failed to promote a homelike dining experience. Specifically, the facility failed to ensure staff did not stand to assist residents with the meals for one (1) of one (1) dependent resident (Resident (R)8). Additionally, the facility failed to remove the plated food, eating utensils, and drinks from the serving tray onto the table for three (3) of three (3) residents that dined communally (R1, R2, and R9). Findings include: Review of the facility's policy titled, Resident Rights revised on 10/2015 revealed, . It is the policy of this facility that all residents be treated with kindness, dignity and respect. During a dining observation and interview on 04/15/25 at 12:20 PM, R1, R2, and R9 dined communally in the main dining room, where they all ate directly from the tray the meals were served on. R9 stated, They don't move the tray. During an interview on 04/16/25 at 3:17 PM, the Director of Nursing (DON) confirmed the staff did not remove the serving trays or place the resident's plated meal, eating utensils, or drinks on the table to encourage a homelike experience. The DON stated, It is the expectation that staff should always remove the food from the serving trays, when serving meals to residents. During an observation on 04/15/25 at 1:15 PM, R8 was in bed, with the head of bed elevated approximately 35 degrees, and both of R8's hands drawn to the chest. The Certified Nursing Assistant (CNA)3 stood at the bedside and assisted the resident with the meal, during the 5-minute observation. Review of R8's Face Sheet revealed R8 was admitted to the facility on [DATE], with diagnoses including but not limited to: spinal stenosis, and fusion of spine with quadriplegic (paralyzed from the neck down). Review of R8's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/25, revealed R8's Brief Interview for Mental Status (BIMS) score was 13 out of 15, indicating R8's cognition was intact, further review of the MDS revealed R8 was dependent on staff for assistance with meals and activities of daily living (ADL). During an interview on 04/15/25 at 1:20 PM, CNA3 confirmed she stood to assist the resident with the meal. CNA3 stated, He's a feeder. I know I should sit to feed residents, but I stand with him because it is easier for him.

Based on review of facility policy, observation, record review and interview, the facility failed to ensure call lights were within reach for 6 of 13 residents reviewed. Additionally, the facility failed to ensure that a resident wheelchair arms were not in need of repair, for 1 of 1 resident. Findings include: Review of the facility's Call Light/Bell policy, revised on 05/2007, revealed, . It is the policy of this facility to provide the resident a means of communication with nursing staff . Place the call device within resident's reach before leaving room. Review of R1's Electronic Medical Record (EMR) revealed R1 had an admitted [DATE], with diagnoses including but not limited to: unspecified dementia, unspecified severity, with agitation, repeated fall, other sequelae of cerebral infraction, muscle weakness, restlessness and agitation. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/02/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicates R1 suffered from severe cognitive impairment. Review of R3's EMR revealed R3 had an admitted [DATE], with diagnoses including but not limited to: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, type 2 diabetes mellitus with unspecified complications, major depressive disorder, recurrent, mild, and muscle weakness. Review of R3's MDS with ARD of 12/18/24, revealed R3 had a BIMS score of 14 out of 15, which indicates R3 was cognitively intact. Review of R4's EMR revealed R4 had an admitted [DATE], with diagnoses including but not limited to: history of falling, muscle weakness, and need for assistance with personal care. Review of R4's MDS with an ARD of 12/13/24, revealed R4 had a BIMS score of 10 out of 15, which indicates R4 suffered from moderate cognitive impairment. Review of R5's EMR revealed R5 had an admitted [DATE], with diagnoses including but not limited to: hemiplegia and hemiparesis following cerebral infarction and diffuse traumatic brain injury. Review of R5's MDS with an ARD of 03/11/25, revealed R5 had a BIMS that was not completed. Review of R6's EMR revealed R6 had an admitted [DATE], with diagnoses including but not limited to: muscle wasting and atrophy, and muscle weakness. Review of R6's MDS with an ARD of 07/23/24, revealed R6 had a BIMS score of 8 out of 15, which indicates R6 suffered from moderate cognitive impairment. Review of R9's EMR revealed R9 had an admitted [DATE], with diagnoses including but not limited to: limited sequelae of cerebral infarction. Review of R9's MDS with an ARD of 01/29/25, revealed R9 did not complete a BIMS. Review of R12's EMR revealed R12 had an admitted [DATE], with diagnoses including but not limited to: unsteadiness on feet, difficulty in walking, and muscle weakness. Review of R12's MDS with an ARD of 01/29/25, revealed R12 had a BIMS score of 13 out of 15, indicating R12 had intact cognition. During an observation on 04/15/25 at 12:29 PM, R3's call bell was hanging on the wall and not in reach. During an observation on 04/15/25 at 12:34 PM, R6's call bell was hanging on the wall, and not in reach. During an observation on 04/15/25 at 12:44 PM, R4's call bell was on the floor, and not in reach. During an observation on 04/15/25 at 12:56 PM, R1's call bell was hanging on the wall, and not in reach. During an observation on 04/15/25 at 1:01 PM, R12's call bell was on the floor, and not in reach. During an observation on 04/16/25 at 9:37 AM, R5's call bell was hanging off the bed, and not within reach. During an observation on 04/15/25 at 12:20 PM, R9's wheelchair arms were observed tattled, peeling and worn. During an interview on 04/16/25 at approximately 2:44 PM, the Director of Nursing (DON) and Administrator revealed that call bells' should always be within reach of residents.

Based on observation, record review and interviews the facility failed to ensure (1) the fall mat was in a position to prevent an accident for 1 of 5 residents reviewed, Resident (R)2. The facility also failed to ensure resident bathroom/shower room floors were not excessively slippery, for 4 of 5 residents reviewed, R3, R7, R10, R11. Additionally, (2) the facility failed to provide appropriate supervision for R1, resulting in R1 falling and suffering injuries, for 1 of 5 residents reviewed. Findings include: Review of the facility's Environment Conditions/Environmental Rounds, policy revised on 11/2019, revealed, . it is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public though monthly environmental rounds. (1) Review of R1's Electronic Medical Record (EMR) revealed R1 had an admitted [DATE], with diagnoses including but not limited to: unspecified dementia, unspecified severity, with agitation, repeated fall, other sequelae of cerebral infraction, muscle weakness, restlessness and agitation. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/02/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicates R1 suffered from severe cognitive impairment. Review of R2's EMR revealed R2 had an admitted [DATE], with diagnoses including but not limited to: unspecified sequelae of cerebral infarction, spinal stenosis, cervical region, and major depressive disorder, single episode. Review of R2's MDS with an ARD of 11/03/24, revealed R2 had a BIMS score of 8 out of 15, which indicates moderate cognitive impairment. Review of R3's EMR revealed R3 had an admitted [DATE], with diagnoses including but not limited to: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, type 2 diabetes mellitus with unspecified complications, major depressive disorder, recurrent, mild, and muscle weakness. Review of R3's MDS with an ARD of 12/18/24, revealed R3 had a BIMS score of 14 out of 15, which indicates R3 was cognitively intact. Review of R7's EMR revealed R7 had an admitted [DATE], with diagnoses including but not limited to: idiopathic progressive, arthritis, and cerebrovascular. Review of R7's MDS with an ARD of 07/23/24, had a BIMS score of 15 out of 15, which indicates R7 was cognitively intact. Review of R10's EMR revealed R10 had an admitted [DATE], with diagnoses including but not limited to: muscle wasting and atrophy. Review of R10's MDS with an ARD of 01/07/25, revealed R10 had a BIMS score of 4 out of 15, which indicates R10 suffered from severe cognitive impairment. Review of R11's EMR revealed R11 had an admitted [DATE], with diagnoses including but not limited to: muscle weakness and sarcopenia. Review of R11's MDS with an ARD of 01/28/25, revealed R11 had a BIMS score of 11 out of 15, which indicates R11 had moderate cognitive impairment. During an observation on 04/15/25 at 12:15 PM, R2's fall mat was stuck under the wheel of the resident's bed and protruding from under the bed, creating an accident hazard for the resident. During multiple observation on 04/15/25 at approximately 12:30 PM, revealed a bathroom containing a shower in the rooms of R3, R7, R10, and R11. Further observation revealed a buildup of a grey substance on the floors and the floors appeared to be greasy. This surveyor attempted to walk on the floors and the floors were excessively slippery, like walking on oil. During an interview on 04/15/25 at 12:29 PM, R3 stated he has fallen in the bathroom shower, when the floor is wet it's very slippery like oil. R3 further stated that he does not want to take showers anymore. During an interview on 04/15/25 at approximately 12:42 PM, R7 revealed the bathroom floor is always slippery when it is wet, he has had a fall due to it. During an interview on 04/16/25 at 10:39 AM, Licensed Practical Nurse (LPN) stated the bed should not be on top of the fall mats, as it does present an accident hazard for the resident. During an interview on 04/16/25 at 3:17 PM, the Administrator and Director of Nursing (DON) stated that they were not aware of the residents' bathroom floor being slippery. During an interview on 04/16/25 at 5:18 PM, the Maintenance Director (MD) revealed that rooms are checked for cleanliness twice a week. Work order system is utilized to inform housekeeping staff of conditions of each resident rooms. The MD stated he was not aware of the slippery floors. The MD concluded that could be due to either not mopping/rinsing as directed and/or adding to much cleaning solution while mopping. (2) Review of R1's EMR revealed R1 had an admitted [DATE], with diagnoses including but not limited to: unspecified dementia, unspecified severity, with agitation, repeated fall, other sequelae of cerebral infraction, muscle weakness, restlessness and agitation. Review of R1's MDS with an ARD of 12/02/24, revealed R1 had a BIMS score of 5 out of 15, which indicates severe cognitive impairment. Attempted interviews with R1, were unsuccessful. During an interview on 04/16/25 at approximately 10:52 AM, Registered Nurse (RN) revealed R1 was a two person assist. The RN confirmed that R1 was a fall risk and had multi-falls, due to this, staff are aware and should always keep eyes on R1. During an interview on 04/16/25 at 1:40 PM, Certified Nursing Assistant (CNA)2 revealed he was assigned to R1 and had just brought him back from the dining room back into the resident's room. CNA2 stated R1 was in the geri-chair and CNA2 had locked the wheels on the chair and went to get clothing and an adult diaper so that he could get the resident ready from bed. CNA2 stated he heard R1 fall to the floor, R1 fell off the side of the chair. CNA2 further stated the resident had shown signs of anxiety on the day of the incident and he was shocked to see R1 on the floor. CNA2 continued that he saw blood coming from the resident's head. CNA2 stated he immediately ran to get the nurse, and she came to the room, assessed the resident, applied pressure to his head as she observed a laceration. R1 was sent out to the hospital for further evaluation. CNA2 concluded to prevent the fall, he should have gotten all supplies out of the closet and not turn his back on the resident, he needed to keep eyes on the resident. During an interview on 04/16/25 at 2:48 PM, the DON revealed R1 was care planned for falls. R1 appeared to be comfortable in the geri-chair until the day of the incident. The DON stated to prevent the resident's fall, staff should have made sure that he had all the supplies that was needed for the resident with him, and he should not have turned his back on the resident.

Based on observation, record review and interview, the facility failed to assist or offer residents hand hygiene before and/or after meals for 4 of 4 residents. Additionally, the facility failed to ensure bath basins were labeled and cover for 3 of 4 residents. Findings include: Review of R2's Electronic Medical Record (EMR) revealed R2 had an admitted [DATE], with diagnoses including but not limited to: unspecified sequelae of cerebral infarction, spinal stenosis, cervical region, and major depressive disorder, single episode. Review of R2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/24, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicates R2 was moderately cognitively impaired. Review of R3's EMR revealed R3 had an admitted [DATE], with diagnoses including but not limited to: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, type 2 diabetes mellitus with unspecified complications, major depressive disorder, recurrent, mild, and muscle weakness. Review of R3's MDS with an ARD of 12/18/24, revealed R3 had a BIMS score of 14 out of 15, which indicates R3 was cognitively intact. Review of R5's EMR revealed R5 had an admitted [DATE], with diagnoses including but not limited to: hemiplegia and hemiparesis following cerebral infarction and diffuse traumatic brain injury. Review of R5's MDS with an ARD of 03/11/25, revealed R5 was not able to complete the BIMS. Review of R6's EMR revealed R6 had an admitted [DATE], with diagnoses including but not limited to: muscle wasting and atrophy and muscle weakness. Review of R6's MDS with an ARD of 07/23/24, revealed R6 had a BIMS score of 8 out of 15, which indicates moderate cognitive impairment. During an observation on 04/15/25 at 12:15 PM, revealed staff did not offer to assist R2 with hand hygiene before and/or after meals. During an observation on 04/15/25 at 12:28 PM, revealed uncovered/unlabeled bath basins under the vanity sink of R3, which was shared by two residents. Further observation revealed staff did not offer to assist R3 with hand hygiene before and/or after meals. During an observation on 04/15/25 at 12:34 PM, revealed uncovered/unlabeled bath basins under the vanity sink of R6, which was shared by two residents. Further observation revealed staff did not offer to assist R6 with hand hygiene before and/or after meals. During an observation on 04/16/25 at 9:37 AM, revealed uncovered/unlabeled bath basins under the vanity sink of R5, which was shared by two residents. Further observation revealed staff did not offer to assist R5 with hand hygiene before and/or after meals. During an interview on 04/16/25 at 3:19 PM, the Director of Nursing (DON) stated it is the procedure that basins should be labeled and covered with plastic. The thermometer should be labeled. The DON further stated in regards to residents hand hygiene before and after meals, residents should be assisted with cleaning their hands before and after meals.

Based on observations, interviews, record review and review of facility policy, (1) the facility failed to ensure that proper infection control measures were taken regarding aerosol drainage bags for Resident (R)62 and R68, for 2 of 5 residents reviewed. Furthermore, (2) the facility failed to properly clean and disinfect blood glucose metered device, that was shared with multiple residents, R388, R45, and R340, for 3 of 5 residents revealed. On 11/25/24 at 8:19 AM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 12/16/24, the facility was notified that the failure to properly clean and disinfect a multi-use glucometer, between residents constituted Immediate Jeopardy (IJ) at F880. On 12/16/24 at 5:48 PM, the survey team provided the Director of Nursing (DON) with a copy of the CMS IJ Template, informing the facility IJ existed as of 11/25/24. The IJ was related to S483.80 Infection Control. On 12/16/24 the facility provided an acceptable IJ Removal Plan. On 12/16/24 the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F880 at a lower scope and severity of D. Findings include: (1) Review of the facility's policy titled Infection Control Prevention and Control Program dated September 2021, indicated, The goal of the Infection Control Program are to: a. decrease the risk of infection to residents and personnel, b. recognize infection control practices while providing care, c. identify and correct problems relating to infection control practices . Review of R62's Face Sheet revealed R62 was admitted to the facility with diagnoses including but not limited to, chronic respiratory failure. Review of R62's Physician Order revealed, Change aerosol components every Friday day shift and PRN (Corrugated tubing/Drain Bag/Trach Mask), and Continuous cool mist aerosol therapy via trach collar for humidity. Review of R62's Care Plan revealed, Tracheostomy r/t respiratory failure and secretions r/t ICH. Review of R68's Face Sheet revealed R68 was admitted to the facility with diagnoses including but not limited to: acute respiratory failure with hypoxia, acute respiratory failure with hypercapnia, centrilobular emphysema, and tracheostomy status. Review of R68's Physician Orders revealed, Change aerosol components every Friday day shift and PRN (Corrugated tubing/Drain Bag/Trach Mask) and Continuous cool mist aerosol therapy via trach collar for humidity. Review of R68's Care Plan revealed, acute respiratory failure and tracheostomy with secretions and suctioning - has history of malignant neoplasm of larynx with acquired absence of larynx - oropharyngeal cancer. During multiple observations on 11/24/24 at 10:50 AM, 11/25/24 at 8:30 AM, and 11/26/24 at 8:42 AM, revealed R68's aerosol drainage bag on the bedroom floor. During multiple observations on 11/24/24 at 8:48 AM and 11/25/24 at 8:44 AM, revealed R62's aerosol drainage bag present on the bedroom floor. During an interview on 11/26/24 at approximately 11:38 AM, the Director of Nursing (DON) stated that the drainage bags shouldn't have been on the floor due to infection control. 49918 (2) Review of the facility's policy titled, Glucometer, Cleaning and Decontamination of revised on 12/2009, revealed, It is the policy of this facility to follow recommendation from the CDC. The CDC states that HBV can survive for at least one week in dried blood on environmental surfaces or on contaminated instruments. The following recommendations provide guidance for cleaning and decontamination of glucometers that may be contaminated with blood and body fluids. Procedures: 1. Clean after each use. 2. Disinfect after each use the exterior surfaces following the manufacturer's directions using a cloth/wipe with either an EPA-registered detergent/germicide with a tuberculocidal or HBV/HIV label claim, or a dilute bleach solution of 1:10 (one part bleach to 9 Parts water) to 1:100 concentration. Review of the True Metrix Pro Manufacture recommendation revealed, We recommend using only one meter per patient. Cleaning removes blood and soil from the meter. Disinfecting removes most, but not all possible infectious agents (bacteria or virus) from the meter, including blood-borne pathogens. Clean and disinfect immediately after getting any blood on the meter or if the meter is dirty. Meter should be cleaned and disinfected between patients. Clean and disinfect the meter before allowing anyone else to handle it. Review of R45's Face Sheet revealed (R)45 was admitted to the facility on [DATE], with diagnoses including but not limited to: Parkinsonism, Unspecified, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Chronic Systolic (Congestive) Heart Failure. Review of R45's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/03/24, revealed R45 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R45 had moderate cognitive impairment. Review of R45's Care Plan with a start date of 06/28/21 documented, Has Type 2 Diabetes Mellitus. Further review of the Care Plan revealed the following approach, Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of R45's Physician Orders dated 06/24/24, revealed the following order, Finger Stick Blood Sugar (FSBS) two times a day. Review of R45's Progress Note dated 11/08/24 at 11:43 AM, revealed, Blood Glucose is being Monitored BS 127.0 - 11/18/2023 08:25 blood glucose level at baseline, well controlled Teachings/Education was not provided regarding Blood Glucose levels. Vital Signs do not show any fluctuations from baseline that require intervention(s). Other observations and interventions include FSBS, and insulin administration as ordered. Resident has a medical dx of TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY. Resident displays no s/s of hypo/hyperglycemia. Review of R340's Face Sheet revealed (R) 340 was admitted on [DATE], with a diagnosis including but not limited to: Acute Respiratory Failure with Hypoxia, Type 2 Diabetes Mellitus with Other Diabetic Kidney Complication, Chronic Kidney Disease, Stage 3B. Review of R340's Admission MDS with an ARD of 11/20/24, revealed R340 had a BIMS score of 15 out of 15, indicating no cognitive impairment. Review of R340's Care Plan with a start date of 11/20/24 documented, Has Diabetes Mellitus. Further review of the Care Plan revealed the following approach, Fasting Serum Blood Sugar as ordered by doctor. Review of R340's Physician Orders dated 12/11/24, revealed the following order Check FSBS BID two times a day. Review of R388's Face Sheet revealed R388 was admitted to the facility on [DATE], with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, Unspecified, End Stage Renal Disease, Dependence on Renal Dialysis. Review of R388's Admission MDS with an ARD of 11/20/24, revealed R388 had a BIMS score of 15 out of 15, indicating no cognitive impairment. Review of R388's Care Plan with a start date of 11/20/24, documented, [resident] has type 2 diabetes with moderate nonproliferative diabetic retinopathy of both eyes/double vision and long-term use of insulin. Further review of the Care Plan revealed the following approach, Fasting Serum Blood Sugar as ordered by doctor. Review of R388's Physician Orders dated 11/18/24 revealed the following order, Check FSBS BID two times a day. Review of R388's Physician Orders dated 11/19/24 revealed the following order, ENHANCED BARRIER PRECAUTIONS: PPE required for high resident contact care activities. Indication: wounds, indwelling medical device. every shift. Review of R388's Progress Note dated 11/19/24 revealed, Diagnosis or Condition(s) being monitored: Chronic Obstructive Pulmonary Disease, Unspecified, Acquired Absence of Left Leg Above the knee, Chronic Respiratory, Failure with Hypoxia, Heart Failure, unspecified, End stage renal Disease, Type 2 Diabetes Mellitus with moderate Non-proliferative Diabetic Retinopathy without Macular Edema, Bilateral, Essential (PRIMARY) Hypertension, Morbid (SEVERE) Obesity Due To Excess Calories Vital Signs: BP 126/58 - 11/19/2024 20:03 Position: T 97.4 - 11/19/2024 20:03 Route: Temporal Artery P 67 -11/19/2024 20:03 Pulse Type: Regular R 18.0 - 11/19/2024 20:03O2 95.0 % - 11/19/2024 20:03 Method: Room Air Pain: No Pnl 0 - 11/19/2024 21:55 Pain scale: Numerical Blood Glucose is being Monitored BS 112.0 - 11/19/2024 16:53 blood glucose level at baseline, well controlled Teachings/Education was not provided regarding Blood Glucose levels. Vital Signs do not show any fluctuations from baseline that require intervention(s) Other observations and interventions include Fasting blood glucose checks and insulin as ordered. No signs or symptoms of hypo/hyperglycemia. During an observation on 11/25/24 at 8:21 AM, Licensed Practical Nurse (LPN)1 did not place a barrier on the mayo stand prior to placing the glucometer down. LPN1 did not sanitize hands after obtaining glucometer levels prior to touching the medication cart. During an interview on 11/25/24 at 8:28 AM, LPN1 stated, I don't know what the policy says. During an observation on 11/25/24 at 3:04 PM, LPN4 wiped off a glucometer machine with an alcohol wipe and then inserted a glucometer strip. During an interview on 11/25/24 at 3:06 PM, LPN4 stated, I am unsure I will go ask someone about the policy. During an interview on 11/25/24 at 3:08 PM, LPN4 stated, We clean glucometers with MicroWipes, let sit 3 min, use barrier, afterwards clean with barrier and let sit for 3 min. LPN4 stated, she spoke with LPN1. During an observation on 11/25/24 at 3:30 PM, RN2 removed the glucometer machine from inside of the medication cart and placed it on top of the medication cart. During an interview on 11/25/24 at 3:30 PM, RN2 stated, This glucometer machine was cleaned already. After cleaning the glucometer machine, RN2 placed the glucometer on top of the medication cart again. RN2 did not sit the glucometer in microwipe for 3 minutes. During an interview on 11/25/24 at 3:41 PM, the DON stated, They clean in between each resident using the proper solution and clean workstation and use a barrier to prevent spills if necessary. During an interview on 12/16/24 at 5:10 PM, the DON stated, The glucose meter must be cleaned in between, before and after resident use. During an interview on 12/16/24 at 5:12 PM, the Administrator stated, We continue to do in-services as needed. Clean in between residents before and after the procedures with the proper sanitary materials. On 12/16/24 the facility provided an acceptable IJ Removal Plan, which included the following: 1. Corrective Action accomplished for those residents found to be affected by the alleged deficient practice. *Resident sample numbers #388, #45, #340 the licensed nurses on staff at that time on 11/22/24 were immediately in-serviced once notified by surveyor to prevent future occurrences, glocometer cleaned and disinfected, notifications of incident made to Medical Director and Nurse Practitioner with no new orders. 2. Identify other residents who have the potential to be affected by the same deficient practice. A. All residents that require glucose monitoring by glucometer have the potential to be affected. 3. Measures/Systemic changes put in place to ensure the deficient practice does not reoccur. A. Inservice initiated with all licensed nurses beginning on 11/25/24 and completed prior to the nurses next scheduled shift by the Director of Nursing and/or clinical supervisors, staff were educated on equipment cleaning of the glucometer devices to include cleaning and disinfecting before and after each resident's use. Staff educated to clean with an EPA disinfectant for the wet time that is indicated by manufacturer guidelines that is effective against blood borne pathogens that meet OSHA's standards. Licensed nurses educated on utilizing a barrier between the glucometer device and in contact with surface areas to prevent cross contamination and the prevention of the spread of blood borne pathogens. B. Staff education reinforced on 12/12/24 at the Annual Skills Fair. C. All licensed nurses will be educated on the glucometer policy upon hire and during new hire orientation. 4. Monitoring of corrective action to ensure the deficient practice will not reoccur. A. The clinical nursing supervisors will complete audits 5 times a week x 1 week, 3 times a week x 2 weeks, and 2 times a week x 1 week and weekly thereafter x 2 months to ensure that all staff remain in compliance with infection control procedure for glucometer cleaning and disinfecting of blood glucose devices. B. ADHOC QAPI meeting held on 11/29/2024 to discuss alleged deficiencies and implementation of POC. C. Findings of the audit will be reported to the Administrator and Director of Nursing for compliance review. D. Failure to adhere to facility policy will be considered a violation. Violations will result in disciplinary action in accordance with the facility progressive disciplinary policy. E. A report of findings and subsequent disciplinary action, if applicable, will be reported to the facility Quality Assurance Committee consisting of Director of Nursing, Medical Director, Administrator, Pharmacy Consultant x 3 months to review the need for continued intervention or amendment of and disposed of in accordance with the facility policies and procedures. Date of Compliance 11/29/2024

Based on observation, interviews and review of the facility policy, the facility failed to ensure foods was labeled, stored, and discarded according to the expiration date, in 1 of 1 main kitchen. This failure had the potential to cause foodborne illnesses. Findings include: Review of the facility policy titled, Labeling and Dating of Foods dated 2020, documented All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Newly opened food items will need to be closed and labeled with an open date and used by the date that follows guidelines . (EXCEPTION: Milk is to be used by its stamped expiration date.) During an initial tour of the kitchen on [DATE] at 10:10 AM, the dry storage revealed the following: - 25 lb bag of brown rice with no open date and no label. - 40 oz bag of Seasoned Homestyle Croutons with no open date and no label. - 10 oz bag of Puff Marshmallow opened with no label. - 5 lb bag of Spaghetti noodles opened with no expiration. - ,d+[DATE] bag of Macaroni Noodles with no expiration. - Pioneer Country Cream Gravy with no expiration. - Instant Vanilla Pudding Pie with no expiration. The walk-in refrigerator revealed the following: - Square yellow cheese, approximately 15 slices opened with no expiration. - [NAME] mozzarella cheese, approximately 15 slices opened with no label. - Feathered Shredded Mild Cheese not labeled with no expiration. - 5 lb bag Roseli Grated Parmesan Cheese expired on [DATE]. The deep freezer revealed the following: - 30 lb box of [NAME] seasoned crisp delivery cut crinkle cut wedge potatoes expired on [DATE]. - Sausage link package opened with no label. - Spinach bag opened with no label. Shelf items revealed the following: - Wheat bread dinner rolls expired on [DATE]. - 10 loaves of bread expired on [DATE]. - 1 loaf white bread expired on [DATE]. - 1 - 16 pack hot dog buns expired on [DATE]. All items were removed and discarded on [DATE], by the Lead Cook. During an interview on [DATE] at 5:00 PM, the Lead [NAME] revealed her role in storing and labeling, is to date everything properly, label items, and discard them. The Lead [NAME] states there is no possible way to determine when an item was opened. The Lead [NAME] further stated she looks daily through storage items to ensure they are labeled and dated. Her expectations of others as well as herself are to check items daily. During an interview on [DATE] at 5:01 PM, the Regional Dietician (RD) revealed when deliveries are received the date of delivery is labeled on each item and stored properly. Monthly walkthroughs are conducted to ensure food items are labeled and dated. Staff reports to Kitchen Manager (KM) for a summary of improperly labeled items. The RD's expectation is to monitor food storage areas closely. The facility typically does not maintain a high volume of food so it's unusual that they have expired foods. During an interview on [DATE] at 5:19 PM, the KM revealed she usually knows the expiration dates of the food items. She states that food items are dated per the delivery date and Dry Goods Storage Guidelines. Items that are already prepared have 48 - 72 hours to be used. The KM's expectation is to ensure everything is dated, they use First In, First Out method.

Based on observation, interviews, record review and facility policy review, the facility failed to ensure a comfortable and homelike environment was provided for 2 residents, (Resident (R)56, R12), of 10 sampled residents whose rooms were reviewed. Finding include: Review of a facility policy titled, Environmental Conditions/Environmental Rounds with a revised dated of 11/19, revealed, It is the policy of this facility that the facility must provide a safe, functional, sanitary and comfortable environment for residents, staff and the public . residents rooms must be designed and equipped for adequate nursing care, comfort and privacy of residents. Review of R56's, Face Sheet revealed R56 was admitted to the facility with diagnoses including but not limited to: presence of chronic diastolic congestive heart failure, alcohol abuse, generalized anxiety disorder, major depressive disorder, hypertension, unspecified psychosis, chronic kidney disease stage 3A, unsteadiness on feet, weakness and need for assistance with personal care. During an observation and interview on 11/27/24 at 11:41 PM, revealed R56's breakfast tray was still on her table. R56 stated, I'm not treated like I need assistance. I am very independent, but they don't help me, I have to change my own trash and we are heading into lunch and my breakfast tray is still in here at 11:45 AM. During an observation on 11/25/24 at 9:33 AM, revealed a large, covered trash can in the middle of R56's shower. During an interview on 11/25/24 at 9:33 AM, R56 revealed she takes her own showers and must move the trashcan out of the shower herself. During an observation on 11/25/24 at 4:35 PM, revealed the trashcan was still in R56's shower. Certified Nursing Assistant (CNA)1 lifted the lid of the trashcan and revealed the trashcan had trash in it. During an interview on 11/25/24 at 4:35 PM, CNA1 revealed they do not usually keep trashcans in the shower, but the large trash cans are used for PPE and are usually kept in the room. CNA1 stated the trash can should not be in the shower. Review of R12's Face Sheet revealed R12 was admitted to the facility with diagnoses including but not limited to: peripheral vascular disease, lymphocytic leukemia, and chronic kidney disease. During observations on 11/24/24 at 8:42 AM, 11/25/24 at 8:45 AM, and 11/26/24 at 10:15 AM, revealed chips scattered across the left side of the bedroom floor of R12's room. During an interview on 11/26/24 at approximately 10:50 AM, the Environmental Services Director revealed that R12's bedroom should have been swept and mopped daily. During an interview on 11/25/24 at 4:47 PM, the Director of Nursing (DON) revealed it is expected that there should not be a trashcan in a residents shower at all.

Based on interviews, record review, and review of facility policy, the facility failed to provide services or care that are acceptable standards of practice. Specifically, the facility failed to obtain lab orders for a redraw, after an anticoagulant (Coumadin) adjustment for 1 (Resident (R)388's) of 1 resident reviewed for unnecessary medications. Findings include: Review of the facility policy titled Anticoagulation -Clinical Protocol last revised in November 2018, revealed, The physician will prescribe anticoagulation therapy (for example, low molecular weight heparin, warfarin, or other oral anticoagulant) appropriately, consistent with the recognized guidelines . The physician should adjust the anticoagulant dose or stop, taper, or change medications that interact with the anticoagulant, and/or monitor the PT/INR very closely while the individual is receiving warfarin, to ensure that the PT/INR [A prothrombin time (PT or PT/INR) test measures how quickly your blood clots.] stabilizes within a therapeutic range. Review of R388's Face Sheet revealed R388 was admitted to the facility on [DATE], with diagnoses including but not limited to: proximal atrial fibrillation, Type 2 Diabetes, history of deep vein thrombosis, and hypertension. Review of R388's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/24/24, revealed R388 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicates that she is cognitively intact. Review of R388's Physician Progress Notes dated 11/23/24, documented, was initially noted to have supratherapeutic INR and therefore warfarin was held. She then became subtherapeutic and warfarin was resumed with heparin bridge. Patient's INR improved to 3.3 on day of discharge. Her Coumadin dose was decreased to 5 mg daily. Patient will require INR checks at rehabilitation facility with adjustment in warfarin dosing. Review of R388's Physician Notes dated 11/24/24, revealed R388 coumadin-monitor with PT/INR, INR on Friday was 1.8 - change dosing to 7.5mg on Fridays and 5 mg all other days. Review of R388's Care Plan last reviewed/revised on 11/18/24, revealed, Anticoagulant therapy r/t: prevention of blood clots/ recurrent DVTs. Resident receives medication with a Black box warning: see MD order. [R388] will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Antidote is Vitamin K. Have on hand for emergencies. Labs as ordered. Report abnormal lab results to the MD. Monitor and report s&sx of thromboembolism: acute onset of shortness of breath, pleuritic chest pain, cough, coughing up blood, syncope and anxiety. Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , bleeding, blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. During an interview on 11/26/24 at 11:00 AM, the Director of Nursing (DON) was unable to locate an order for a repeat INR after the 11/22/24 medication adjustment for Warfarin. The DON placed a call to the Nurse Practitioner and an Order was given to repeat PT/INR on 11/28/24. During a follow up interview on 11/26/24 at 12:23 PM, the DON stated that the nurses should follow the provider's order related to PT/INR orders for residents. If the provider does not write orders regarding follow up PT/INR labs, the nurse should call the doctor or Nurse Practitioner and get orders for follow up labs. During a phone interview on 11/26/24, at 12:37 PM, the Nurse Practitioner (NP) stated that she usually writes orders for PT/INR a day or two after admission. The NP further stated, I expect the nurses to make sure that the residents get the medication. When the nurses receive the PT/INR results, they should call me with the results so I can make adjustments. After an adjustment, I repeat the PT/INR in 2 days to make sure the medication level has increased. If I forget to order a repeat PT/ INR, the nurses know me well enough that they should call me and ask me about it. During an interview on 11/26/24 at 1:04 PM, Registered Nurse (RN)1 stated, If there are no PT/INR orders I would hold the Coumadin until I have gotten in touch with the practitioner for new PT/INR orders.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure 1 (Resident (R)78) of 1 resident reviewed for nutrition was provided nutritional supplements per physician orders to prevent potential nutritional problems or further weight loss. Findings include: Review of a facility policy titled Diet Orders states, Diet orders prescribed by the physician will be provided by the Food and Nutrition Services department. Nursing will send a Diet order Communication slip to the Food and Nutrition Services department. The FNS Director or [NAME] in charge will make or adjust the diet profile and tray card as prescribed. The diet count is also to be adjusted as needed. The diet profile and tray card will be removed upon discharge or transfer. Any discrepancy in the diet order slip will be clarified by the FNS Director or [NAME] in charge with nursing. Review of R78's Face Sheet revealed R78 was admitted to the facility on [DATE], with diagnoses including but not limited to: cerebral infarction due to unspecified occlusion or stenosis of an unspecified cerebral artery, Type 2 Diabetes Mellitus, dependence on renal dialysis, muscle weakness, heart failure, and weakness. During an observation and interview on 11/24/24 at 12:44 PM, revealed R78 in her room, sitting in her non-motorized wheelchair in a locked position, with the over bed table in front of her at the appropriate level, a lunch tray set up in front of her with approximately 50 percent food remaining. R78 appeared weak and malnourished. The meal ticket was located on R78's tray and the lunch ticket stated regular diet 11/24/24, with no special instructions. R78 stated she was admitted in August 2024, following multiple hospital stays. R78 stated she also attends dialysis 3 times a week. R78 stated she is on fluid restriction, and she is getting weighed weekly at the facility and had ongoing weight loss since admission. R78 further stated the facility is doing nothing about the weight loss. R78 stated, Look at me, I'm skin and bones, pretty soon I'll deteriorate. R78 stated that she has not received any supplements since admission, just a meal tray and one drink due to fluid restrictions. R78 stated she will ask for snacks at night which will consist of a peanut butter and jelly sandwich or some chips. Review of R78's Electronic Health Record (EHR) revealed a Physician Order for, fortified pudding with lunch and dinner due to risk for malnutrition, no directions specified for order with an active date of 08/25/24. Further review of the Physician Order revealed an order for, renal diet, regular texture, thin liquids consistency with an active start date of 09/30/24. Review of R78's Weight Summary, revealed the following weights: 11/26/2024 - 113.4 Lbs. (pounds) 11/19/2024 - 114.8 Lbs. 11/11/2024 - 114.5 Lbs. 11/04/2024 - 113.0 Lbs. 10/03/2024 - 126.9 Lbs. 09/17/2024 - 124.5 Lbs. 09/09/2024 - 123.6 Lbs. 09/02/2024 - 121.6 Lbs. 08/29/2024 - 119.8 Lbs. 08/23/2024 - 120.9 Lbs. Review of R78's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/24, revealed R78 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates that she is cognitively intact. Furthermore, under Section K- Swallowing/Nutritional status revealed R78's Weight (in pounds) - 114, indicating R78 had weight loss and was not on prescribed weight loss regimen. Review of R78's Care Plan last reviewed/revised on 11/24/24, revealed, Has risk for malnutrition r/t GERD, Vitamin D Deficiency, dysphagia, Constipation, Pain. Goal - Will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition through the review date. Interventions directed staff to: Administer medications as ordered. Monitor/Document for side effects and effectiveness. Diet as ordered by the physician. Fortified pudding with lunch and dinner due to risk for malnutrition. Give supplements - Prostat & Boost - as ordered. Honor resident rights to make personal dietary choices and provide dietary education as needed. Observe/record/report to MD/NP PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss. Therapy evaluation and treatment per physician orders. Weights as ordered. Review of R78's Nutrition - Admission Evaluation dated 08/29/24, revealed diet order is renal, texture is ground and mechanical soft, Fluid consistency is thin, Supplement ordered- yes- fortified pudding bid, Food likes- see tray card, Food dislikes- see tray card. Under physical information, most recent weight was 119.8 lbs, and dining ability was - tray set up. Additional intervention by a Registered Dietician states, Recommendation: need fluid restriction with labs, will see if fortified pudding with Ca and P Ph content is appropriate. Nepro may be a better choice. Review of R78's Admission Nutritional assessment dated [DATE], revealed R78 scored a 4 per scale indicating she was malnourished. Review of R78's Nutrition - Quarterly Evaluation dated 11/19/24, revealed diet order is renal, texture- regular, fluid consistency- thin, portion size- regular, most recent weight 114.5 lbs via Hoyer scale. Weigh history states, 1 week ago 113, 1 month ago 126.9, admit 8/23 128.9 sig loss. New request - NO. Registered Dietician states, Monthly nutrition labs from dialysis, fortified pudding bid protein supplement 30 ML/d, Ca was low labs on 10/29. During an interview with the Dietary Aide/Cook alongside the Registered Dietician (RD) on 11/26/24 at 10:39 AM, confirmed he had just received the printed meal tickets for lunch trays. The Dietary Aide/Cook found R78's lunch meal ticket and stated R78 meal ticket did not reflect fortified puddings and does not recall giving it to the resident. The Dietary Aide/cook stated if it was not addressed on her meal ticket, it would not get put on her tray. The Dietary Aide/Cook stated the Dietary Manager would be responsible for updating and printing the meal ticket. The Dietary Aide/Cook stated the tickets get printed daily. During a follow-up interview with the Registered Dietician (RD) on 11/26/24 at 10:50 AM, revealed typically once a resident is admitted , follow-up on previous diets and diet assessment would be done. The RD stated if a resident requires nutritional supplements, RD's or MDs (Medical Doctors) can put in the order. Once the order is put in, the dietary department is responsible for making sure the supplements are addressed on the resident's meal ticket. The RD confirmed she saw the resident had an order in [DATE] to start fortified pudding for lunch and dinner trays. The RD also confirmed the resident's meal tickets do not reflect fortified puddings. The RD stated if the resident's meal ticket did not address the fortified puddings, that means she has not been receiving it since the order was placed. The RD stated, after reviewing R78's chart, she does not see the resident refusing and advised to speak with the Dietary Manager. During an interview with the Dietary Manager (DM) on 11/26/24 at 11:18 AM, revealed that once a resident receives a new dietary order for supplements or shakes that are an active order, then a diet communication form is to be filled out by nursing staff. The DM stated once received, dietary staff is to make two copies, one is for dietary aides to use for plating, and the other copy is to be placed in her office to update the meal ticket using an online system called Dining RD. Then it has to get manually put in under the notes section so it can reflect on the meal ticket once printed. The DM confirmed receiving R78's diet communication form, however does not remember when she received it. The DM states meal tickets get printed daily, and somehow she forgot to manually modify R78's meal ticket to reflect the fortified puddings. The DM also confirmed that as a result, R78 never received her supplement per physician orders. During an interview with the Director of Nursing (DON) on 11/26/24 at 11:50 AM, revealed that she had been in her position for approximately 2 weeks, before her role she was the MDS Nurse. The DON stated her expectation is for all pertinent staff to follow Physician and dietary orders and for the residents to receive exactly what they are ordered to have to prevent further decline in residents. Furthermore, the DON stated it is not professional standards of practice. During an interview with the Administrator on 11/26/24 at 4:41 PM, revealed he has an open-door policy for residents, staff, and family to voice their concerns. The Administrator revealed he had not been aware of R78's weight loss and staff not executing physician orders. The Administrator stated he will discuss this matter in the next QAPI meeting scheduled at the end of the week, 11/29/2024, with all department heads. The Administrator stated his expectation is for staff to simply follow physician orders.

Based on observations, interviews, and record reviews, the facility failed to provide respiratory care in accordance with professional standards. The facility failed to ensure 1 (Resident (R)140) of 5 residents reviewed for respiratory care, received the correct oxygen flow rate per the physician order. Findings include: Review of a facility policy titled, Oxygen Administration with a revision date of 05/2007, revealed that it is the policy of this facility that oxygen therapy is administered, as ordered by the physician, or as an emergency measure until the order can be obtained. Purpose: The purpose of oxygen therapy is to provide sufficient oxygen to the bloodstream and tissues. Review of R140's Face Sheet revealed that R140 was admitted to the facility on [DATE], with diagnoses including but not limited to: paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic systolic (congestive) heart failure, and nonrheumatic mitral (valve) insufficiency. Review of R140's Physician Order revealed, Oxygen on at 2 LPM (Liters per Minute) via nasal cannula, mask, non-breather continuous, every shift with an active date of 11/22/24. Review of R140's Baseline Care Plan dated 11/24/24, revealed, Has COPD (Chronic Obstructive Pulmonary Disease) The resident has respiratory failure diagnosis with chronic SOB [shortness of breath]. The goal documented, Will be free of s/sx of respiratory infections through the review date. Interventions directed staff to, Give oxygen therapy as ordered by the physician. During observations conducted on 11/24/24 at 12:01 PM and 11/25/24 at 9:12 AM, revealed R140 was lying in bed with the head of bed elevated approximately 45 degrees. R140 was receiving oxygen via nasal cannula at 2.5 LPM, with tubing dated 11/22/24. During an observation on 11/25/24 at 2:40 PM, R140 was receiving oxygen at 1.5 LPM. During an interview with R140 on 11/24/24 at 12:01 PM, revealed she had been admitted to the facility less than a week ago following a hospital stay. R140 states once staff came to talk to her and got her settled in, they hooked her up to the oxygen machine, and that's the last she saw them check the machine. R140 stated she does not know how to maneuver the machine or the settings. During an interview with Registered Nurse (RN)1 on 11/25/24 at 2:44 PM, confirmed to be R140's nurse. RN1 states nurses and respiratory therapists are who check the residents who receive oxygen therapy. RN1 states if a resident requires oxygen, there's an order, located in the resident's EHR. Nurses are to check resident's oxygen machines and tanks, specifically checking to ensure proper rate every shift in the resident order. RN1 confirmed R140 is on oxygen at 2 LPM, via nasal cannula continuously, at all times. When R140 is out of bed, she is to use an oxygen tank, R140 has not been out of bed since admitted . RN1 confirmed the resident's oxygen tank was reading 1.5 LPM. RN1 asked R140 if she touched her oxygen tank and R140 replied no, she didn't know how. During an interview with the Director of Nursing (DON) on 11/26/24 at 11:37 AM, revealed that it is not acceptable for residents not to receive the correct flow rate, especially when a resident is dependent on oxygen continuously. The DON revealed that she had been in her position for approximately 2 weeks, before her role she was the MDS Nurse. The DON stated her expectation is for all pertinent staff to follow Physician orders and for the residents to receive exactly what they are ordered, to have to prevent further decline in residents.

Based on the facility policy, observations and interviews, the facility failed to ensure that drugs and biologicals were properly stored in 2 of 5 treatment/medication carts. Findings include: Review of the facility policy, copyright 2014, titled, Medication Storage in the Healthcare Centers documents, Medications and biological are stored safely, securely, and properly following manufacturer's recommendation or those of the supplier. The medication supply is accessible to licensed nursing personnel and pharmacy personnel. Respiratory Therapist may access medications used in the provision of respiratory services . 3. Nurses are required to check all medications for deterioration and expiration before administration. Nurses are also required to inspect medication storage facilities, including medication carts, routinely. Medication storage areas are to be kept clean, well-lit and free of clutter. Nursing staff who administer medications are responsible for the cleaning and organization of medication carts and storage. During an observation on [DATE] at 11:24 AM, of the Transitional Care Unit (TCU) Treatment Cart revealed the following: Border gauze labeled ,d+[DATE] [NAME] D3, opened and no longer sterile. Maxorb II Alginate wound Dressing 1x 12 rope 1x 12 in (2.5 x 30cm) Ref # MSC7312EP Lot (10) 83624057788 manufacturer Medline exp 2027 05 01, opened and no longer sterile. Swabcap Lot 5855906 Expired 2024 02 01. Maxorb II AG Alginate wound dressing w/ antibacterial silver 4x5 rectangle 4x5 in 910 x 12.5 cm) ref# MSC9945EP manufacturer Medline Expires 2027 05 01 LOT (10) 83624057803, opened and no longer sterile. During an interview on [DATE] at 11:30 AM, Registered Nurse (RN)1, for TCU & Continuing Care Unit (CCU), stated, Once a sterile item is open, we throw it away. During an observation on [DATE] at 11:31 AM, RN1 discarded open and expired items in trash on the medication cart. During an observation on [DATE] at 11:34 AM, of the Continuing Care Unit (CCU) Treatment Cart revealed the following: Curad plain packaging Strip sterile ,d+[DATE] in x 5 yd (1.27 cm x 4. 57m) Ref Non255125, Not labeled, seal broken and not dated. Maxorb II AG Alginate wound dressing w/ antibacterial silver 8 x 12 rectangle 8 x12 (20 x 30cm ) 1 sterile wound dressing Ref MSC 99812EP, opened and no longer sterile. Mesalt 5 x 5 cm/2 x 2 in Sterile manufacturer Molnlycke Lot 23048410, Expires 2025 12 28 Ref 285580, opened and no longer sterile. Maxorb II Alginate wound Dressing 1x 12 rope 1x 12 in (2.5 x 30cm) Ref # MSC7312EP manufacturer Medline Expires 2027 05 01 Lot (10) 83624057788, opened and no longer sterile. Medline Versatel One silicone wound contact layer Ref MSC184SEP , opened and no longer sterile. Hydrofera Blue Classic Antibacterial Foam Dressing Ref HB4414, open and no longer sterile, no label or date. During an interview on [DATE] at 11:51 AM, RN1 stated, each nurse is educated and responsible for their own dressing changes. During an observation on [DATE] at 11:51 AM, RN1 discarded open items in trash on the CCU treatment cart.

Based on facility policy review, record review, observations, and interviews, the facility failed to ensure respiratory equipment was maintained and stored appropriately for three of three residents (Resident (R) 245, R71, and R48) reviewed for respiratory care out of a total sample of 28 residents. The facility's deficient practice increased the resident's risk of respiratory complications. Findings include: Review of the facility's Oxygen Concentrator - Policy and Procedure, dated 04/2022, revealed It is the policy of this facility to provide oxygen in a safe and therapeutic manner using the oxygen concentrator equipment. 1. Review of R245's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed R245 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia (low oxygen levels) and dependence on supplemental oxygen. Review of R245's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/23 and located in her EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R245 was cognitively intact. Review of R245's Physician's Orders, located in the resident's EMR under the Orders tab, revealed Change O2 [oxygen] tubing, H2O [water] bottle and filter every day shift every Thursday. Review of R245's comprehensive Care Plan, under Care Plan tab located in her EMR, revealed no intervention to maintain R245's oxygen filters or external cleaning. During an observation and interview on 02/06/23 at 3:25 PM, R245 confirmed she was administered oxygen therapy. R245's oxygen concentrator filter on the back was unclean and covered with dust (color was gray). R245 had oxygen administered via nasal cannula. The tubes were not dated to identify the last date they were changed. During an interview on 02/08/23 at 8:03 AM with the Respiratory Therapist (RT) revealed she and the maintenance department oversee maintaining the oxygen machines. RT stated she is responsible for the tubing, filters, and concentrators. Upon observation of R245's oxygen machine, RT stated it is her expectation for the filter to be completely clean. RT stated she cleans the filters once a month so it must have gotten that dirty since the last time I cleaned it. RT also stated regarding the undated tubing Honestly, I have not been putting those [the dates] on there. I don't know where I would put it because the tape doesn't stick very well. I guess I could tag it. 2. Review of R71's undated Admission Record, located in the resident's EMR under the Profile tab, revealed R71 was admitted to the facility on [DATE] with diagnoses which included chronic diastolic (congestive) heart failure, atrial fibrillation (irregular heartbeat), and acute and chronic respiratory failure with hypoxia. Review of R71's admission MDS with an ARD of 01/11/23 and located in her EMR under the MDS tab, revealed a BIMS score of 15 out of 15, indicating R71 was cognitively intact. Review of R71's Physician's Orders, located in the resident's EMR under the Orders tab, revealed Change O2 tubing, H2O bottle every day shift every Thursday. There were no orders regarding maintaining R71's oxygen filter. Review of R71's comprehensive Care Plan, under Care Plan tab located in her EMR, revealed no intervention to maintain R71's oxygen filters or external cleaning. During an interview on 02/08/23 at 8:20 AM with the RT, she confirmed that R71 also did not have tubing that was dated and initialed to confirm the last time the tubing was changed. RT stated, I guess I'll start tagging it. RT unscrewed R71's oxygen filter cover to reveal a filter that was dirty and covered with gray dust. RT stated Oh, it's [the filter] way bad. She proceeded to wash the filter in the sink and replaced it in R71's oxygen machine. 3. Review of R48's undated Admission Record, located in the resident's EMR under the Profile tab, revealed R48 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. Review of R48's admission MDS with an ARD of 01/27/23 and located in his EMR under the MDS tab, revealed a BIMS score of 07 out of 15, indicating R48 was cognitively impaired. Review of R48's Physician's Orders, located in the resident's EMR under the Orders tab, revealed Clean O2 concentrator and filter weekly and PRN [as needed] one time a day every Wednesday. Review of R48's comprehensive Care Plan, under Care Plan tab located in his EMR, revealed no intervention to maintain R48's oxygen filters or external cleaning. During an interview on 02/08/23 at 8:30 AM with the RT, she confirmed there were no dates or initials on R48's oxygen tubing to indicate when they had last been changed. RT removed R48's oxygen filter. It was dirty and covered in gray dust. RT stated [the filter is] dirty. The RT proceeded to wash the filter in R48's sink and replaced it.

Based on review of the facility's policy, observation, and interviews, the facility failed to store ice cream in a kitchen freezer at zero degrees Fahrenheit (F) or lower. This had the potential to affect residents who consumed ice cream from the kitchen. Findings include: Review of the facility's policy, dated 2018 and titled, Procedure for Freezer Storage, specified, Frozen foods should be immediately stored in the freezer upon delivery. The freezer should be maintained at a temperature of 0 [degrees] F [Fahrenheit] or lower. Review of the monthly December 2022 and January 2023 temperature logs for the kitchen's chest freezer revealed daily temperatures that ranged from nine degrees F. to 12 degrees F. Further review of these temperature logs revealed the freezer temperature never measured at zero or below. Observations on 02/06/23 at 8:35 AM revealed the interior temperature of the kitchen's chest freezer was measured at ten degrees F. Ice cream was the only food observed stored inside this freezer. Review of the monthly February 2023 temperature log for this freezer revealed from 02/01/23 to 02/06/23 staff documented this freezer's temperature as 12 degrees F. Observations on 02/07/23 at 3:55 PM revealed the interior temperature of the kitchen's chest freezer was measured at 10 degrees F. Ice cream was the only food observed store inside this freezer. Review of the freezer's monthly February temperature log revealed on 02/07/23 staff documented this freezer was operating at nine degrees F, all other temperatures were documented at 12 degrees F. Observations on 02/08/23 at 8:45 AM, revealed the kitchen's chest freezer interior temperature was measured at 10 degrees Fahrenheit. Ice cream was the only food observed stored inside this freezer. Observations of ice cream stored inside this freezer revealed they were not completely frozen. Temperature monitoring of one of the single serve ice creams revealed it measured at a temperature of 21 degrees F. During an interview on 02/08/23 at 8:45 AM, the Dietary Manager (DM) stated the dietary staff had not reported to the maintenance department about this freezer operating at temperatures above zero degrees F., during the past two months. The DM stated the maintenance department should have been notified the chest freezer was operating at temperatures above zero degrees F. During an interview on 02/08/23 at 9:39 AM, the Administrator verified that the ice cream freezer was documented above zero degrees for the months of December 2022, January 2023, and February 1 through 7, 2023.

Based on facility policy review, document review, and interviews, the facility failed to complete resident assessments (Minimum Data Set (MDS)) quarterly (every 3 months) for one (Resident (R) 66) of the 28 residents reviewed for Resident Assessment. Findings include: Review of the facility policy ''Resident Assessment,'' Revised in March of 2022, revealed PPS Assessments .1. The resident assessment coordination is responsible for the ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirement: .(2) Quarterly Assessments. Review of R66's electronic medical record (EMR) Census tab revealed an admitted [DATE]. Review of the EMR MDS tab revealed R66's last assessment was a comprehensive MDS assessment completed 09/15/22. The facility failed to perform the next quarterly assessment. During an interview with the Director of Nursing, DON, on 02/08/23 at 3:15 PM she stated, I am unsure why that assessment was missed, I will look into that. During an interview with the MDS Coordinators, (MDSC 1 and MDSC 2) on 02/08/23 at 3:30 PM it was confirmed they missed one of R66's Quarterly Assessments and did not know they missed it.

Based on observation, record review and staff interview, the facility failed to maintain an effective pest control program, evidenced by observations and consistent discovery of live pests inside the kitchen and dining room during the three-day survey. This failure has the potential to affect multiple residents. Findings include: A tour of the facility's kitchen, dishwasher area, dry storage area, and outside dumpster area was conducted on 6/27/21 at 12:43 p.m. with the Certified Dietary Manager (CDM). An observation of the main kitchen and preparation area revealed flying insects buzzing around the preparation area containing the tray line. A wall mounted glue board light fly trap was observed on the wall near the door leading directly outside. An observation of the refuse dumpster located in a gated enclosure outside of the kitchen revealed that the lids were closed, and the unit was underneath a pine tree. An observation of the ground area around the base of the dumpster revealed several items of trash on the ground. Items included: empty food containers, gloves, and other unidentified trash items. Flying insects were observed in the immediate vicinity. An interview was conducted with the CDM on 6/27/21 at 12:50 p.m. during the tour. The CDM stated that the facility was in the process of getting a second light fly trap for the area near the exit of the kitchen. Observations of the dining room located next to the kitchen, on 6/27/21 through 6/30/21 revealed that the dining room contained several flying insects. The dining room contained an emergency exit door that led directly outside and contained gaps large enough to allow pest access. Flying insects were observed by members of the survey team entering the room through the gaps in the door. A second dumpster located on the other side of the facility was observed with an open lid on 6/27/21 from 10:00 a.m. until 3:30 p.m. Staff were observed disposing of bagged trash periodically throughout the day in the second dumpster. An interview with the Administrator was conducted on 6/29/21 at 9:10 a.m. The Administrator provided invoices for the services rendered by the pest control agency dated from January 2021 to present. The Administrator also provided copies of maintenance service requests dated from January 2021 to present. An inquiry was made regarding any documented recommendations for preventative measures made by the pest control agent to assist with pest prevention. The Administrator stated that the agent made verbal recommendations but would check with the maintenance director regarding any documented recommendations to help with pest prevention. Review of the pest control invoices from January 2021 - June 2021 revealed that the invoices did not contain any information regarding recommendations for prevention of pests. The invoices only noted the dates of services and chemicals used. No pest control policy was provided by the facility. An observation of the facility's kitchen, dishwasher area, and outside area was conducted on 6/29/21 at 11:36 a.m. with the Certified Dietary Manager (CDM). An observation of the main kitchen and preparation area revealed flying insects buzzing around the area. Several flying insects were observed buzzing around the dishwashing area. A fly was observed on the outside of the wall mounted glue board light fly trap. An observation of the refuse dumpster located in the gated enclosure outside of the kitchen revealed that the lids were closed but the ground area around the base of the dumpster still contained several items of trash on the ground. Items included: empty food containers, gloves and other unidentified items. Flying insects were observed in the immediate vicinity. An interview was conducted with the CDM on 6/29/21 at 11:47 a.m. The CDM stated that the she had asked maintenance to pick up the trash and would request it to be done again. The CDM confirmed that existence of the flying insects and observed the insects in the kitchen and agreed that an air curtain or similar device would be helpful in keeping insects out of the kitchen and building. An interview with Administrator was conducted on 6/29/21 at 12:33 p.m. The Administrator brought in an invoice for a recently ordered air curtain device. Review of the invoice confirmed that the delivery date would approximately be between July 7-12, 2021. The Administrator confirmed that there were no documented recommendations for prevention. The Administrator stated that the only recommendation from the pest control agent was to continue receiving pest control applications. The Administrator confirmed that existence of the insects and confirmed that entry points in the door leading directly outside. The Administrator expressed an understanding that the effectiveness of the pest control program included a prevention component.

Based on observation, interview, and record review, the facility failed to ensure transmission-based precautions were implemented for two of five sampled residents (Resident #2 and Resident #3). This failure has the potential to negatively affect all residents receiving care in the facility. Findings include: Observations conducted on 06/09/2020 at 11:00 AM revealed the facility had a unit designated for the isolation of newly admitted residents who were awaiting two negative COVID-19 results. Observations on 06/09/2020 at 11:00 AM included the rooms where Resident #2 and Resident #3 were residing in the designated unit in the facility. The observations revealed no indication that Resident #2 and Resident #3 were on transmission-based precautions. Transmission-based precautions include contact and droplet precautions. Contact precautions require the use of Personal Protective Equipment (PPE) of gloves and gowns while providing care. Droplet precautions require the use of PPE of gloves, gowns, and a mask or respirator when providing care. Use and disposal of the proper PPE helps prevent the spread of infection. On 06/09/2020 at 4:39 PM, an interview was conducted with Licensed Practical Nurse (LPN) #7. LPN #7 stated that residents who were placed on transmission-based precautions have PPE and signs posted outside their room doors to alert staff to don PPE prior to entering the resident's room. On 06/09/2020 at 4:42 PM, an interview was conducted with the Registered Dietician (RD). The RD stated that s/he had been trained on the proper use of PPE and would know to utilize PPE by the posting of signs on the residents' doors and PPE being available outside the room. Observations on 06/09/2020 at 11:00 AM revealed no PPE or signage posted outside the doors of Resident #2's and Resident #3's rooms. 1. A review of the electronic health record (EHR) revealed Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Admission documents found in the EHR revealed Resident #2 had a negative COVID19 test on 06/05/2020 at the hospital prior to admission to the facility. Review of the EHR physician orders [REDACTED].#2's admission. Further review of the EHR revealed results from a second COVID19 test, administered on 06/08/2020, had not been received by the facility as of 6:00 PM on 06/09/2020. In a follow-up interview conducted on 06/09/2020 at 6:30 PM, the Administrator stated the results of Resident #2's second COVID19 test was received by the facility on 06/09/2020 at approximately 6:15 PM. The Administrator stated that the result of Resident #2's second test was negative for COVID19. 2. A review of the EHR revealed Resident #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The EHR for Resident #3 indicated the resident received a COVID19 test on 06/02/2020 at 12:48 PM at the hospital prior to admission and a second COVID19 test was administered on 06/03/2020 at 11:30 AM (approximately 22 hours and 42 minutes between testing). A review of the physician orders [REDACTED].#3 was placed on transmission-based precautions at the time of admission and was removed from transmission-based precautions on 06/04/2020 based on the negative results of the second COVID19 test. On 06/09/2020 at 12:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that s/he was responsible for the infection prevention and control program of the facility and that transmission-based precautions were implemented for all newly admitted residents. The DON stated that the facility used a test-based strategy for discontinuing the use of transmission-based precautions. The DON further stated that once a newly admitted resident received two negative COVID19 tests, transmission-based precautions were discontinued. Once transmission-based precautions were discontinued then the requirement to use PPE, specifically gowns and respirators, when caring for the resident is discontinued. However, the DON did not provide an explanation for why Resident #2 did not have an order to be placed on transmission-based precautions at the time of the resident's admission to the facility. During a follow-up interview with the DON on 06/09/2020 at 2:25 PM, the DON confirmed that Resident #2 never received an order to be placed on transmission-based precautions at the time of admission to the facility. In addition, the DON confirmed that Resident #3 was taken off of transmission-based precautions on 06/04/2020 based on the test results of the resident's second COVID19 test done on 06/03/2020. The DON confirmed that Resident #3's second test was collected before the required 24-hour time period between each COVID19 test was reached. On 06/09/2020 at 2:40 PM, an interview was conducted with the facility Administrator. The Administrator stated that the facility required two confirmed negative COVID19 tests for newly admitted residents before discontinuing the use of transmission-based precautions and the use of PPE while providing care. In addition, the Administrator stated that he was not aware Resident #2 did not have an order for [REDACTED].#3's second COVID19 test was collected prior to the required 24-hour time period between each COVID19 test. Review of facility policy titled, Emerging Infectious Disease (ElD): Coronavirus Disease 2019 (COVID-19), revised 04/08/2020, stated that the facility will ensure facility policies and practices are in place to minimize exposures to respiratory pathogens including [DIAGNOSES REDACTED]-COV-2, [MEDICAL CONDITION] that causes COVID19. Measures should be implemented before patient arrival, upon arrival, throughout the duration of the patient's visit, and until the patient's room is cleaned and disinfected. The policy further indicated that newly admitted residents were to be isolated in private rooms for 14 days and transmission-based precautions would be implemented. In addition, the policy indicated the facility will, adhere to Standard and Transmission-Based Precautions. The policy further stated that the decision to discontinue Transmission Based Precautions should be made using a test-based strategy (two negative tests) or a non-test-based strategy (i.e., time-since-illness-onset and time since recovery strategy) . The policy also refers to the guidance provided by the Centers for Disease Control (CDC) requiring a second COVID19 test to be completed by the facility, equal to or greater than 24 hours after the first COVID19 test.

Based on observation and interview, the facility failed to discard expired foods from a reach-in cooler and the emergency food supply for one of one kitchens observed. Findings: During the initial kitchen observation on [DATE] at 9:19 AM, the surveyor and certified dietary manager (CDM) noticed an unopened 5 pound box of potatoe salad with a used by day of [DATE]. On [DATE] at 4:00 PM, during emergency food supply observation and review, six #10 cans of Pear slices and seven # 2.5 cans of cream of celery expired on ,[DATE]. The CDM was present during the observation and review. S/he confirmed that these items expired on ,[DATE].

Based on observations, interviews and facility policy the facility failed to assure that medications were securely stored in 1 of 2 medication rooms. The findings include: On 2/4/20 at approximately 9:48 AM the Station One Medication Room was observed open with an unaccompanied [ENTITY] representative inside the room. On 2/4/20 at approximately 9:50 AM s/he stated that a nurse let him into the medication room to exchange oxygen tanks which are stored there. On 2/4/2020 at approximately 9:57 AM, when asked about access to the medication room, RN (Registered Nurse) # 1 stated Isn't the oxygen guy in there? indicating RN#1 was aware the Oxygen Supply representative was in the Medication Room unaccompanied. On 2/4/20 at approximately 10:11 AM the Station One Medication Room was inspected and revealed unlocked cabinets which contained over-the-counter floor stock medications and 10 milliliter syringes of [MED] Chloride 0.9 % (percent) for Injection. On [DATE] at approximately 10:37 AM the Administrator provided a copy the Medication Storage in the Healthcare Centers policy revised 9/15/17. A review of the policy revealed under Policy Statement The medication supply is accessible only to licensed nursing personnel and pharmacy personnel, under Scope This policy applies to all licensed nursing staff of a [ENTITY] and under Procedure: 2. Only licensed nurses and the pharmacy personnel are allowed access to medications. On 2/4/20 at approximately 10:59 AM RN # 1 stated that one of the nurses must have let the oxygen supplier in the med room and didn't stay with him. On 2/4/20 at approximately 1:06 PM the Director of Nursing stated there should have been a licensed staff member with her/him in the Medication Room.

Based on record review, interview, and review of the facility policy titled, Abuse: Prevention of and Prohibition Against the facility failed to ensure Resident #11 was free from abuse related to misappropriation of the resident's property related to diversion of narcotic medication. The findings included: The facility admitted resident # 11 on 04/11/2018 with [DIAGNOSES REDACTED]. Review of the Facility's Five Day Report on 11/25/2019 at approximately 10:00 AM revealed that at approximately midnight between 03/10/2019 and 03/11/2019, Licensed Practical Nurse (LPN) # 1 observed a potentially missing [MEDICATION NAME] 10/325 milligrams (mg) for Resident #11 on the Transitional Care Unit (TCU) medication cart #2. She stated that upon removing the card, a pill fell out of the card and into the lock box. She removed the pill. On 03/10/2019 at approximately 11:30 PM she identified it based on the number imprinted on the pill as Tylenol Extra Strength 500 mg. She had another nurse verify that the pill she observed falling out of the narcotic card was not the [MEDICATION NAME] as ordered for Resident #11. She observed that the narcotic card appeared to be tampered with and what she identified as another Tylenol Extra Strength 500 mg in the card. LPN #1 ensured that Resident #11 received his pain medication and stated that he did not appear to be in pain or verbalize any pain. Further review revealed that LPN #1 notified the Director of Nursing (DON) via voicemail of the missing medication. The DON and the Assistant Director of Nursing (ADON) arrived that AM and completed an audit of all medication cart controlled substances and it was determined that two [MEDICATION NAME] 10/325 mg pills were missing. No other controlled substance pill cards were noted to be tampered with during the 100% audit. LPN #1 stated that her control substance count was correct at the beginning of her shift and she did not notice any evidence of tampering with the medication cards at that time. LPN #2, the oncoming nurse, stated that she would waste the two pills identified as Tylenol. LPN #1 advised LPN #2 to leave the remaining pill believed to be Tylenol in the card for review per the DON, but LPN #2 punched it out into a cup. After LPN #2 had a meeting with the DON and Executive Director, she was informed of her suspension pending the investigation. LPN #2 stated she was in need of seeking medical attention and left the facility and never returned. No documentation existed as proof that the two missing pills were administered or destroyed. As a result of the facility's investigation, LPN # 2 was terminated and reported to the State Board of Nursing for possible drug diversion.

Based on record review and interview, the facility failed to provide supervision to resident #1, who repeatedly interfered with intravenous access, causing repeated visits to the emergency room for intervention. 1 of 3 residents reviewed for a peripheral intravenous central catheter (PICC) line use. The findings included: Cross refer to F157, Notification of resident pulling out PICC line, INT's, removal/discontinuing IV (intravenous) antibiotics. The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed Nurses Notes from 2/17/17-3/15/17. Resident received [MED] and [MED] via double Lumen PICC line to right upper arm for an infected blood clot in the lung. Review of the Nurses Notes revealed: 2/22/17: PICC would not flush. Hospital placed an IV in left antecubital so resident could receive antibiotic. 2/26/17: Upon walking in the room to check on patient IV bag noted IV not on pole. IV bag in the bed with resident almost completely full. Patient clamped the PICC line her/himself to prevent the medication form running probably. 3/4/17: Resident returned from hospital after pulling out PICC line during day shift. Hospital placed INT 3/5/17: Resident has had 4 PICC lines placed. 3/6/17: Resident is experiencing some behavioral disturbance related to dementia and non-compliance with medication regimen including antibiotic administration via iv/picc. Resident pulled PICC line out on 3/4/17 and went out to hospital to have it replaced. Hospital was unable to replace line due to radiology being unavailable. Hospital placed a INT in right hand to administer medications until Monday. On 3/5/17 resident pulled INT out and nurse was unable to establish a new line. Resident has been educated on need for ABX (antibiotic) and continues to be non-compliant at times. No access present at this time for antibiotic therapy. 3/9/17: Resident allowed nurse to administer half the antibiotic via int access then took them down her/himself. Resident has been educated several times. In an interview with the surveyor on 6/27/16 at 11:55 AM the Director of Nursing stated s/he kept pulling out her/his PICC line. We did some education and s/he would be in agreement. We tried to make sure s/he got her/his antibiotics. We notified his family and his son tried to talk to him about it.

Based on observation, record review, interview, manufacturer package inserts, product labeling, and pharmacy labeling, the facility failed to ensure that residents were free of significant medication errors. During inspection of 3 of 5 medication carts it was determined that Resident's #13, #14 and #15 received outdated insulin; Resident #12 received improperly stored and outdated [MEDICATION NAME] and Resident #22, 1 of 8 residents reviewed for pain received the wrong dose of [MEDICATION NAME]. The findings included: CFR 483.60(a) & (b)(1) Pharmacy Services, F425 was identified at Immediate Jeopardy with a scope and severity of K related to the failure of the facility to ensure that expired medications were not being stored with other medications. [MEDICATION NAME] for Resident #12 was improperly stored with other medications. Insulin for Residents #13, #14, and #15 was stored with other medications after discard/expired dates. CFR 483.60(e) Storage of Drugs and Biologicals, F431 was identified at Immediate Jeopardy with a scope and severity of K related to the failure of the facility to ensure that medications were being stored under proper temperature control. Failure to store [MEDICATION NAME] under proper temperature control for Resident #12 resulted in the potential for clinically significant adverse consequences. Subsequent to finding expired insulins and expired/improperly stored [MEDICATION NAME] 20 % (percent) in 3 of 5 medication carts a review of the physicians orders and MAR (Medication Administration Record) was conducted revealing the following: A review of the April and May, 2015 Physicians Orders and MARs for Resident #13 provided by RN (Registered Nurse) #4 on 5-4-15 at approximately 2:30 PM revealed that the expired [MEDICATION NAME] had been administered 5 times between 4-10-15 and 5-3-15. The Facility admitted Resident #13 with [DIAGNOSES REDACTED]. A review of the April and May, 2015 Physicians Orders and MARs for Resident #14 provided by RN (Registered Nurse) #4 on 5-4-15 at approximately 2:40 PM revealed that expired [MEDICATION NAME] had been administered 36 times between 4-15-15 and 5-3-15. The Facility admitted Resident #14 with [DIAGNOSES REDACTED]. A review of the April and May, 2015 Physicians Orders and MARs for Resident #15 provided by RN (Registered Nurse) #4 on 5-4-15 at approximately 2:55 PM revealed that the expired [MEDICATION NAME] had been administered 5 times between 4-28-15 and 5-3-15. The Facility admitted Resident #15 with [DIAGNOSES REDACTED]. A review of the March, April and May, 2015 Physician order [REDACTED].#12 provided by RN #4 on 5-4-15 at approximately 3:20 PM revealed an order for [REDACTED]. The Facility admitted Resident #12 on 3-10-15 with [DIAGNOSES REDACTED]. On 5-6-15 at approximately 12:45 PM during a telephone interview, Agape Pharmacy reviewed the [MEDICATION NAME] 20 % dispensing records for Resident #12 and stated that the following had been dispensed for Resident #12: 3-10-15: 3 x 30 ml vials (90 ml), 4-01-15: 3 x 30 ml vials (90 ml), 5-04-15: 3 x 30 ml vials (90 ml). Dispensing on 5-04-15 occurred after the pharmacy opened at 8:00 AM. Further review of this March, April and May MARs on 5-6-15 at approximately 2:10 PM revealed that a total of 6 bottles (180 ml) or ninety (90) 2 ml doses of [MEDICATION NAME] 20% had been dispensed between 3-10-15 and when TCU (Transitional Care Unit) medication cart #2 was inspected on 5-4-15 at approximately 8:12 AM. Each 30 ml bottle contained fifteen (15) 2 ml doses. No doses were administered on 3-10-15. If all bottles dispensed (180 ml) had been refrigerated for 96 hours after opening, then discarded as specified by the manufacturer and the pharmacy, there would have been enough dispensed to administer 90 doses, yet 193 doses had been charted as given. Resident #22 was admitted to the facility on [DATE]. Review of Resident #22's Telephone Physician order [REDACTED]. Review of Resident #22's MAR for March 2015 revealed [MEDICATION NAME] 4 milligrams was signed as given on 3/7/15 at 11:40 AM for pain. Review of the Agape Senior West Columbia Stat Kit Replacement Only form completed for Resident #22 revealed the resident received 1 [MEDICATION NAME] 2 milligram tablet on 3/7/15. Further review of the resident's MAR for March 2015 revealed an N documented at 2:13 AM on 3/9/15 for [MEDICATION NAME] 4 milligram tablet every 3 hours as needed. Review of the Administration Records revealed at 3:06 AM on 3/9/15 the nurse documented the medication was effective. In an interview with the surveyor on 5/6/15 at approximately 3:55 PM, the nurse consultant stated that only 1 tablet of [MEDICATION NAME] 2 milligrams was given to Resident #22 on 3/7/15. The nurse consultant stated s/he was not sure why only 2 milligrams was given instead of 4 milligrams. The nurse consultant stated that s/he could not provide the log of [MEDICATION NAME] given from the e-kit to show tracking of the amount of tablets removed from the e-kit. The nurse consultant also stated the N on the 3/9/15 [MEDICATION NAME] order meant there was no dose given. The nurse consultant stated s/he was not sure why the nurse documented the medication was effective. The nurse consultant stated that the e-kit sheet on 3/7/15 for [MEDICATION NAME] 2 milligrams was the only e-kit sheet for Resident #22. The Allegation of Compliance (AOC) was submitted, reviewed, and approved on 5/6/15 at 4:00 PM: 1. Licensed staff will not administer medication that are expired or not stored properly. Medical Director was notified of possible medication administered expired or not stored properly on resident #12,#13,#14, & #15. Medication for resident #12 was discontinued. New insulin pens ordered for #13, #14, #15. All expired medications were discarded immediately. 2. All residents with orders for insulin or Acetylcyst have the potential to be affected. 3. An audit was conducted by Staff and Pharmacy on 5-4-2015 of all residents with insulin pens/Vials and orders for acetylcyst to ensure no cases of expired or improperly stored medications are on carts or in medication room. All 5 medication carts and 2 medication rooms audited for any expired medications. During the audit, medication that was improperly stored or expired was discarded and new medications ordered. No additional residents on acetylcyst. 4. All nursing staff was in-serviced on 5-4-15 by Corporate Clinical Specialist, Director of Nursing and/or Pharmacy regarding medication expiration dates and storage policy and procedure, prior to next shift, continuing until all nursing staff have been in-serviced. No employees will be allowed to work until the training has been completed. Insulin pens and vials will be labeled by pharmacy with bright orange stickers that list date open and date expires blanks for licensed nursing staff to write the open date and expires. Insulin pens and vials will be maintained in the refrigerator if un-opened. Opened pens or vials of insulin will be maintained in the cart for administration until expiration date, then will be discarded. Pharmacy has ordered alternate larger colored refrigerate labels for medication to easily identify items needing refrigeration. Observations, record reviews, and interviews revealed the AOC submitted by the facility on 5/6/15 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. The Administrator was informed of this on 5/6/15 at approximately 4:00 PM and the Immediate Jeopardy at F333, F425, and F431 was removed with the Scope and Severity of each citation lowered to an E.

Based on observation, record review, interview, manufacturer package inserts, product labeling, and pharmacy labeling the facility failed to provide pharmaceutical services to meet the needs of residents. Expired medications were given and stored with other medications for 3 of 5 medication carts observed. Acetylcysteine for Resident #12 was administered after it expired and improperly stored with other medications. Insulin for Residents #13, #14, and #15 was administered after it expired and stored with other discard/expired medications. The findings included: CFR 483.25(m)(2) Free of any Significant Medication Errors, F333 was identified at Immediate Jeopardy and Substandard Quality of Care with a scope and severity of K related to the failure of the facility to ensure that 4 residents were free of significant medication errors. Resident #12 received multiple doses of expired and improperly stored acetylcysteine. Residents #13, #14, and #15 received multiple insulin doses after expired/discard dates. CFR 483.60(e) Storage of Drugs and Biologicals, F431 was identified at Immediate Jeopardy with a scope and severity of K related to the failure of the facility to ensure that medications were being stored under proper temperature control. Failure to store acetylcysteine under proper temperature control for Resident #12 resulted in the potential for clinically significant adverse consequences. On 5-4-15 at approximately 7:35 AM inspection of the TCU (Transitional Care Unit) medication cart # 1 revealed the following: -One opened Novolog FlexPen (insulin aspart) belonging to Resident #13, which had been dated by the facility as having been opened on 3-12-15. The Novolog FlexPen had been labeled not to use 28 days after opening and the manufacturer's package insert stated Cartridges and pens that have been punctured (in use), should be stored at temperatures below 30 degrees Centigrade (86 degrees Fahrenheit) and used within 28 days, do not freeze or refrigerate. RN (Registered Nurse) #1 verified that the Novolog Flexpen expired on 4-9-15 and stated that it was rarely used. On 5-4-15 at approximately 8:12 AM inspection of the TCU medication cart # 2 revealed the following: -One opened and unrefrigerated 30 ml (milliliter) bottle of Acetylcysteine Solution 20 % (percent), USP (United States Pharmacopoeia) belonging to Resident #12, which had been dated by the facility as having been opened on 4-4-15. The bottle had been labeled by the manufacturer and the pharmacy, Use within 96 hours of opening. Store in refrigerator after opening. RN #2 stated that s/he was unaware of the labeling requirements and that the bottle was still being used during nebulizer therapy to Resident # 12. ¡¡ On 5-4-15 at approximately 9:07 AM, inspection of the CCU (Comprehensive Care Unit) medication cart 2 revealed the following: -One opened Lantus SoloStar (insulin glargine) belonging to Resident #14, dispensed 3-18-15 had not been dated as to when it was opened or an expiration date. The manufacturer's package insert stated: The opened (in-use) SoloStar must be discarded 28 days after being opened. RN #3 verified on 5-4-15 at approximately 9:15 AM that the Lantus SoloStar expired on 4-15-15 and stated that it had probably been opened when received on 3-18-15 and was being used to administer insulin to Resident #14. The Facility admitted Resident #14 on 10-29-14 with [DIAGNOSES REDACTED]. -One opened Lantus Insulin vial belonging to Resident #15 and dated as opened on 3-30-15. The manufacturer package insert stated: Once punctured (in use), store vials refrigerated or at room temperature lower than 30 degrees C (centigrade) (lower than 86 degrees F (Fahrenheit) and use within 28 days. RN #3 verified on 5-4-15 at approximately 9:15 AM that the Lantus Insulin vial (insulin glargine) was expired on 4-28-15 and was being used to administer insulin to Resident #15. The Facility admitted Resident #15 on 5-26-14 with [DIAGNOSES REDACTED]. On 5-4-15 at approximately 2:55 PM, inspection of the CCU medication room refrigerator revealed one opened, not dated floor stock vial of Tuberculin, Purified Protein Derivative 5 TU (test units)/0.1 ml (milliliter) (10 tests), 1 ml Rx 4, dispensed on 4-15-15. RN #3 verified that the medication had not been dated when opened. The manufacturer label on the vial stated that the medication should not be used more than 30 days after opening. Facts and Comparison, page 2001, stated Discard vials in use for more than 30 days because of possible oxidation and degradation that may affect potency. This finding was verified by RN #3 on 5-4-15 at approximately 3:00 PM. During an interview on 5-4-15 at approximately 3:40 PM, RN #4 stated that it was the facility policy for nurses and pharmacy to assure proper storage of medications and provided a facility policy on Storage of Medications and Pharmacy Inspection Reports for April 2015. The Storage of Medications policy stated: 2. The nursing staff shall be responsible for maintaining, medication storage AND preparation areas in a clean, safe and sanitary manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. 9. Medications requiring refrigeration must be stored in a refrigerator located in a refrigerator located in the drug room at the nurses' station or other secured location. The pharmacy Inspection Report dated 4-6-15 revealed: TCU Cart 1 and Med Room: 21. All medications are within expiration date; 27. Proper storage of all medications: [REDACTED]. Multiple pens of the same insulin are being stored on the cart. TCU Cart 2: 21. All medications are within expiration date; 27. Proper storage of all medications -YES checked. CCU Cart 2 and Med Room: 21 All medications are not within expiration date. The Allegation of Compliance (AOC) was submitted, reviewed, and approved on 5/6/15 at 4:00 PM: 1. Licensed staff will not administer medication that are expired or not stored properly. Medical Director was notified of possible medication administered expired or not stored properly on resident #12,#13,#14, & #15. Medication for resident #12 was discontinued. New insulin pens ordered for #13, #14, #15. All expired medications were discarded immediately. 2. All residents with orders for insulin or Acetylcyst have the potential to be affected. 3. An audit was conducted by Staff and Pharmacy on 5-4-2015 of all residents with insulin pens/Vials and orders for acetylcyst to ensure no cases of expired or improperly stored medications are on carts or in medication room. All 5 medication carts and 2 medication rooms audited for any expired medications. During the audit, medication that was improperly stored or expired was discarded and new medications ordered. No additional residents on acetylcyst. 4. All nursing staff was in-serviced on 5-4-15 by Corporate Clinical Specialist, Director of Nursing and/or Pharmacy regarding medication expiration dates and storage policy and procedure, prior to next shift, continuing until all nursing staff have been in-serviced. No employees will be allowed to work until the training has been completed. Insulin pens and vials will be labeled by pharmacy with bright orange stickers that list date open and date expires blanks for licensed nursing staff to write the open date and expires. Insulin pens and vials will be maintained in the refrigerator if un-opened. Opened pens or vials of insulin will be maintained in the cart for administration until expiration date, then will be discarded. Pharmacy has ordered alternate larger colored refrigerate labels for medication to easily identify items needing refrigeration. Observations, record reviews, and interviews revealed the AOC submitted by the facility on 5/6/15 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. The Administrator was informed of this on 5/6/15 at approximately 4:00 PM and the Immediate Jeopardy at F333, F425, and F431 was removed with the Scope and Severity of each citation lowered to an E.

Based on observation, record review, interview, manufacturer package inserts, product labeling, and pharmacy labeling, the facility failed to ensure that medications were being stored under proper temperature control during inspection of 1 of 5 medication carts. Failure to store acetylcysteine under proper temperature control for Resident #12 resulted in the potential for clinically significant adverse consequences The findings included: CFR 483.25(m)(2) Free of any Significant Medication Errors, F333 was identified at Immediate Jeopardy and Substandard Quality of Care with a scope and severity of K related to the failure of the facility to ensure that a resident was free of significant medication errors. Resident #12 received multiple doses of improperly stored acetylcysteine. On 5-4-15 at approximately 8:12 AM inspection of the TCU (Transitional Care Unit) medication cart #2 revealed the following: -One opened and unrefrigerated 30 ml (milliliter) bottle of Acetylcysteine Solution 20 % (percent), USP (United States Pharmacopoeia) belonging to Resident # 12 which had been dated by the facility as having been opened on 4-4-15. The bottle had been labeled by the manufacturer and the pharmacy, Use within 96 hours of opening. Store in refrigerator after opening. Registered Nurse #2 stated that s/he was unaware of the labeling requirements and that the bottle was still being used during nebulizer therapy to Resident #12. During an interview on 5-4-15 at approximately 3:40 PM, RN #4 stated that it was the facility policy for nurses and pharmacy to assure proper storage of medications and provided a facility policy on Storage of Medications and Pharmacy Inspection Reports for April 2015. The Storage of Medications policy stated: 2. The nursing staff shall be responsible for maintaining, medication storage AND preparation areas in a clean, safe and sanitary manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. 9. Medications requiring refrigeration must be stored in a refrigerator located in a refrigerator located in the drug from at the nurses' station or other secured location. The pharmacy Inspection Report dated 4-6-15 revealed: TCU Cart 2: 21. All medications are within expiration date; 27. Proper storage of all medications - YES checked. The Allegation of Compliance (AOC) was submitted, reviewed, and approved on 5/6/15 at 4:00 PM: 1. Licensed staff will not administer medication that are expired or not stored properly. Medical Director was notified of possible medication administered expired or not stored properly on resident #12,#13,#14, & #15. Medication for resident #12 was discontinued. New insulin pens ordered for #13, #14, #15. All expired medications were discarded immediately. 2. All residents with orders for insulin or Acetylcyst have the potential to be affected. 3. An audit was conducted by Staff and Pharmacy on 5-4-2015 of all residents with insulin pens/Vials and orders for acetylcyst to ensure no cases of expired or improperly stored medications are on carts or in medication room. All 5 medication carts and 2 medication rooms audited for any expired medications. During the audit, medication that was improperly stored or expired was discarded and new medications ordered. No additional residents on acetylcyst. 4. All nursing staff was in-serviced on 5-4-15 by Corporate Clinical Specialist, Director of Nursing and/or Pharmacy regarding medication expiration dates and storage policy and procedure, prior to next shift, continuing until all nursing staff have been in-serviced. No employees will be allowed to work until the training has been completed. Insulin pens and vials will be labeled by pharmacy with bright orange stickers that list date open and date expires blanks for licensed nursing staff to write the open date and expires. Insulin pens and vials will be maintained in the refrigerator if un-opened. Opened pens or vials of insulin will be maintained in the cart for administration until expiration date, then will be discarded. Pharmacy has ordered alternate larger colored refrigerate labels for medication to easily identify items needing refrigeration. Observations, record reviews, and interviews revealed the AOC submitted by the facility on 5/6/15 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. The Administrator was informed of this on 5/6/15 at approximately 4:00 PM and the Immediate Jeopardy at F333, F425, and F431 was removed with the Scope and Severity of each citation lowered to an E.

On the days of the complaint inspection, based on record reviews, observation, and interviews, the facility failed to provide adequate supervision and implementation of functional devices and fall prevention measures to prevent accidents for two of three residents reviewed for falls. The facility failed to provide fall prevention interventions post hospitalization resulting in Resident #10 sustaining a second hip fracture. Although no significant changes were noted in the resident's mental status from date of discharge (7-23-13) to readmission (7-29-13), the amount of assistance required with activities of daily living increased, and the resident was at high risk for falls based on the facility's assessment, the facility failed to reinstate fall precautions upon readmission that were present prior to hospitalization . Resident # 2, with a history of falls had a non-functional pad alarm in place. The findings included: The facility admitted Resident #10 initially on 5-30-13 for short-term rehabilitation following a fall resulting in a right femoral fracture. [DIAGNOSES REDACTED]. Record review on 10-10-13 at 3:55 PM revealed that Resident # 10 was sent to the hospital on 7-23-13 and admitted for Acute Respiratory Failure secondary to Flash Pulmonary Edema. S/he was readmitted to the facility on [DATE]. Review of the 7-23-13 Discharge Minimum Data Set Assessment revealed that Resident #10 was discharged "with return anticipated." The resident was noted with a short-term memory problem and signs and symptoms of delirium. S/he had fluctuating difficulty focusing attention, disorganized thinking, and altered level of consciousness. The resident exhibited wandering behavior 4-6 days during the look-back period. S/he required limited assistance with all activities of daily living and was frequently incontinent of bowel and bladder. Section J noted history of a fall since the prior assessment. Section N noted no psychoactive medications administered in the previous seven days. Review of the 8-3-13 Five Day/Discharge Minimum Data Set (MDS) Assessment revealed that the resident had a Brief Interview for Mental Status score of 12. Resident #10 was noted with signs and symptoms of delirium. S/he had fluctuating ability focusing attention, disorganized thinking, and altered level of consciousness. S/he required extensive assistance with all activities of daily living (except eating) and was frequently incontinent of bowel and bladder. Balance was noted as unsteady during transfers. Review of Resident Incident Reports on 10-10-13 at 4:15 PM revealed that Resident #10 was "guided to the floor on 7-17-13 at 2:30 PM when the "Therapist observed resident getting out of w/c (wheelchair). Resident became unsteady." Risk factors noted on the form related to the incident included a history of falls, confusion/disorientation, and incontinence. Immediate Post-Incident Action was to "Re-educate on locking brakes on w/c before standing." Review of the 7-17-13 Daily Skilled Nurse's Notes revealed no reference to an alarm or any other fall prevention measures in place. On 8-3-13, just five days after readmission, Resident #10 was "lying on the floor when nurse arrived. 3 CNA's (Certified Nursing Assistants) in the room with patient... lifted her (him) off the floor and placed her (him) in w/c." The section on the report entitled "Resident Condition at Time of Incident" was not completed. Immediate Post-Incident Action noted "Interventions in place", but did not specify which specific interventions were in use at the time of the fall. Review of the Medication/Treatment Administration Records revealed no fall prevention measures documented as in use from 7-29-13 to date of the 8-3-13 fall. Review of the 7-29-13 Admission Assessment revealed that Resident # 10 suffered from Anxiety. Section B Resident Status noted that the resident was confused, withdrawn, and incontinent of bowel and bladder. The resident was noted as dependent for bed mobility and transfers. Review of the 8-3-13 Daily Skilled Nurse's Note revealed that the resident continued to have both short- and long-term memory problems, had an unsteady gait and balance problems. Record review on 10-10-13 at approximately 4:25 PM revealed a 5-31-13 physician's orders [REDACTED]." Review of the Care Plan dated 6-12-13 revealed no reference to the pad alarm. Though the resident was noted with short-term memory deficit, the Care Plan was updated following the 7-17-13 fall with an approach to "Reeducate locking of brakes on w/c prior to standing." Review of 5-13, 6-13, and 7-13 Treatment Records revealed that the pad alarm was noted as used from physician order [REDACTED]. The 7-13 Treatment Records were continued upon the resident's return on 7-29-13. However, the pad alarm was not reinstated. There was no evidence in the record that use of the alarm was questioned. Also, the alarm was not documented as in place as ordered multiple times (on 6-1, 6-3, 6-7, 6-14, 6-16, 6-17, 6-18, 6-19, 6-22-13; on 7-13-13; on 9-12, 9-14-13). Review of the 7-29-13 physician's orders [REDACTED]. There was no evidence in the record that use of the alarm was questioned, though the 7-29-13 (Re)Admission (Nursing) Assessment noted a fall risk score of "10", with 10 or above representing high risk for falls. Following an 8-3-13 fall resulting in a left femoral fracture, Resident #10 was readmitted on [DATE] with orders for a tab alarm and low bed for safety. There was no evidence in the record that use of the alarm was questioned. During an interview on 10-12-13 at 4:15 PM, when a concern was identified related to the alarm not being reordered/utilized upon readmission on 7-25-13, the Director of Nurses stated that Resident # 10 had been discharged on [DATE] and was considered a new admission on 7-29-13 with a new fall assessment. S/he stated the nurse on duty was not aware that the resident had been at the facility previously. The DON verified that the alarm had not been reinstated and noted that use of non-skid footwear and bed in its lowest position were put in place. No further explanation was given. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 10/10/13 revealed documentation that Resident #2 sustained eight falls since 5/15/13 as follows: 5/15/13 at 6:55 AM-Resident stood up and fell to the floor skin tear to pointer finger on left hand. 5/15/13 at 9:11 AM- Patient located sitting on the shower floor of his bathroom. He stated he was "going to take a shower."-no injury noted. 5/17/13 at 7:30 AM-CNA (Certified Nursing Assistant) observed resident lying on floor by bed small open laceration to right of forehead. 5/21/13 at 7:35 PM-Attempting to get up out of wheelchair without assistance and tripped over leg of chair in day area no injuries noted. 6/2/13 at 3:15 PM-Patient on floor-abrasion to forehead. 6/7/13 at 2:55 AM-Resident on floor beside bathroom door sitting. Abrasion noted. 6/8/13 at 11:45 PM-Resident noted on floor sitting up in front of the sink. 10/7/13 at 8:30 AM-Patient kneeling next to his bed, right knee on blue mat the other in the bed-no injury noted. Further review of the resident's current care plan revealed that on 8/2/13 the resident was care planned for at risk for falls related to impaired mobility, history of falls, history of Alzheimer's dementia, and use of psychotropic medications. Interventions included use of a pad alarm to bed and tab alarm. The intervention of the tab alarm did not include when it was to be used and was not observed to be in place. Review of the 8/13 and 9/13 Medication/Treatment Administration Records revealed fall prevention measures were not applied as ordered as follows: Pad alarm to bed-8/12/13 & 9/25-26/13; Tab alarm for safety-8/1, 3, 4, 7, 12, 13, 14, 16, 17, 19, 21, 22, 25, 28-31/13 and 9/3, 4, 7, 10, 11, 13, 20, 25, 26, 27, & 29/13. Observation of Resident #2 during care on 10/10/13 revealed a pressure pad alarm was on the resident's bed. During the care of the resident, the alarm did not sound. RN (Registered Nurse)#1 was asked to show the surveyor the pad alarm and to test the alarm. After observing the alarm, RN #1 confirmed that the alarm did not work. Review of the Grievance Log on 10/10/13 at 10:15 AM revealed on 9/19/13 a grievance was documented related to a pad alarm in chair not working.

On the days of the Recertification, Complaint and Extended Survey, the facility failed to provide the necessary care and services to attain the physical, mental, and psychosocial well-being for Residents #21, #20 and #8. Resident #21 with multiple instances of 4 days without a bowel movement was not thoroughly assessed by the staff or provided the necessary care he/she needed. Resident #20 from 06/26/2012 through 07/07/2012 was noted as incontinent of bowel, with no documentation of the characteristics of the bowel movements, that the physician was aware the resident was incontinent of stool or that the bowel movements were numerous and/or loose. Resident #8 with no followup on an order for [REDACTED]. The findings included: Resident #21 admitted with [DIAGNOSES REDACTED]. He/she was admitted to the facility for short term rehabilitation. Review of the CNA (Certified Nurse Aide) BM (bowel movement) Report revealed Resident #21 was not adequately monitored regarding his/her bowel movement. He/she had no BMs from 03/03/2012 through 03/07/2012 (4 days). From 03/28/2012 through 03/31/2012 (4 days) the resident had no BMS; on 04/01/2012 he/she had a loose BM with no documentation of the amount or consistency; his/her next BM was a formed BM on 04/02/2012 again no documented description of the BM. The next BM was on 04/08 and 09/2012 when the documentation of the BM stated loose. Resident #21 did not have a BM from 04/10/2012 through 04/13/2012 (4 days). The resident received Milk of Magnesia 30 cc by mouth two times a day for 72 hours per the physician's standing orders; there was no documentation that the physician was aware that the resident was not having regular bowel movement until 04/09/2012 when it was addressed in the Physician's Encounter notes. The resident complained of frequent nausea, a sore throat, had a poor appetite and refused medications at times from 03/09/2012 until 04/13/2012. The family asked for lab studies on 03/30/2012 and for a change in the resident diet on 04/02/2012. There was no documentation the family or resident was educated regarding the frequent refusal of medication and the consequences of the refusal. Resident #21's needs were not thoroughly identified and addressed to meet his/her individual needs. Review of the Nurse's Notes from 02/29/2012 through 04/13/2012 revealed Resident #21 on 03/01 through 03/07/2012 was alert and oriented with periods of confusion. On 03/09/2012 he/she vomited once. The notes documented that the resident had a moderate bowel movement on 03/13/2012. From 03/14/2012 through 03/16/2012 he/she continued to be alert and oriented with confusion at times. On 03/18/2012 he/she vomited and was able to respond to simple questions. On 03/19/2012 he/she was alert and oriented x two with confusion at times and his/her speech was unclear at times. On 03/20 and 03/23/2012 he/she was medicated for nausea. On 03/24/2012 he/she was nauseated, had a poor appetite; speech was documented as minimal and unclear and noted as hard of hearing. At 8:05 AM he/she vomited his/her med pass; 9:00 AM he/she refused medication and Milk of Magnesia was administered due to his/her last bowel movement occurring 03/21/2012. He/she continued to refuse medication and was nauseated. At 7:00 PM the MOM was discontinued and Senna was ordered, his/her speech was unclear. The documentation stated on 03/26/2012 he/she's speech was unclear again hard of hearing was noted, he/she was confused and nauseated; [MEDICATION NAME] was ordered three times a day times 7 days as needed. From 03/27 through 03/29/2012 he/she exhibited unclear speech, confusion and nausea at times. On 03/30/2012 the family of Resident #21 expressed their concerns regarding the resident's mental state and deconditioning and requested that lab work be done; the staff notified the physician. On 04/01/2012 the resident was ordered an antibiotic for a urinary tract infection. Resident #21 on 04/02/2012 remained nauseated, confused, refused his/her medication and had a poor appetite the family/MD were notified. The family requested a change in the resident's diet; it was changed to mechanical soft. Resident #21's appetite remained poor, his/her speech was unclear and he refused his/her medication from 04/03 through 04/07/2012; family/MD were aware of the resident condition. The documentation on 04/09/2012 stated the resident had difficulty speaking and was hard of hearing he/she was alert and oriented with confusion at times. The MD/family was aware of the resident's condition and he/she was monitored. The documentation stated that [MEDICATION NAME] was ordered daily times 3 days. Resident #21 was documented on 04/10/2012 as having no bowel movement and the MD was notified the resident was monitored. Resident #21 exhibited facial grimacing when swallowing, had little energy and a poor appetite on 04/11/2012. There was no documentation of a bowel movement. On 04/12/2012 the documentation stated he/she was alert and oriented times one, appeared weak, and had a poor appetite at breakfast. A cough with congestion was documented, increased nausea and alterations in breath sounds, the MD was notified. The 04/13/2012 Nurse's Note stated, "8 AM resident lying in bed, lethargic, pale, SOB (short of breath), has shallow breathing, respirations 30, c/o (complains of) SOB denies pain, pupils sluggish and equal... notified physician and family. 10 AM physician ordered labs stat... family notified. 2 PM resident continues to be SOB, IV (intravenous) patent... 3 PM family walks into room, resident not breathing, physician notified. 3:04 PM time of death..." Review of the Physician's Encounter Notes from 03/05/2012 through 04/13/2012 documented the following: "03/05/2012 09:33 AM History of Present Illness... Patient (Pt) has baseline dementia but family noted increased confusion and patient dragged his/her right foot. CT (computed tomography) scan in the ER (emergency room ) revealed an acute lucunar infarct. ...Plan... Follow up in 2 weeks or as needed... 03/09/2012 01:51 PM History of Present Illness... patient presents today for a follow up visit for sinusitis. Note for "Sinusitis": Pt c/o sinus congestion "states it may be allergies [REDACTED]. If pt complains for chest pain, inform MD or send pt to ER (emergency room )... 03/12/2012 11:38 AM... presents with a complaint of Vomiting. Note for "Vomiting": Had an instance of vomiting today, refused standing order medication instead requested ginger ale; he states he only had vomiting for 1 day and it is now resolved... Procedures ordered today: No procedures were ordered today. Laboratory tests ordered today; No lab tests... Instructions and recommendations discussed today Follow up as needed, handwashing... 03/19/2012 09:02 AM History of Present Illness... [AGE] year old... presents for an initial visit (needs [MEDICATION NAME] ordered prn (as needed) for nausea/vomiting (n/v) (s.o. 2 doses already used)). ... Abdomen Inspection: Inspection of the abdomen reveals - no abnormal pulsations... Assessment and Plans: Nausea and vomiting Medications [MEDICATION NAME] 25 mg (milligrams)/ml (milliliter), 1 solution as needed, 4 solution, 4 days starting 03/20/2012... 03/21/2012 11:34 AM History of Present Illness... [AGE] year old... presents with a complaint of Nausea. The course has been constant. The symptoms are aggravated by eating. The symptoms are relieved by nothing (given 2 standing orders (s.o.) of [MEDICATION NAME] but still no relief)... Assessment and Plan... Current Plans: [MEDICATION NAME] 25 mg/ml, 1 Solution as needed, 4 Solution, 4 days starting 03/27/2012... Persistent nausea might be [MEDICAL CONDITION] gastroenteritis, medications or neurologic problems. Pt says the nausea is better this morning, has been eating better. If symptoms come again will use [MEDICATION NAME] for possibility of [MEDICAL CONDITION] ulcer or gastroenteritis. pt is stable and doing well. 03/26/2012 History of Present Illness... [AGE] year old who presents for an initial visit ([MEDICATION NAME] not working need order to D/C (discontinue) still n/v can't keep meds down and having poor appetite). ...Abdomen... Palpation and Percussion of the abdomen reveal - Soft (with normal bowel sounds. No masses or tenderness.)... 03/28/2012 10:26 AM History of Present Illness... [AGE] year old presents with a sore throat. Symptoms include sore throat. The patient describes the pain as aching. Symptoms are exacerbated by swallowing liquids and swallowing solids... Assessment and Plan: Tylenol Allergy Multi-Symptom 2-5-325 MG, 1 Tablet three times daily, #15, 5 days starting 03/30/2012... Pt tongue is white. req nurse's attention. CNA (certified nurse aide) showed up to clean pt's throat after the nurse called. Pt is stable... 03/31/2012 11:24 AM History of Present Illness... [AGE] year old... an initial visit (mental condition declining family request lab work to be order)... he states he is doing ok except for nausea; family states he doesn't look like himself... Physical Exam: General ...Oriented x 3. Well developed and Well nourished... Chest and Lung Exam... - normal. Cardiovascular... -normal S1, S2... Assessment and Plan: Basic Metabolic Panel; Routine, CBC (complete blood court) w/PLT (plattlets) & Diff (differential); Routine, Urinalysis; Routine, Urine culture and sensitivity; Routine... 04/03/2012 9:03 AM History of Present Illness... to discuss laboratory test results... follow up to check on Lab results of BMP (basis metabolic panel), CBC and Urinalysis. ua (urinalysis) neg (negative) for uti (urinary tract infection). still awaiting creatinine. no white count... Physical Exam Chest and Lung Exam... Cardiovascular... Assessment & Plan Today's Impression: seems resolved, nausea better as well. pt NAD (no apparent distress). fu (follow up) as needed... 04/04/2012 8:21 AM History of Present Illness ...an initial visit (Refused ABT (antibiotic) (Bactrim DS) medication). No documentation on the encounter that the resident was examined. 04/05/2012 History of Present Illness ...to discuss laboratory test results. Note for "Follow up laboratory tests": Follow up to review urinalysis lab results. Additional complaint: routine visit... an initial visit (Decreased appetite from 75-100% to 25-50%)... he is still complaining of nausea; meds were adjusted a couple of days ago. he is still refusing meds, especially the big ones. he states they make him nauseas... Physical Exam General... Orientation - Oriented to person... Chest and Lung Exam... - normal. Cardiovascular... - normal S1, S2... Assessment & Plan UTI... change bactrim to cipro... continue [MEDICATION NAME] and [MEDICATION NAME] will continue to monitor... 04/09/2012 10:12 AM History of Present Illness ...says had bm (bowel movement) this am. no stomach pain, nausea or vomiting... Physical Exam Chest and Lung Exam... Expiratory wheeze - none. Inspiratory wheeze - none. Rales - none. Cardiovascular... normal S1, S2. Abdomen Palpation/Percussion: Palpation and Percussion of the abdomen reveal - Soft, Non Tender and nondistended. Auscultation:... - bowel sounds positive x 4. Assessment & Plan... Constipation Today's Impression: seems resolved... will follow in few days to make sure does not recur... 04/11/2012 02:49 AM History of Present Illness ...presents with a complaint of Bowel problems. Note for Bowel problems: continuing to refuse meds Senna 8.6 (Dok+) has no successful BM... No procedures were ordered today. No lab test ordered today... There was no documentation of a physical exam at this encounter. 04/12/2012 09:42 AM History of Present Illness ...present with a complaint of Tremor. Note for "Tremor": Failure to thrive, lethargic, tremors, nausea, and increased depression; he has been refusing his meds for several days due to nausea, today he is less alert and somewhat somnolent. he does answer questions with a nod and squeezes my hand... Vital signs... Temperature 98.8 degrees F... Physical Exam General... - oriented to person. Build & Nutrition - Well developed and Well nourished. Chest and Lung Exam... - normal. Cardiovascular... - normal S1, S2. Assessment & Plan Symptom, Nausea ... : [MEDICATION NAME] HCL 25 mg/ml, 1 solution one time dose... 04/12/2012. Fever [MEDICATION NAME] 1 GM (gram)... 1 day starting 04/12/2012... No procedures were ordered today. No lab tests were ordered today... 04/13/2012 10:08 AM History of Present Illness ...he is somewhat somnolent today no different from yesterday. he answers questions with nods and shaking of his head. he does seem alert enough to know what is going on. he was given a 1 time dose of [MEDICATION NAME] im (intramuscularly) yesterday along with a one time dose of [MEDICATION NAME] im. no change today. nurse stated yesterday that he had taken his meds for her in the am. he has been refusing on and off since he got here. he has not been eating the last couple of days. he does open his eyes when his name is called... Additional complaint: Cough is described as the following: ...productive (yellow clear mucous)... staff states he has a productive cough that has been occurring since yesterday... Physical Exam General... Not in acute distress or Restless. Orientation - Oriented x 3... Well developed and well nourished. Hydration - Dehydrated. Chest and Lung Exam... normal. Cardiovascular... - normal S1, S2... Assessment & Plan Cough... chest x-ray; Routine (stat today) Altered mental status... Urine culture and sensitivity; Routine, Basic Metabolic Panel; Routine (stat today), Urinalysis; Routine (stat today) Constipation... Magnesium [MEDICATION NAME] 1/2 (one half) bottle one time after kub (x-ray kidney, ureter, bladder) obtained... Symptom, Nausea... all results are to be called to me if not here..." Review of the Medical Nutrition Therapy assessment dated [DATE] stated in summary that the resident consumed 75-100% of his/her food. The Registered Dietician (RD) recommended he/she drink adequate fluids secondary to possible bowel/fluid alteration. The fluid cart was recommended three times a day with fluid also at the bedside and on the resident's tray. The RD recommended [MEDICATION NAME] Renal daily and nourishment at bedtime to meet his/her nutritional needs. On 04/04/2012 a Nutritional Progress Note addressed a decrease in the resident appetite resulting in a change in consumption from 75-100% to 25-50%. The RD increased [MEDICATION NAME] Renal from daily to three times daily. Nourishments at bedtime were continued to add additional opportunity for nourishment. The note stated the family and physician were notified. There was no documentation in the RD's note that the resident and his/her family requested a change in diet on 04/02/2012 to a mechanical soft, ground meat, thin liquids. There was no documentation the resident/family was asked by the RD about his/her intake or given the opportunity for input as to why there was a decrease in his/her intake. Review of the Physician orders [REDACTED]. 03/08/2012 MOM (milk of magnesia) 30 cc PO (by mouth) BID (twice a day) x 72 hrs (hours) 03/10/2012 [MEDICATION NAME] 25 mg (milligrams) PO Q 6 hours PRN (as needed) N/V (nausea/vomiting) Max. (maximum) 2 doses 03/13/2012 MOM 30 cc PO BID x 72 hr 03/21/2012 [MEDICATION NAME] 12.5 mg take 1 po q 6 h (hours) prn N/V 03/16/2012 Senna S 8.6 mg 2 PO BID x 72 hours Constipation no tolerate to MOM 03/25/2012 MOM 30 cc PO BID x 72 hrs. DC (discontinue) MOM 30 cc po BID due to intolerance give Senna 8.6 mg po 2 tabs BID x 72 hrs Constipation 04/02/2012 Diet Clarification: d/c Reg (regular), thin NAS (no added salt) Start: Mech (mechanical) Soft, grd (ground) mts (meats), thin NAS secondary to Pt's (patients) diff (difficulty) chewing and swallowing 04/04/2012 D/C MOM secondary to CKD ([MEDICAL CONDITION]) d/c [MEDICATION NAME] renal po qd (daily) start [MEDICATION NAME] renal po tid (three times a day) secondary to 25% po intake 04/08/2012 Senna 8.6 mg ii tabs po BID x 72 hrs no BM x 5 days 04/09/2012 Order clarification: [MEDICATION NAME] daily 1 scoop daily x 3 doses, please give dose now constipation 04/10/2012 [MEDICATION NAME], 4 MG 1 tablet, oral, three times daily, 30 days nausea 04/10/2012 [MEDICATION NAME], 10 mg 1 tablet, oral, four times daily; 30 minutes ac and hs... nausea 04/10/2012 [MEDICATION NAME] HCL 12.5 mg 1 tablet, oral, every six hours, as needed... nausea 04/11/2012 Pt to D/C 4/25/12... 04/12/2012 [MEDICATION NAME] 25 mg IM x 1 dose stat now, [MEDICATION NAME] 1 gm IM x 1 dose stat now, encourage fluids 04/13/2012 CXR (chest x-ray) stat, UA (urinalysis) stat, BMP (basic metabolic panel) stat - call me results; Mag [MEDICATION NAME] 1/2 bottle po now, KUB (x-ray kidney, ureter, bladder) stat - call me indication - cough, AMS (altered mental status), dehydration, constipation, nausea/constipation 04/13/2012 IVF's (intravenous fluids) NS (normal saline) at 100 cc/hr x 1 L. (liter), Place INT, encourage fluids... Review of the CNA (Certified Nurse Aide) BM (bowel movement) Report revealed Resident #21 had 23 stools in the 44 days he/she lived at the facility; 6 formed BMs and 14 loose BMs, 3 of the BMs were not identified as formed or loose. Resident #21 had no BMs from 03/03/2012 through 03/07/2012 (4 days). From 03/28/2012 through 03/31/2012 (4 days) the resident had no BMS on 04/01/2012 he/she had a loose BM with no documentation of the amount or consistency his/her next BM was a formed BM on 04/02/2012 again no documented description of the BM. The next BM was on 04/08 and 09/2012 when the documentation of BM stated loose. Resident #21 did not have a BM from 04/10/2012 through 04/13/2012 (4 days). Review of the current Care Plan dated 03/09/2012 listed the following problems: a problem of cognitive deficit related to impaired thought processes and a [DIAGNOSES REDACTED]. Approaches related to constipation included assess and report to the physician signs and symptoms of constipation: abdominal pain... nausea/vomiting, fever, altered mental status... Administer laxatives as ordered and monitor for side effects, effectiveness. Monitor BM pattern, and record on flow sheet. Notify nurse if no BM in 3 days. In an interview with the surveyor on 09/26/2012 at approximately 2:45 PM the Director of Nursing was asked why the resident was not sent to the emergency room for evaluation. She stated that the resident's family was aware the resident refused his/her medication and food. She stated that the resident could tell the facility if he/she needed to go to the hospital. The facility admitted Resident #20 with [DIAGNOSES REDACTED]. The resident was noted as alert and oriented x 3. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the CNA (Certified Nurse Aide) BM (bowel movement) Report from 06/22/2012 through 07/07/2012 documented approximately 23 loose BM's out of 27 total bowel movements. There was no documentation regarding the characteristics of the stools. Review of the Nurse's Notes from 6/21/2012 through 07/07/2012 revealed Resident #20 was assessed on admission as having no obvious problems related to the elimination of his/her bowel. On 06/22/2012 the resident was noted as incontinent of bowel; noted on 06/23/2012, 06/24/2012 and 06/25/2012 as continent of bowel. From 06/26/2012 through 07/07/2012 the resident was noted as incontinent of bowel, there was no documentation of the characteristics of the resident's bowel movements or that the physician was aware the resident was incontinent of stool or that the bowel movements were numerous and/or loose. Resident #8 was admitted to the facility on [DATE]. Review of the admission physician's orders [REDACTED]." During interview on 9/25/12 at approximately 3:15 PM the Medical Secretary stated that when a resident is admitted , the admission nurse brings him/her paperwork related to appointments the resident needs and he/she schedules the appointments. Review of the appointment schedule book revealed Resident #8 did not have an appointment scheduled for a pacemaker check. Review of the Pacemaker check book revealed that Resident #8 was not listed in the book. During interview on 9/25/12 at approximately 3:30 PM the Director of Nursing (DON) stated that the Pacemaker check book is used to make sure pacemaker checks are completed for residents. The DON also stated that when a resident is admitted with a pacemaker the Medical Secretary would call the resident's Cardiologist to find out when the pacemaker should be checked within the first week of admission. The Medical Secretary would place the appointment in the schedule book.

On the days of the Recertification and Extended Survey, based on observations, interviews, record reviews, and review of the U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, treatment of [REDACTED].#2, #6 and #20). The findings included: Nursing documentation on 06/21/2012 revealed that Resident #20 was admitted to the facility with a stage I pressure ulcer to the sacral area measuring 6 centimeter (cm) x 5.2 centimeters; a stage 1 pressure ulcer to the right buttocks measuring 3 centimeters x 2.8 centimeters described as pink and non blanching. An area described as a 2nd degree burn was noted to the resident's right upper back. A stage 1 pressure ulcer was noted on the right heel measuring 4 centimeters x 3.7 centimeters and a stage 1 pressure ulcer on the left heel measuring 4 centimeters x 3.1 centimeters described as pink and non blanching. Review of the closed medical record revealed no orders for an air mattress during the resident's stay at the facility and heel boots were placed on 07/04/2012, 13 days after admission, to float the heels to prevent pressure. Review of the initial Dietary Assessment done on 07/03/2012 documented the resident's weight as 194.9 pounds and height as 66 inches. The note indicated the Registered Dietician (RD) recommended to the resident that he/she drink adequate fluids secondary to a possible bowel fluid alteration. The RD also recommended Ensure and gelatin three times a day and a multivitamin. The treatment to the sacral area from 06/21/2012 through 06/26/2012 was [MEDICATION NAME] cream every shift, applied by the CNAs; on 06/26/2012 the treatment to sacrum to be performed by the licensed staff, was changed to clean right and left buttock with normal saline and cover with Opitfoam non adhesive twice a day and as needed. The treatment to the sacral ulcer was changed on 07/03/2012 from twice a day to once a day. Review of the Physician's Follow up Notes documented the physician first addressed the presence of skin concerns on 07/06/2012. Review of the hospital records at the time of discharge to the emergency roiagnom on [DATE] documented Resident #20's pressure ulcer to his/her sacrum as a stage 4 (extending down to the coccyx and sacrum) measuring 21 centimeters x 14 centimeters. The hospital records stated that a debridement of a stage 4 sacral ulcer and a stage 3 right heel ulcer was performed on 07/10/2012. The facility admitted Resident #20 with [DIAGNOSES REDACTED]. The resident was noted as alert and oriented x 3. Review of the closed medical record revealed Departmental Notes documenting assessments of pressure wounds from 06/21/2012 through 07/04/2012 that indicated the following: "06/21/2012 Skin assessment complete... Stage 1 to sacral area measuring 6 x 5.2, stage 1 to R (right) buttocks measuring 3 x 2.8, pink and non blanching. 2nd [MEDICAL CONDITION] to R upper back d/t the use of a heating pad... Stage 1 to R heel measuring 4 x 3.7, stage 1 to L (left) heel measuring 4 x 3.1, areas pink and non blanching..." 07/03/2012 Assessed wound to upper back, sacrum, and heels. Burn to upper back noted with 100% of yellow slough. Area to sacrum noted with 90% black hard eshar (sic) and 10% yellow slough. No odor noted at this time. Surrounding skin red and purple and nonblanching. New order written to sacral area. MD to eval (evaluate) other areas in am. Family called and made aware of decline in wound condition. 07/04/2012 MD evaluated areas this AM. New order written for BMP (basic metabolic profile) on 7/9/12 and new orders for treatments to bilateral heels... Bunny boots placed on and heels floated to prevent pressure." Review of the Weekly Skin Assessments performed on the following dates for Resident #20 indicated the resident's pressure ulcers increased in size between his/her admission on 06/21/2012 and his/her transfer to the hospital on [DATE]. "06/21/2012 Sacrum (date wound identified on admission 06/21/2012) - Stage 1 - 6.0 cm x 5.20 cm Right Heel (date wound identified on 06/21/2012) - Stage 1 - 4.0 cm x 3.70 cm 06/26/2012 Sacrum (date wound identified on admission 06/21/2012) - Stage 2 - 7.20 cm x 5.80 cm (centimeters) Wound bed: 25% [MEDICATION NAME] tissue and 75 % granulation tissue; Wound edges: border definition - distinct, outline clearly visible, description - normal healthy skin... Notes: area to sacrum has declined, new tx (treatment) in place, family and MD aware. [MEDICATION NAME] ordered, will continue to monitor. 06/28/2012 Right Buttock (date wound identified - 06/21/2012) - Stage 1 - 3.00 cm x 2.80 cm. 07/03/2012 Sacrum 20.00 cm x 17.00 cm; Drainage: serosanguineous (sic), small; Wound bed: slough - 10% eschar - 90%; Wound edges: border definition - indistinct, diffuse, not clearly visible, description - normal healthy skin... Right Lateral Malleolus (date wound identified - 07/03/2012) 4.00 cm x 3.50 cm. Left Heel (date wound identified - 06/21/2012) 7.00 cm x 6.50 cm" Review of the Wound Healing Progress Report indicated the following: 06/21/2012 Pressure Ulcer left heel 4.00 x 3.10 06/28/2012 4.00 x 3.10 07/03/2012 7.00 x 6.50 06/21/2012 Pressure Ulcer Sacrum 6.00 x 5.20 06/28/2012 7.20 x 5.80 07/03/2012 20.00 x 17.00 06/21/2012 Pressure Ulcer right heel 4.00 x 3.70 06/28/2012 4.00 x 3.70 07/03/2012 6.00 x 5.50 07/03/2012 Pressure Ulcer right lateral Malleolus 4.00 x 3.10 Pressure Ulcer left lateral Malleolus 4.30 x 3.50 Review of Physician Follow up notes revealed Resident #20 was seen on the following dates: "06/29/2012 ...initial visit... General Appearance - ... Well developed, well nourished, average weight and frail... Integnumentary (sic): General characteristics: Color - normal coloration of skin. Skin Moisture - dry. Temperature - normal warmth is noted... Failure to thrive syndrome - current plans: [MEDICATION NAME] Oral... Suspension... needs to have potassium re checked in 3 days... day 4 to have renal panel... 07/04/2012 The patient is a [AGE] year old... Note for Follow up laboratory tests: pos (positive) [MEDICATION NAME] low colony ct. pt (patient) feels good. better... Assessment and Plan: UTI (urinary tract infection) Today's Impression: cont (continue) current medicine. 07/06/2012 The patient is a [AGE] year old... who presents to discuss laboratory test results. Past medical history includes other (decreased po intake. CBC obtained due to wound infection to sacrum.)... Additional complaint: Skin changes are described as the following: The onset of the skin changes has been gradual and they have been occurring in a persistent pattern for weeks. The course has been constant. The skin changes are described as severe (large decubitus ulcer to the sacral region... Now malodorous. Wound care daily with [MEDICATION NAME].) Note for skin changes: Has been referred to wound consult... General: General Appearance - ...Well developed, well nourished, average weight and frail... Integumentary: large wound to sacrum with 90% hardened eschar, measures 20 x 17 cm, 10% wound bed soft to borders. malodorous with purulent drainage to borders..." Review of the physician's orders [REDACTED]. "06/21/2012 initial orders to clean the right back with normal saline, cover with hydrogel gauze and cover with gauze change every 3 days and as needed. [MEDICATION NAME] cream to sacral area every shift and keep at bedside applied by CNA (certified nurse aide), skin prep bilateral heels daily. 06/26/2012 clean right and left buttock with normal saline and cover with [MEDICATION NAME] non adhesive twice a day and as needed, pre [MEDICATION NAME]. 06/26/2012 ... Discontinue pre [MEDICATION NAME] for 06/26/2012 and draw pre [MEDICATION NAME] on 06/29/2012. 06/29/2012 1). Potassium K... 40 meq (milliequivalents) TID (three times a day) x 3 days 2.) Recheck renal panel 7-2-12 3.) Potassium 40 meq daily starting 7-2-12 4.) [MEDICATION NAME] 625 milligrams (mg) po (by mouth) QID (four times a day). 6/29/2012 Order clarification: [MEDICATION NAME] 40 mg/ml (milliliters), 200 mg (5 ml) po QID. 07/02/2012 start Ensure 1 can by mouth three times a day, start gelatin 1 ct by mouth three times a day, start multivitamin 1 tab by mouth daily. Draw CMP (complete metabolic profile). 07/03/2012 Discontinue current treatment to sacrum. Clean area to sacrum with normal saline, skin prep area and apply [MEDICATION NAME] nonadhesive and secure with tape qd (daily) 07/04/2012 1000 cc (cubic centimeters) fluid restriction, BMP 7/9/12 continue skin prep to bilateral heels qd (daily) cover with [MEDICATION NAME] nonadherent, wrap with Kling qd (daily), skin pre bilateral malleolus daily. Wound clinic referral re: possible debridement sacral wound... 07/05/2012 ... start Prostat 64... tid (three times a day)... 07/07/2012 Send to ER (emergency room ) for evaluation" Review of the Daily Skilled Nurse's Note for documentation related to the resident's pressure sore revealed a note dated 06/25/2012 at 3:30 PM that stated, "...Resident repositioned q (every) 2 hours but continues to place herself back in supine position... area to sacrum has increased in size and declined to a stage 2 measuring 7.2 x 5.8 with 75% granulation tissue surrounding pink with slow blanching". On 07/01/2012 at 11:25 AM the nursing documentation stated, "...Dressing changed to sacrum. Large amount of brown drainage. Strong odor noted. Area cleansed with NS (normal saline)... MD notified of foul smell to wound..." The nursing documentation on 07/07/2012 at 4:00 PM stated the resident was sent to the hospital due to a change in mental status. Review of the hospital records for Resident #20 revealed an operative report dated 07/10/2012 that stated, "...Procedure (s) performed: Excisional debridement of right scapula, sacrum and right heel... Findings: The right scapula ulcer was stage 2... It measured 5 cm in [MEDICATION NAME] diameter and 3 cm in vertical diameter... The sacral decubitus ulcer was a giant ulcer measuring 21 cm in [MEDICATION NAME] diameter and 14 cm in vertical diameter. It was a stage 4 ulcer extending down to the coccyx and sacrum. The ulcer was covered by a necrotic skin eschar. Beneath the eschar there was liquefactive necrosis of the soft tissues extending down to the periosteum of the sacrum and coccyx. Following radical debridement of this wound to remove all the devitalized, nonviable, grossly infected soft tissues... The right heel ulcer was covered by a thick, dry eschar. The ulcer measured 6.5 cm in [MEDICATION NAME] diameter and 5 cm in vertical diameter. It was a stage 3 ulcer extending through the subcutaneous fatty tissue into the fascia and muscle..." In an interview with the surveyor on 09/25/2012 at approximately 1:00 PM Registered Nurse #7 stated that a physician's orders [REDACTED].#20 had an air mattress. After reviewing Resident #20's closed medical record she confirmed that an air mattress had not been ordered for the resident. RN #7 confirmed that the resident had very little control over her lower body due to her [MEDICAL CONDITION]. Review of the CNA (Certified Nurse Aide) BM (bowel movement) Report from 06/22/2012 through 07/07/2012 documented approximately 23 loose BM's out of 27 total bowel movements. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Nurse's Notes from 6/21/2012 through 07/07/2012 revealed Resident #20 was assessed on admission as having no obvious problems related to the elimination of his/her bowel. On 06/22/2012 the resident was noted as incontinent of bowel; noted on 06/23/2012, 06/24/2012 and 06/25/2012 as continent of bowel. From 06/26/2012 through 07/07/2012 the resident was noted as incontinent of bowel, there was no documentation of the characteristics of the resident's bowel movements or that the physician was aware the resident was incontinent of stool or that the bowel movements were numerous and/or loose. Review of the closed medical record revealed the following laboratory findings: 07/02/2012 Renal Function Panel Out of Range Reference Range Sodium 132 (L) 136-145 mEq/L Potassium 3.1 (L) 3.5-5.5 mEq/L Chloride 86 (L) Glucose <41 (CL) 70-105 mg/dL A note on the lab findings stated, "MD aware see orders..." 07/04/2012 Complete Metabolic Out of Range Reference Range Sodium 128 (CL) 136-145 mEq/L Potassium 3.2 (L) 3.5-5.5 mEq/L Glucose <40 (C) 70-105 mg/dL Alkaline [MEDICATION NAME] 168 (H) 34-104 U/L A note on the lab findings stated, "MD aware see orders..." Review of the U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, treatment of [REDACTED]. If the condition of the patient or of the wound deteriorates, reevaluate the treatment plan as soon as any evidence of deterioration is noted." Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. On admission to the facility the resident had three pressure ulcers; Right Ankle: 6.00 cm (centimeters) X 4.50 cm X 0.00 cm, unstageable. Left heel: Stage I 5.50 cm X 4.00 cm, and Right Heel: Stage I, 7.00 cm X 5.20 cm. On 9/19/12 the Wound Healing Progress Report stated the left heel pressure sore was measured to be 7.00 cm X 3.00 cm, Stage I . The Pressure Ulcer on the Sacrum measured 5.5 cm. X 4.50 cm. X 0.00 Stage II. The Pressure Ulcer on the Right Heel measured 5.38 cm X 3.00 cm. Review of the resident's care plan dated 8/30/12 revealed a Care Plan for Pressure Sores. A goal of the care plan stated, "Use pillows, air mattress, other supportive/protective devices to assist positioning. During the days of the survey the resident was observed not to have an air mattress on her bed. The Pressure Ulcer Risk Evaluation dated 8/10/12 had the resident coded as a 24. 12 or above was identified to be at high risk. The facility had not obtained labs for the resident admitted with [DIAGNOSES REDACTED]. The resident was readmitted to the hospital in September and readmitted back to the facility. Review of the Transfer Summary from the hospital dated 9/19/2012 revealed the resident's [MEDICATION NAME] level was 2.4. (Normal 3.5-5 g/dl (grams/deciliter). The Transfer Summary also stated, "...was evaluated by our wound care nurse who recommended that the patient not have Santyl and silver together on her wound due to interaction....)..." The resident was admitted to the facility with [DIAGNOSES REDACTED]. The resident did not receive aggressive treatment to heal the pressure sores. There were no labs to monitor the residents protein while at the facility. The resident was placed on a pressure reducing mattress and not a pressure relieving mattress. The hospital discharge summary stated the facility treatment of [REDACTED]. The resident maintained Stage I pressure sores for over four weeks before she was readmitted to the hospital. Although the measurements of the areas showed the reduction in the size of the pressure sores, There were no changes in the Staging of the Pressure Sores. Stage I pressure sores were described as reddened areas that are unblanchable. The facility readmitted Resident #6 with [DIAGNOSES REDACTED]. Record review on 9/25/12 at 2:00 PM revealed Weekly Wound Reports for Resident #6. According to the documentation, on the week of 8/25/12 through 8/30/12, Resident #6 had a stage 4 wound to her sacrum (identified 3/21/12) that measured 4 X 3, a stage 1 to her left heel (boggy heels) measuring 4.7 X 3.6 (Identified 8/14/12), a stage 1 to her right heel measuring 4.8 X 3.8 (Identified 8/14/12), and a stage III to her left malleolus measuring 1.3 X 1.2 (Identified 3/21/12). Review of the 9/15/12 - 9/21/12 wound notes revealed the resident's sacral wound currently measured 3.8 X 3.0, her left heel measured 4 X 3, her left malleolus measured 1.3 X 1.2, and her right heel measured 4 X 3. Review of readmission cumulative physician's orders [REDACTED]. Review of lab reports provided by the facility and in the chart revealed no indication that a [MEDICATION NAME] level had been drawn to determine the resident's nutritional status. Review of the resident's Care Plan with a Problem Onset Date of 8/30/12 revealed "Resident has one stage 1 Pressure Ulcer to her left heel, one stage 3 pressure area to her left lateral malleolus, and one stage 4 pressure ulcer to her sacrum. She is at risk for further skin breakdown related to impaired mobility and episodes of bowel incontinence...". The approaches listed included "Offer supplemental nutrition to resident as ordered"; and "Dietician/CDM (Certified Dietary Manager) to evaluate resident nutritional status". Review of the facility's Medical Nutrition Therapy assessment dated [DATE] revealed the resident was on a Regular, no added salt diet with thin liquids. According to the assessment, Resident #6 had wounds, a stage I to the right heel, a stage III to the right lower extremity, and a stage IV to the sacrum. The summary stated the resident was consuming 75%-100% of trays (varied for breakfast). According to the notes, the resident needed increased protein for wounds and the diet and nutritional interventions were not adequate for nutrient needs. The summary stated that the RD had notified the Hospice RN to increase the needs for wounds. Review of the hospital Clinical Nutrition Services note dated 8/2/12 revealed that while in the hospital, the resident had been on a heart healthy diet with magic cup and Ensure TID (Three times daily) and that interventions in place included food supplements. According to the note, the resident was eating all or greater than half of her food two times a day, and eating some of the magic cup. The note stated the resident had a sacral wound (stage IV) and had increased nutrient needs for protein that was ongoing. During an interview on 9/26/12 at 9:30 AM, the facility RD reviewed her 8/27/12 notes and stated she had notified the Hospice RN (Registered Nurse) on 8/27/12 or 8/28/12 of the resident's increased needs. She reviewed the 8/2/12 nutrition notes from the hospital and verified they indicated the resident was on supplements at the hospital. She stated that since the resident was on Hospice, the Hospice nurse would need to write the order for any supplements. She stated that she did not know what Hospice did with the information she gave them. She stated that Hospice "does their own thing". She verified that supplements had not been ordered. According to the RD, Resident #6 is on Palliative Care. She stated that this may be the reason supplements weren't ordered. When the surveyor commented that there were other residents on Palliative Care that had ordered supplements, she agreed. During an interview on 9/26/12 at 10:27 AM, the Hospice Nurse stated he could not recall having been notified by the RD that resident #6 had a need for any nutritional interventions and could provide no documentation of this. He stated that he had been with the facility for 3 months and had never written orders for nutritional supplements. He stated that Hospice didn't have to write the order, and the RD would know better what to recommend. He stated if she would have spoken to him about anything, he would have told her to go ahead and order what she thought best for the resident. Review of the policy provided by the facility entitled "Wound Treatment Protocol" revealed that for high risk residents, a nutritional consult would be done along with weight and food preferences. For stage two wounds, the dietary manager would be notified for additional nutritional interventions as needed. For Stage 4 wounds, all interventions through stage III would be implemented along with treatment orders.