Every finding on record at Oswego Operator, LLC

The facility reported a census of 29 residents and one kitchen. Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation to prevent the spread of food borne illness to the residents of the facility. - Initial tour of the kitchen on 12/28/25 at 10:40 AM, revealed the following areas of concerns:There was an area on the floor at the entry to the kitchen from the dining area, approximately six inches long and one inch wide, that was missing tiles.There were multiple areas of the ceiling, including one area above the hand washing sink, that had flaking paint.There were three flies in the kitchen and an open tub of butter sitting on the counter next to an open bag of biscuits.There were various food waste items on the floor.In the food storage pantry, there was a package of spaghetti that was open with no date on the package.There was scattered flour on top of a flour container, the floor and on several shelves of a transport cart.The spice drawer had 16 open spice containers that were not dated. An opened smoked paprika container was expired with an expiration date of 11/14/25. There was a whole thyme container with a best by date of 02/12/24, and there was a pumpkin spice container with a best by date of 08/14/25. During an observation and interview on 12/29/25 at 09:20 AM, with Dietary CC, there was an open cinnamon container on the counter with no dating and she stated that the date was 11/11, with only the number 11 visible. Dietary CC stated that each cook was responsible for dating opened food items and throwing out the expired items. Dietary CC also stated that the night cook on 12/28/25 went through the spice drawer and dated the spices container and threw out the expired spice containers. Observed on 12/29/25 from 10:30 AM to 11:30 AM, the heating table temperatures, that were holding foods to be served to residents, were not temperature checked or recorded. The rice was temperature checked before it was pureed, but was not temperature checked any time after that, and no food was temperature checked before it was served. Observed on 12/29/25 at 10:55 AM, Dietary DD chopped lettuce and then bent over and coughed into the bottom of her shirt as she was holding the shirt with her gloved hand. Immediately after coughing into her shirt, she returned to her task of chopping the lettuce without performing hand hygiene or changing her gloves. Observed on 12/29/25 at 11:25 AM, Dietary DD used the knife that she was chopping chicken to open the plastic overwrap on a bottle of barbeque sauce and then returned to chopping chicken without washing or changing knives. Observed on 12/29/25 at 12:04 PM, Dietary GG delivered a food sample tray the surveyors and the food temperatures were not checked upon plating of the food or upon delivery of the food. During an observation and interview on 12/29/25 at 12:13 PM, Dietary CC delivered a cheeseburger to Resident (R) 18 in his room; the cheeseburger was not assessed for temperature prior to being delivered. R18 and his wife reported that the cheeseburger was cold. The food temperature logs, reviewed on 12/29/25 at 08:00 AM, revealed no meals served on 12/28/25 had temperatures recorded for the mechanical soft or pureed meals served. This was the same for 12/27, 12/26, 12/25. The main entree temperature for supper on 12/28/25 was 50 degrees, the vegetable temperature was 40 degrees, and the desert temperature was 80 degrees. During an interview on 12/28/25 at 12:05 PM, R2 reported that often the hot food is not hot. She reported that she sent her tray back on 12/27/25 and it was over 30 minutes before she received her food back. She also stated that meats were often cold when she received her meals. R2 also stated that she sent her meats back and sometimes it came back hot and sometimes not. During an interview on 12/28/2025 2:35 PM, R7 reported that hot food was not always hot, often the meat was cold. During an interview on 12/29/25 at 08:10 AM, Dietary DD stated that pureed and mechanical soft diets were temperature checked and delivered meals were assessed for temperature just before being delivered to the residents. During an interview on 12/29/25 at 08:15 AM, Dietary CC stated that the steam table temperatures were checked throughout the meal serving time. She also stated that the cooks had always done just one temperature for the foods, they did not do another temperature after the foods were prepared for pureed or prepared as mechanical soft. Dietary CC also stated that the supper meal for 12/28/25 was tuna salad sandwiches, sliced tomatoes and the dessert was cherry cobbler. She then stated that the 50-degree temp for the tuna salad, which was served, concerned her. During an interview on 12/29/25 at 08:30, Dietary CC stated that the floor had been missing tiles since she started in June of 2025. During an interview on 12/29/25 at 11:30 AM, Dietary DD stated that she should have washed the knife or gotten a new one before she continued cutting chicken after she opened the condiment bottle. During an interview on 12/29/25 at 11:39 AM, Dietary DD stated that the storage temperature was 40 degrees Fahrenheit or below for any cold sandwich item, such as egg, tuna, or chicken salad. Dietary DD stated that the expectation was that if a cold entree such as tuna salad had temperature above the required temperature of 41 degrees, it should be thrown out and remade and the temperature verified before serving to the residents. During an interview on 12/2925 at 11:57 AM, Dietary BB stated that foods were to be temperature checked on the steam stable, and if there were resident complaints about cold food, a test tray was to have been done. Dietary BB also stated that pureed food should have been made, then reheated and temperature checked, then rechecked prior to sending out to the resident. She also stated that pureed temperatures should have been reordered, and that tuna salad should not be served at 50 degrees, without knowing how long it was at that temperature, and that it should have been chilled to the proper temperature before serving which should have been 41 degrees. During an interview on 12/29/25 at 12:37 PM, Dietary BB stated that a kitchen utensil that was being used for food preparation should not have been used to open a condiment bottle. She also stated that if a cook was preparing food and coughed or sneezed, that person should have changed gloves and washed hands before preparing food again. During an interview on 12/30/25 at 09:56 AM, Dietary GG stated that a person must perform proper hand hygiene after coughing or sneezing when preforming any task and returning to that task. He also stated that if a food preparation utensil that was being used for food preparation and then used on something else should be washed appropriately or a new one obtained before returning to food prep. During an interview on 12/30/25 at 10:00 AM, Dietary CC stated that a food preparation utensil used on food and then on another object could not then be used on the food again until it was properly washed because of cross contamination. She also stated that proper hand hygiene should be performed, and new gloves donned after touching clothes and/or coughing or sneezing. Dietary CC also stated that all temperatures, pureed, mechanical soft, and main entree should have been recorded, to include holding temperatures. During an interview on 12/30/25 at 12:10 PM, Dietary GG stated that the dietary aides and cooks were responsible for cleaning the kitchen and food pantry and that the kitchen was cleaned daily, and the pantry was cleaned weekly. During an interview on 12/30/25 at 12:15 PM, Dietary EE stated that the cook on duty was responsible for cleaning the kitchen daily and the food pantry weekly. During an interview on 12/30/25 at 12:20 PM, Dietary CC stated that the cook was responsible for cleaning the kitchen daily and that she was responsible for cleaning the food pantry every Tuesday or weekly. The facility policy Food Preparation and Service, dated 10/2025, defined food danger zone as temperatures above 41 degrees Fahrenheit and below 135 degrees F as this range would allow rapid growth of pathogenic microorganisms that could cause foodborne illness. This policy also documented that thermometers would be placed in hot and cold storage areas and checked for accuracy in accordance with accepted public health standards. The facility policy further documented that the temperature of food held in steam tables would be monitored by food service staff. The facility policy Food Safety Requirements, dated 10/2025, documented that food services, or other designated staff, would maintain clean food storage areas at all times.

The facility reported a census of 29 residents. Based on observation, interview and record review the facility failed to provide a safe and functional handrails in three of four hallways. Findings included:- Observed on 12/28/25 2:15 PM, there was a total of four loose handrails in the north resident hall. Observed on 12/29/25 at 09:53 AM, five handrails on the east resident hall were loose. There were three handrails on the south resident hall that were loose. Observed on 12/30/25 at 10:20 AM, administrative staff were checking the handrails throughout the building and marking those handrails that were loose for residents and staff to safely identify. During an interview on 12/30/25 at 09:44 AM, Administrative Nurse D stated that every employee was responsible and could submit work orders. Administrative Nurse D confirmed there were loose handrails on the resident halls. During an interview on 12/30/25 at 09:56 AM, Dietary GG stated every staff person was responsible for building maintenance and reporting damage. During an interview on 12/30/25 at 10:08 AM, Maintenance U stated that all staff were responsible for identifying and submitting maintenance work orders. Maintenance U also stated that handrails were checked every three to four months, and when walking down the hall. She further stated that she had not received any work orders that identified loose handrails. During an interview on 12/30/25 at 10:14 AM, Administrative Staff A stated that regular rounds were performed with an environmental checklist to maintain a safe and homelike environment. Administrative Staff A also stated that all staff were responsible for identifying any maintenance issues and submitting work orders.The facility policy Work Orders, Maintenance, dated 10/2025, documented that maintenance work orders should be completed in order to establish a priority of maintenance service.

The facility reported a census of 29 residents. The sample included 12 residents with four residents reviewed for hospitalization. Based on interview and record review, the facility failed to provide Resident (R) 4, R9, and R32 a written notification of transfer to the resident and/or his representative as soon as practicable and failed to send a copy of that notification to the ombudsman. The facility also failed to provide R4 or the responsible party with a bed hold. Findings included:1. R4's Electronic Medical Record (EMR) revealed a diagnosis of end-stage renal disease (ESRD- a terminal disease of the kidneys), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and dependance on dialysis (a procedure where impurities or wastes are removed from the blood).R4's Nursing Progress Note dated 08/20/25 at 06:38 PM documented R4 was not to eat or drink in the morning, and was to have a shower with Hibiclense (a strong hospital-grade antiseptic cleanser).R4's Nursing Progress Note dated 08/21/25 at 03:40 PM documented R4 was admitted to the hospital for observation due to having an allergic reaction to antibiotics given after surgery.R4's EMR lacked documentation of a signed bed hold or a written notification to the resident and/or her representative, which explained the reason for the transfer to the hospital. 2. R9's EMR revealed a diagnosis of hydronephrosis (swelling of the kidneys) with renal and ureteral calculous obstruction (kidney stones causing obstruction) and acute (a condition characterized by a relatively sudden onset of symptoms that are usually severe) kidney failure.R9's Social Services Note dated 12/05/25 at 09:56 AM documented R9 was transported to the hospital for a surgical procedure. The bed hold was signed.R9's EMR lacked documentation of a written notification to the resident and/or her representative, which explained the reason for the transfer to the hospital. 3.R32's EMR revealed a diagnosis of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid).R32's Nursing Progress Note dated 10/22/25 at 11:50 AM documented R32 was transported to the hospital for a cough with an oxygen level of 85 percent (%). Oxygen applied. R32 had weakness and was unable to swallow.R32's EMR lacked documentation of written notification to the resident and/or her representative, which explained the reason for the transfer to the hospital. On 12/29/25 at 10:49 AM, Social Services X stated that she was the person who goes over the bed hold with the resident and/or the resident's representative. Social Services X said she was unaware of the regulation to notify the resident in writing and notify the ombudsman of transfers. On 12/29/25 at 1:46 PM, Administrative Staff A stated the bed hold should be completed and signed when a person was transferred out of the facility. Administrative Staff A said she was unaware of the regulation to notify the resident's representative in writing of a discharge or transfer and confirmed the facility had not been notifying the ombudsman. The facility's F 628 Transfer and/or Discharge, Including Against Medical Advise (AMA), Discharge Notification (old 622, F623) policy dated 10/2025 documented the resident and/or representative will be provided a notice in writing with the reason for the transfer, effective date of the transfer, location to where the resident is being discharged /transferred, appeal rights, name, address, and telephone number of the ombudsman and the stated health department agency that has been designated to handle appeals of transfers and discharges.

The facility reported a census of 29 residents; there were 12 residents sampled, which included two residents selected for closed record review. Based on observation, interview, and record review the facility failed to ensure nursing documentation in Resident (R) 10's health record met the professional standards of care when staff repeatedly documented application and removal of compression stockings even when they were not applied, inaccurately representing the provision of treatments. Findings included:- R10's Electronic Medical Record (EMR) documented diagnosis of rhabdomyolysis (breakdown of damaged skeletal tissue), unspecified atrial fibrillation (rapid, irregular heartbeat), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). R10's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated some cognitive impairment. The assessment documented R10 required supervision or touching assistance for upper body dressing and all footwear, to include socks. R10 required partial to moderate staff assistance for lower body dressing, The Activities of Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented that R27 required ADL assistance for self-care or mobility activities. R10's Quarterly MDS, dated 10/10/25, documented a BIMS score of 12, indicating moderate cognitive impairment. The assessment documented R10 required set-up or clean-up assistance for upper and lower body dressing, and footwear. R10's Care Plan recorded an intervention dated 06/02/25 that directed staff to encourage R10 to have her legs elevated when seated and to have thrombo-embolic-deterrent hose (TED hose - specialized compression stockings designed to help manage swelling of the feet/legs) on in the morning and removed at bedtime. R10's Orders tab revealed a physician order, dated 09/30/25, that documented R10 was to have compression hose on in the morning and off at bedtime for lower extremity swelling. R10's December 2025 Medication Administration Record/ Treatment Administration Record (MAR/TAR) reviewed from 12/01/25 through 12/30/25 had no documentation of application or removal of the compression stockings for 12/25/25. On 12/28/25, the MAR/TAR was documented R10's compression stockings had been applied at 06:00 AM and removed at 07:00 PM, and on 12/29.25, they were documented as on at 06:00 AM. Observed on 12/28/25 at 03:06 PM, R10's feet and ankles had swelling. She was not wearing compression stockings. Observed on 12/29/25 at 10:10 AM, R10 ambulated in the hall with her walker. Her feet and ankles appeared swollen, and she was not wearing compression stockings. During an interview on 12/29/25 at 10:35 AM, Certified Nurse Aide (CNA) M stated that CNAs and the nurse would double-check that treatments were performed. She also stated that if a resident refused a treatment, even compression stockings, CNA staff notified the nurse. CNA M also stated that the CNAs would report any observed swelling to the nurse. During an interview on 12/29/25 at 10:42 AM, Licensed Nurse (LN) G stated that the CNAs put on the compression stockings, and the nurse verified it was done; this was then recorded on the MAR/TAR. LN G also stated that the CNA would report refusal, and the refusal would then be charted on the MAR/TAR. She further confirmed that R10 was supposed to wear compression stockings daily and further confirmed that R10 was not wearing them currently. LN G further stated that R10 was independent with dressing and would put her compression stockings on herself, but would sometimes forget. LN G also stated that the MAR/TAR was charted in the morning, and she had assumed that R10 had put them on this AM, and she had not confirmed it before charting the stockings as on. During an interview on 12/29/25 at 11:04 AM, Administrative Nurse D stated that before charting any treatment, it was expected that the nurse would verify the treatment was performed before charting that it was completed or done. Administrative Nurse D also stated that if a resident was independent and would put her compression stockings on themselves, then it was expected that staff would verify that they were on. She further stated that if the resident did not want to wear compression stockings, then it would be charted as a refusal, and if this was consistent, then the provider would be notified, and a discussion would be had about possibly removing the order for compression stockings, and the care plan would be updated to reflect the change. The facility policy Documentation Guidelines, dated 05/2025, documented those services provided to the resident, or any changes in the resident's medical or mental condition, should be documented in the resident's medical record.

The facility reported a census of 29 residents. Based on interview and record review, the facility failed to electronically submit complete and accurate staffing information to the Federal regulatory agency through Payroll-Based Journaling (PBJ) when the facility failed to accurately submit hourly staffing data for all nursing personnel for weekends. Findings included:- The PBJ Staffing Data Report for Fiscal Year (FY) for Quarter 3 - 2025 (April 1 - June 30), indicated the facility had excessively low weekend staffing. On 12/30/25 at 09:28 AM, Administrative Staff A reported payroll data and scheduling data reflected the facility had the same coverage on weekends, if not more than every other day. On 12/30/25 at 10:28 AM, Consultant II stated that all registered nurses except the director of nursing were reported under the same category; therefore, the administrative nurses who work during the week were reported under the same category as licensed nurses who worked the floor. Consultant II stated that is why it appeared they had fewer staff on the weekend when the administrative staff were not working. The facility provided the Centers for Medicare and Medicaid Services Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual version 2.7 dated June 2025, documented the direct care staffing and census data will be collected quarterly and is required to be timely and accurate.

The facility reported a census of 29 residents. Based on observation, interview, and record review, the facility failed to ensure staff distributed ice to residents in a sanitary manner, failed to sanitize glucometers with appropriate sanitizing agent and failed to ensure staff administered medications in a sanitary manner to prevent the spread of infections amongst the residents. Findings included: - Observation, on 05/15/24 at 10:05 AM, revealed housekeeping staff U distributed ice to residents' mugs. The ice was in a large, uncovered container on the snack cart with the scoop stored directly in the ice. Interview, at that time with housekeeping staff U, revealed she did not know the ice should have a lid and the scoop should be kept out of the ice. Interview, on 05/15/24 at 10:15 AM, with Administrative Staff A, confirmed she would expect staff to keep the ice in a covered container and the scoop separate from the ice to prevent contamination of the ice. The facility policy Food Preparation and Service dated 2024, instructed staff to serve food in a manner that complies with safe food handling, and food should be covered when traveling a distance such as down a hallway. The facility failed to ensure staff provided ice to the residents in a sanitary manner to prevent the spread of infection. - Observation, on 05/15/24 at 11:21 AM, revealed Licensed Nurse (LN) N, obtained blood glucose from Resident (R) 7. LN N stated each resident had their own glucometer that the facility provided, but if a meter malfunctioned, the facility had an extra meter that could be used. LN N stated five residents required blood glucose monitoring with a glucometer. LN N proceeded to wipe the resident's glucometer with a sanitizing wipe. The sanitizing product did not list hepatitis as susceptible to the chemicals in the wipe. LN N stated usually the wipes had a purple top. Interview, on 05/15/24 at 11:30 AM, with Administrative Nurse D, confirmed the wipes were not appropriate for sanitizing the glucometers per the manufacturer's instructions. Interview, on 05/15/24 at 11:40 AM, with Administrative Staff A, revealed staff may have run out of the appropriate sanitizing wipes, and substituted a non-medical grade wipe. The Manufacturer's Instruction Manual Cleaning and Disinfection Procedure instructed staff to cleaning and disinfecting the meter with four brands of wipes with EPA (environmental protection agency) registration numbers. The facility failed to clean and disinfect the glucometers with appropriate manufacturer's recommended sanitizing agent to prevent the spread of infection. - Observation, on 05/20/24 at 09:00 AM, revealed Certified Medication Aide (CMA) R prepared medication to administer to Resident (R) 19. CMA R, without sanitizing hands or wearing gloves, opened three capsules of Rytary 48.75/194 milligrams (a medication for Parkinson's disease a disease which is a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) into a medicine cup. CMA R then wiped the end of a paper clip with an alcohol wipe and poked an Occuvite gel tab (a vitamin formula specifically for eye health) and expressed the gel into the medication cup. Interview, on 05/20/24 at 09:30 AM, with Administrative Nurse D, revealed she would expect staff to administer medications in a sanitary manner and with proper hand hygiene. The facility policy Handwashing/Hand Hygiene dated 2024, instructed staff to perform hand hygiene before preparing or handling medications. The facility did not provide a policy specifically for preparing medications (opening capsules). The facility failed to ensure staff prepared medications for administration in a sanitary manner to prevent the spread of infection.

The facility reported a census of 29 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS), complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal [PBJ]), related to licensed nursing coverage 24 hours/day. Findings included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for the second quarter of fiscal year (FY) 2023 (01/01/23 through 03/31/23), documented the facility lacked Licensed Nursing Coverage 24 hours/day on Sunday (SU) 01/01/2023, Saturday (SA) 01/07/2023, (SA) 01/15/23, (SU) 01/21/23, (SA) 01/29/23, (SU) 02/05/23 (SU), (SA) 02/11/23, (SA) 03/11/23, (SU) 03/12/23, (SA) 03/18, (SA) 03/25/23, and (SU) 03/26/23. Review of the facility's time sheets for licensed nursing staff and Staff Posting on the above dates, revealed the facility with RN coverage for eight consecutive hours each of those days. The facility reported inaccurate staffing data as noted above. Review of the Payroll Base Journal (PBJ) Staffing Data Report for the third quarter of fiscal year (FY) 2023 (04/01/23 through 06/30/23), documented the facility lacked Licensed Nursing Coverage 24 hours/day on (SA) 04/08/23 (SU) 04/16/23, (SA) 04/29/23, (SA) 05/06/23, (SA) 05/13/23, (SA) 05/20 /23,(SU) 05/28/23, Monday (MO) 05/29/23, (SU) 06/04/23, (SA) 6/10/23, (SU) 06/11/23, (SA) 06/17/23, and (SU) 06/18/23. Review of the facility's time sheets for licensed nursing staff and Staff Posting on the above dates, revealed the facility with RN coverage for eight consecutive hours each of those days, 24/7 licensed nursing staff, and/or required weekend staffing. The facility reported inaccurate staffing data as noted above. On 05/20/24 10:30 AM, Administrative Staff A and Administrative Staff B confirmed the facility PBJ reporting to CMS lacked accurate data to reflect direct care provided by administrative nursing staff (RN) and licensed nurse (LN) staffing due to the removal of 30-minute meal break when licensed nurse and/or RN remained on site. Administrative Staff A and Administrative Staff B confirmed the facility had 24-hours of a LN on duty each day, RN coverage for 8 consecutive hours each day, and consistent weekend staffing. The PBJ staffing report did not reflect the facility's actual coverage as noted above. The facility lacked a policy to address the submission of accurate PBJ staffing report to CMS. The facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal [PBJ]), related to licensed nursing coverage 24 hours/day.

The facility reported a census of 29 residents with 13 residents selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure nursing staff followed antibiotic stewardship for one of the five residents, Resident (R) 28, with a urinary tract infection with a microorganism resistant to the prescribed antibiotic. Findings included: - Review of Resident (R)28's electronic medical record revealed diagnoses that included diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), congestive heart failure (a condition with low heart output and the body becomes congested with fluid) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status Score (BIMS) of 15, which indicated normal cognitive function. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 01/08/24, assessed the resident required partial to moderate assistance for ADLs. The Care Plan reviewed 04/16/24, instructed staff the resident received multiple medications and instructed staff to review the medications with the physician for proper dosing, timing and frequency and supporting diagnosis. A Nurse Note, dated 05/06/24, revealed the R 28 stated she had pain and thought she had a urinary tract infection and wanted a urinalysis (laboratory test to assess urine for infection). On 05/06/24, the physician instructed staff to obtain a urinalysis, culture, and sensitivity for possible urinary tract infection. Review of the Culture Report dated 05/08/24, indicated R28's urine contained greater than 100,000 colonies of the bacteria Escherichia coli, and was resistant (ineffective to the effects) to ciprofloxacin (Cipro). On 05/08/24, a Nurses' note indicated the culture results were reviewed by the physician and the physician instructed staff to administer Cipro (an antibiotic) 500 milligrams, twice a day, for seven days. Review of the Medication Administration Record (MAR) revealed the resident received Cipro from 05/08/24 through 05/14/24 for 14 doses. Review of the Culture Report dated 05/15/24, revealed R28's urine contained greater than 100,000 colonies of the bacteria Escherichia coli and was sensitive to ceftriaxone (an antibiotic that was effective in eliminating the bacteria). On 05/15/24, the physician instructed staff to administer ceftriaxone, one gram, intramuscularly (injected into the muscle), daily, for three days. Interview, on 05/16/24 at 11:51 AM with Licensed Nurse G, revealed the resident had chronic urinary tract infections. Interview, on 05/20/24 at 02:45 PM with Administrative Nurse D, revealed she would expect the nursing staff to review the culture report and inform the physician of the resistive property of the Cipro. Administrative Nurse D stated the urine continued to show greater than 100,000 colonies of Escherichia coli in the repeat culture, which was sensitive to the prescribed antibiotic, ceftriaxone. The facility policy for Infection Control Area for Review undated, instructed staff to provide an Antibiotic Stewardship Program with protocols and monitoring. The facility failed to provide effective antibiotic stewardship for R28, who received an antibiotic that was ineffective for the microorganism that caused the urinary tract infection, which resulted in subsequent antibiotic treatment that was effective for the organism identified.

The facility identified a census of 29 residents, with 13 residents sampled, including five residents reviewed for unnecessary medications. Based on interview, record review, and observation, the facility failed to follow physician's orders for one of the five sampled residents, Resident (R)20, regarding blood pressure (BP-the amount of force your blood uses to get through your arteries) parameters for this resident on anti-hypertensive (medication used to help control BP) medication. Findings included: - Review of Resident (R)20's electronic medical record (EMR) revealed a diagnosis of hypertension (HTN--elevated blood pressure BP). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severely impaired cognition and he had a diagnosis of HTN. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 02/16/24, did not trigger. The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severely impaired cognition and he had a diagnosis of HTN. The care plan for HTN, revised 04/01/24, instructed staff the resident received amlodipine (a HTN medication used to lower BP) 5 milligrams (mg), every day (QD). Staff were to hold the medication if the resident's systolic BP (SBP--the pressure of the blood as it pushes against the artery walls when the heart beats.) was less than 110, if the diastolic BP (DBP--the pressure your blood is pushing against your artery walls when the heart beats) was less than 40 or if the resident's pulse (the rhythmical throbbing of the arteries as blood was propelled through them) was less than 40 beats per minute. Review of the resident's EMR revealed the following physician's order: Amlodipine 5 mg, QD for HTN. Hold if the SBP was less than 110, the DBP was less than 40 or if the pulse was less than 40, ordered 12/12/23. Review of the resident's EMR, from 12/12/23 through 05/17/24, revealed the staff failed to obtain a BP before the administration of the medication from 12/12/23 through 05/07/24. From 05/08/24 through 05/20/24, the facility administered the medication to the resident when his BP was outside of the parameters on one occasion. On 05/20/24 at 09:58 AM, Licensed Nurse (LN) H confirmed staff had not obtained BP's before the administration of the amlodipine, as they should. On 05/20/24 at 12:59 PM, Administrative Nurse D stated she would look into the BP's not being taken before the administration of the amlodipine for this resident. The facility policy for Hypertension-Clinical Protocol/Guidelines, effective 04/2023, included: The nursing staff will assess and document vital signs (VS) to the physician, as needed. The facility failed to monitor this dependent residents BP before administering anti-hypertensive medication, as ordered.

The facility reported a census of 29 residents with 13 residents sampled, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the consultant pharmacist identified and reported the facility's staff failure to obtain blood pressures (BP-the amount of force your blood uses to get through your arteries) for one Resident (R)20 prior to administering his anti-hypertensive medication (medication used to help control BP), as ordered. Findings included: - Review of Resident (R)20's electronic medical record (EMR) revealed a diagnosis of hypertension (HTN--elevated blood pressure BP). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severely impaired cognition and he had a diagnosis of HTN. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 02/16/24, did not trigger. The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severely impaired cognition and he had a diagnosis of HTN. The care plan for HTN, revised 04/01/24, instructed staff the resident received amlodipine (a HTN medication used to lower BP) 5 milligrams (mg), every day (QD). Staff were to hold the medication if the resident's systolic BP (SBP--the pressure of the blood as it pushes against the artery walls when the heart beats.) was less than 110, if the diastolic BP (DBP--the pressure your blood is pushing against your artery walls when the heart beats) was less than 40 or if the resident's pulse (the rhythmical throbbing of the arteries as blood was propelled through them) was less than 40 beats per minute. Review of the resident's EMR revealed the following physician's order: Amlodipine 5 mg, QD for HTN. Hold if the SBP was less than 110, the DBP was less than 40 or if the pulse was less than 40, ordered 12/12/23. Review of the resident's EMR, from 12/12/23 through 05/17/24, revealed the staff failed to obtain a BP before the administration of the medication from 12/12/23 through 05/07/24. From 05/08/24 through 05/20/24, the facility administered the medication to the resident when his BP was outside of the parameters on one occasion. On 05/20/24 at 09:58 AM, Licensed Nurse (LN) H confirmed staff had not obtained BP's before the administration of the amlodipine, as they should. On 05/20/24 at 12:59 PM, Administrative Nurse D stated she would look into the BP's not being taken before the administration of the amlodipine for this resident. Administrative Nurse D stated she was responsible for receiving and monitoring the pharmacy consultant recommendations. The pharmacist was not available for an interview. The facility lacked a policy regarding pharmacy consultant responsibilities. The facility failed to monitor this dependent residents BP before administering anti-hypertensive medication, as ordered.

The facility reported a census of 26 residents with three selected for review. Based on observation, interview and record review, the facility failed to monitor blood pressure 19 times for the PM dose, for one resident (R)4 of the three residents, to ensure the blood pressure was within the physician ordered parameters prior to administration of an antihypertensive medication to ensure the resident remained free of adverse effects. Findings included: - Review of Resident (R)4's electronic medical record revealed diagnoses included heart failure (a condition with low heart output and the body becomes congested with fluid), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and hemiplegia (paralysis of one side of the body). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function. The resident required extensive assistance of two staff for bed mobility and transfers. The resident received seven days of insulin and six days of antidepressant, diuretic, and opioid medications in the seven-day look-back period. The ADL (Activities of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 09/22/22, assessed the resident was able to make his needs known and required extensive assistance from staff for ADL but was able to feed himself. The resident had a diagnosis of diabetes and took insulin. The Care Plan, reviewed 07/26/22, instructed staff the resident had hypertension and staff to obtain blood pressure readings prior to administering medication, and to obtain the blood pressure under the same conditions each time. Staff instructed to hold medications if the blood pressure was out of parameters. A Physician's Order, dated 10/23/20, instructed staff to administer Metoprolol Tartrate (a medication used to lower blood pressure), 25 milligrams (mg), twice a day (AM and PM) for hypertension. Staff instructed to hold the medication if the systolic(pressure of blood in the arteries when the heart beats, the top number of a blood pressure reading) blood pressure was less than 90 mm/mercury and/or the diastolic(minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading)blood pressure was less than 50 mm/mercury and to notify the physician if the blood pressure was above 175/09. A Physician's Order, dated 07/21/21, instructed staff to administer Dyazide 37.5-25 mg, once a day. Staff instructed to hold the medications if the systolic blood pressure was less than 90 and/or the diastolic blood pressure was less than 50 and to notify the physician if the blood pressure was above 175/90. Review of the September 2022 Medication Administration Record, (MAR), from 09/02/22 through 09/23/22, revealed the resident received the PM dose of Metoprolol 25 mg, nineteen times without monitoring the blood pressure. The September 2022, MAR, revealed staff did obtain the AM blood pressure for the Dyazide. Interview, on 01/03/22 at 03:00 PM, with Certified Medication Aide (CMA) R, revealed the MAR indicated the need to take a resident's blood pressure prior to administration of a medication by the presence of a heart icon and spaces for the blood pressure for the medication and included the parameters to hold the medication. CMA R stated if the blood pressure fell outside of the parameters, she would hold the medication and notify the nurse. Interview, on 01/03/22 at 03:15 PM, with Administrative Nurse D, confirmed the lack of blood pressure monitoring for the PM dose of metoprolol as ordered by the physician. Administrative Nurse D stated she did not know why the MAR did not contain the indication to obtain the blood pressure but did include the parameters for administration. The facility policy Hypertension-Clinical Protocol/Guidelines reviewed 05/2021, instructed staff blood pressure targets should be obtained by the practitioner for residents with hypertension. Nursing staff instructed to monitor for complications of blood pressure treatments. If complications of treatment were identified, the physician should be alerted to review the situation. The facility failed to monitor this resident's PM blood pressure prior to administration of Metoprolol, as ordered by the physician, to ensure the resident did not receive adverse effects of the medication.

The facility reported a census of 31 resident with 13 selected for review, including three reviewed for accident hazards. Based on observation, record review, and interview, the facility failed to implement an intervention following a fall to prevent further falls for one of the sampled residents, Resident (R)20. Additionally, the facility failed to implement an intervention following a laceration (wound to the skin) to his head which required medical treatment out of the facility, after he bumped it on the corner of a television, located in the common television room of the facility. Findings included: - The medical diagnosis tab in the electronic medical record (EMR) for Resident (R)20, included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), unsteadiness on feet, muscle weakness, and abnormalities of gait (manner or style of walk) and mobility. The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R20 with a Brief Interview of Mental Status (BIMS) score of three, indicating severe cognitive impairment. He required limited assistance of one staff for transfers, supervision, and setup for walking in his room and the corridor/locomotion on and off the unit. He did not require any devices for mobility. The Significant Change MDS dated [DATE], assessed R20 with a BIMS score of zero, indicating severe cognitive impairment. He required extensive assistance of two or more staff for transfers, walking in room and in the corridor/locomotion on and off unit. His balance was not steady during transitions and walking, and required staff assistance to stabilize. R20 used a wheelchair for mobility. R20 had two or more non-injury falls since the last assessment and one fall with injury which was not a major injury, since the last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 06/27/22, revealed R20 had no safety awareness and that put him at risk for falls and injury. The Falls CAA dated 06/27/22 revealed R20 was at risk for falls and he had impairment of his balance, impaired safety awareness, and had three recent falls. R20 also had a history of wandering and a new order for physical therapy and occupational therapy for walker and gait training. The Care Plan dated 08/24/21 included R20 was at risk for falls related to his confusion and wandering. The care plan revealed R20 fell on [DATE], 06/10/22, 06/14/22, and 07/11/22. The intervention put in place for the fall on 06/14/22 was for physical therapy and occupational therapy to evaluate and treat for a walker and gait training. The Progress Notes dated 06/08/22 at 05:30 AM, revealed Certified Nurse Aide (CNA) notified the nurse there was blood on the floor of the television room. The nurse went to the room and noted blood on R20's hand and alongside his neck that led up to the top of his head. R20 had a one inch cut on the top of his head which was bleeding. The area was cleansed, and the staff notified the nurse who ordered to cover the area with a dressing and bring the resident to the clinic later, for sutures or glue. The note lacked an analysis of how the incident occurred. The Progress Note dated 06/08/22 at 09:40 AM, revealed R20 returned back from the doctor's office which glued the cut on his head. The Other post incident report for 06/08/22 at the Immediate Action area included staff cleansed the area and neurological checks (assessment to determine an impairment with the nervous system) started. The report lacked an analysis of how the injury occurred or an intervention to prevent further occurrence. The Progress Notes dated 06/14/22 at 06:40 PM revealed a nurse heard a CNA holler his name and when the nurse got to the end of the hallway into the dining room, R20 was falling over onto the floor. The CNA stated she turned around and saw R20 stumbling backwards, then fell to the floor. The progress note lacked an immediate intervention to prevent R20 from falling again. The immediate action on the post fall investigation report for the fall on 06/14/22 included the staff assessed R20 for injuries and neurological checks. The report lacked an immediate intervention to prevent further falls. On 08/11/22 at 08:42 AM, observed Certified Medication Aide (CMA) R and CNA N transfer R20 from the bed to the wheelchair. Both staff held the gait belt, provided physical support to him during the transfer, and provided cues for the resident to take steps during the transfer. On 08/11/22 at 10:47 AM, observed R20 ambulated along the south hall with nonskid socks on using a walker and assist of two therapy staff. R20 held his head down while walking, Staff had to straighten the walker out as it would go to the side and required cues to move away from the wall and when to turn. R20 walked with rarely having his heels in direct contact with the floor. On 08/11/22 at 02:44 PM, CNA N stated R20 has had a change in the past several months and they kept him in view when he was not resting. He used to walk around on his own without a walker, and now he requires two staff to assist with transfers. When a resident has a fall a witness statement is filled out, but the staff do not huddle to discuss the cause of the fall. On 08/15/22 at 01:51 PM, CNA O stated R20 was a fall risk, and he is kept near the nurse's station so staff can Keep an eye on him and if he got restless, staff should Walk him and stuff. When a resident has a fall, staff fill out a witness statement and the nurse should determine the fall intervention. On 08/15/22 at 03:10 PM, Licensed Nurse G stated after a resident had a fall, staff should place an immediate intervention on the risk form that the nurses completed after the fall and document the fall in the progress notes. On 08/15/22 at 03:18 PM, Administrative Nurse D stated on 06/08/22, R20 bumped his head on the corner of the television that hung on the wall in the common television room. The staff found blood on the bottom corner of the television. Administrative D stated when R20 used to walk around he would lean forward or bend over, so it was thought he was doing that and when he straightened up, he hit his head on the edge of the wall mounted TV. Administrative D stated the facility had a cabinet that should have been located directly underneath the TV, however, the cabinet had been moved to the left side of the TV. An intervention was not placed at the time to prevent reoccurrence. On 08/15/22 at 03:23 PM, Administrative Nurse D stated when a resident had a fall, nurses were encouraged to do reasoning on what was going on at the time of the fall and come up with an intervention. The interdisciplinary team (IDT) would review the fall and the fall notes at the weekly PAR (patients at risk) meeting. Administrative Nurse D stated after R20's fall on 06/14/22, staff failed to place an immediate intervention to attempt further falls and would expect the staff to put one in place after each fall. On 08/15/22 at 03:46 PM, Administrative Staff A stated R20 did not have an immediate intervention in place after the fall on 06/14/22 and expected the staff to put one in place after each fall. The facility policy Falls and Fall Risk, Managing F 689 effective 05/2022 revealed if falling reoccurs despite initial interventions, staff would implement additional interventions. The policy lacked instruction on implementing interventions following non-fall accidents with injuries. The facility failed to implement an immediate intervention following a fall to this confused resident without safety awareness, and failed to implement an intervention after a separate incident that was not a fall, when he hit his head on the corner of a television which required medical treatment to the top of his head.

The facility reported a census of 31 residents, with 13 residents sampled, including two sampled for discharge. Based on interview and record review, the facility failed to complete a discharge summary from the facility, which included a recapitulation of resident (R)33's stay at the facility. Findings included: - Review of Resident's (R)33's, undated Physician Orders, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE], documented the resident admitted on [DATE], with a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. The discharge plan addressed the goal for the resident to return to the community. He did not need a referral to the local contact agency. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 06/08/22, documentation included the resident worked with skilled therapy with the goal to return home. The Discharge Return not Anticipated MDS, dated [DATE], documented the resident discharged to the community. The Care Plan, (CP), dated 06/02/22, directed staff the resident wished to return to his home. The Progress Notes, (PN), dated 06/11/2022 at 02:37 PM, documented the resident as increasingly confused over the last couple hours, not recognizing family members and was not able to hold a full conversation. The family agreed they would like to take him home and use hospice services. The resident's Primary Care physician made aware and gave the order to discharge him to his home with family for end- of -life care. The PN dated 06/11/2022 at 06:16 PM, documented the resident discharged home via emergency medical service accompanied by his wife and daughter. The resident's medical record lacked a discharge summary which included the recapitulation that described the resident's course of treatment while he resided in the facility. The recapitulation included, but not limited to the resident's diagnoses, course of illness, treatment, and/or therapy, pertinent lab, radiology, consultations of the resident's stay. On 08/11/22 at 10:58 AM, Certified Nurse Aide (CNA) M stated the resident had cancer and the family decided to take him home to die. He was only at the facility for a short time. She reported the CNAs did not participate in the follow-up or charting after the resident discharged . On 08/15/22 at 12:03 PM, Licensed Nurse (LN) G stated nurses should should provide discharge instructions to the caregivers of the resident at the destination, count the medications, and ensure chain of custody is documented, and complete a discharge summary to include a recapitulation of the resident's stay. She confirmed the resident admitted to the facility from the hospital following brain surgery to remove a tumor. He declined and the wife and daughter took him home on 06/11/22 with hospice care. On 08/16/22 at 11:28 AM, Administrative Nurse D confirmed the resident's medical record lacked a discharge summary which included the recapitulation of his stay The facility policy Documentation of Transfer/Discharges, dated 05/2022, documentation included . information to the receiving provider will include a copy of the resident's discharge summary, and any other documentation, as applicable to ensure safe and effective transfer. The facility failed to complete a discharge summary that included a recapitulation of the resident's stay at the facility, as required.

The facility identified a census of 31 residents with 13 selected for review including one resident reviewed for activities of daily living (ADL's). Based on observation, interview, and record review, the facility failed to ensure one sampled resident, Resident (R)1, who required staff assistance, received appropriate personal hygiene assistance for cleaning and trimming of his fingernails. Findings included: - The medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) dated [DATE] assessed R20 with a Brief Interview of Mental Status (BIMS) score of zero, indicating severe cognitive impairment. He did not reject care and required assistance of two or more staff for personal hygiene cares. The Cognitive Loss/Dementia Care Area assessment dated [DATE] revealed R20 had inattention, disorganized thinking, was unable to express himself most of the time, and staff needed to anticipate his needs. The Quarterly MDS dated [DATE], revealed no changes to his BIMS score, rejection of care, and assistance needed for personal hygiene. The Care Plan dated 06/23/22 revealed R20 had a self-care performance deficit related to his dementia and required one staff to assist him with personal hygiene cares. He preferred to have a shower in the evening time on Sunday and Thursday. The bathing task, located in the EMR under the Task tab, revealed R20 received some type of bathing on 08/11/22 (Thursday) and 08/14/22 (Sunday). On 08/10/22 at 01:43 PM, observed R20 sitting up in his wheelchair in the dining room. His fingernails on his right hand had a brown substance under them and were long, some nails had a jagged edge. On 08/11/22 at 08:28 AM, observed R20 resting in his room on his bed and his fingernails of both hands were long with a brown substance underneath them. On 08/11/22 at 08:42 AM, observed Certified Medication Aide (CMA) R and Certified Nurse Aide (CNA) N assist resident up from his bed to the wheelchair and provide morning cares which included washing his face. Staff failed to provide care of his fingernails. On 08/11/22 at 02:40 PM, observed R20 sat in the recliner across from the nurse's station, his fingernails continued to be long and had a brown substance underneath them. On 08/15/22 at 12:56 PM, observed R20 sat in the wheelchair in the dining room. His fingernails continued to be long with a brown substance underneath and a few of the nails with jagged edges. On 08/15/22 at 01:51 PM, CNA O stated that fingernail care was usually done by activities, and the last time nails were done was on August sixth and would be doing them again on the seventeenth. She does the male and female resident nails unless they have diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). CNA O stated if the fingernails are bad between and need cleaning staff should provide the nail care with their shower. CNA O stated she had not showered R20 recently as he was scheduled on the evening shift for showers. On 08/16/22 at 09:11 AM, R20 observed in the dining room and no changes observed to his fingernails. On 08/16/22 at 09:13 AM, Activity Staff Z stated she does manicures and emery boarding, however, she does not clean or trim the nails, she may clip the tips if they are long and she takes care of male and female nails. Activity Staff Z stated she had never done R20's nails. On 08/16/22 at 09:18 AM, Licensed Nurse (LN) G stated that fingernail care and trimming should be done by the CNA's when a resident received their shower, unless they are diabetic, then the nurses should provide the nail care. LN G stated the CNA's would be responsible for R20's nails and stated his bathing scheduled for Sunday and Thursday on the evening shift. LN G observed R20's fingernails and confirmed his nails needed cleaning and trimming. On 08/16/22 at 11:39 AM, Administrative Staff D stated activities should provide fingernail care. She sets a date to do it and it was typically on the activity calendar. The CNA's were to clean fingernails on shower days and clip if needed or the nurse would clip them too if needed. Administrative Staff D stated she would have expected the staff to clean and trim his fingernails with his bathing completed on Sunday. The facility policy Care of Fingernails/Toenails dated 05/2022 revealed nail care included daily cleaning and regular trimming. The facility failed to provide appropriate personal hygiene assistance needed for trimming and cleaning this dependent resident's fingernails.

The facility reported a census of 31 residents, with 13 residents sampled, which included three residents sampled for respiratory care. Based on observation, interview, and record review, the facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice related to the storage and routine changing of oxygen tubing/cannula, and humidifier bottles for Resident (R) 3, R 17, and R 28. Findings included: - Review of Resident's (R)3's Physician Orders, dated 06/30/22, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. He exhibited shortness of breath (SOB) or trouble breathing with exertion (e.g., walking, bathing, transferring), sitting at rest, and when lying flat. He used oxygen. The Care Area Assessment (CAA), dated 11/22/21, documentation lacked address of the resident's use of oxygen. The Care Plan, (CP), dated 07/20/22, directed staff the resident had [CONDITION(S)] with altered respiratory status and difficulty breathing. Staff should provide oxygen as ordered. Oxygen at 2 liters via nasal cannula (N/C) as needed (PRN) to keep oxygen saturations (the percentage of oxygen concentration in the blood) above 88 percent (%). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ., initially ordered on 12/27/2018. On 08/10/22 at 11:27 AM, the resident's O2 cannula and tubing laid directly on the floor. The tubing and the oxygen concentrator bottle dated 07/17/22. Social Service Staff K confirmed the oxygen cannula and tubing laid directlyon the floor and the date the oxygen equipment labeled as 07/17/22. She stated the date indicated when the tubing and humidifier was last changed. She confirmed there was not a bag available for the tubing and cannula storage when it was not in use. On 08/11/22 at 10:58 AM, Certified Nurse Aide (CNA) M confirmed the resident used his oxygen. She stated the oxygen tubing and cannula should be stored in a bag when not in use to prevent the spread of infection. She reported the night shift staff were responsible for checking the oxygen equipment and changing the tubing weekly. She confirmed the dates on the humidifier bottles indicated the date they were last changed. On 08/15/22 at 12:03 PM, Licensed Nurse (LN) G reported the night shift nurse was responsible for changing the oxygen equipment and tubing weekly on Sunday nights. She reported the tubing and cannula should be stored in a bag when not in use to prevent cross contamination and the date labeled on the tubing and humidifier bottle indicated the date they were last changed. On 08/16/22 at 09:57 AM, Administrative Nurse D verified the oxygen tubing and cannula should be stored in a bag when not in use to prevent infection. She stated the nursing staff should change and label the tubing, humidifier bottles, and cannula weekly on Sunday nights. Anytime the staff noted the cannula and/or tubing on the floor or was in direct contact with an unsanitized surface, the oxygen equipment should be changed out to prevent infection. The facility's policy for Oxygen Administration, dated 06/20/21, lacked address of the maintenance, upkeep, storage, and routine changing of the oxygen cannula's, tubing and humidifier bottles to prevent infections. The facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice related to the storage and routine changing of oxygen tubing/cannula, and humidifier bottles for this resident that required oxygen. - Review of Resident's (R)17's, Physician Orders, dated 06/22/22, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change in Status Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. She experienced shortness of breath (SOB) with exertion, at rest, and lying flat. The resident received oxygen (O2). The ADL Functional Rehabilitation Potential Care Area Assessment (CAA), dated 12/09/21, documentation lacked address of the resident's oxygen use. The Care Plan, (CP), dated 08/02/22, directed staff the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician Orders, dated 06/22/22, included the following orders: 1. Oxygen at two liters, as needed (PRN), to keep oxygen saturations above 90%. Initially ordered on 05/31/2017. 2. Check and document if oxygen is on (the resident) at bedtime. 3. Change the oxygen tubing and mask/cannula weekly on Sundays. On 08/10/22 at 09:57 AM, the resident's O2 tubing/cannula draped across the turn bar on the right side of the bed with the nasal prongs of the cannula in direct contact with the handle of the turn bar, the call light, and the remote control for the bed. There was not a storage bag available to cover the tubing when not in use to prevent cross contamination. The resident was short of breath and coughed at intervals. The cannula/tubing and humidifier bottle lacked labels to indicate the date they had previous been changed. On 08/10/22 at 09:57 AM, Certified Nurse Aide (CNA) P verified the above findings and proceeded to unwrap the cannula from the resident's bedrail and remote control. She then applied the oxygen cannula in the resident's nose and raised the head of the resident's bed. On 08/11/22 at 10:58 AM, CNA M confirmed the resident used her oxygen and the resident experienced shortness of breath. She stated the oxygen tubing and cannula should be stored in a bag when not in use to prevent the spread of infection. She reported the night shift staff were responsible for checking the oxygen equipment and changing the tubing weekly. She confirmed the humidifier bottles and cannula/tubing should be dated to indicate when they were last changed, and staff should date the humidifier bottles when they were last changed. On 08/11/22 at 12:45 PM, CNA P confirmed the resident used her oxygen and the resident experienced shortness of breath. She reported the oxygen tubing and cannula should be stored in a bag when not in use to prevent cross contamination and the spread of infection. She reported the night shift staff were responsible for checking the oxygen equipment and changing the tubing weekly. CNA P reported the humidifier bottles and cannula's/tubing should be dated to indicate when they are changed. On 08/15/22 at 12:03 PM, Licensed Nurse (LN) G reported the night shift nurse was responsible for changing the oxygen equipment and tubing weekly on Sunday nights. She reported the tubing and cannula should be stored in a bag when not in use to prevent cross contamination and the date labeled on the tubing and humidifier bottle indicated the date they were last changed. On 08/16/22 at 09:57 AM, Administrative Nurse D verified the oxygen tubing and cannula should be stored in a bag when not in use to prevent infection. She stated the nursing staff should change and label the tubing, humidifier bottles, and cannula weekly on Sunday nights. Anytime staff noted the cannula and/or tubing on the floor or laying in direct contact with an unsanitized surface, staff should replace the oxygen equipment to prevent infection. The facility's policy for Oxygen Administration, dated 06/20/21, lacked address of the maintenance upkeep, storage, and routine changing of the oxygen cannula's, tubing and humidifier bottles to prevent infections. The facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice related to the storage and routine changing of oxygen tubing/cannula, and humidifier bottle for this resident that required oxygen. - Review of Resident (R)28's Physician Orders, dated 06/22/22, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS), dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 14, which indicated cognitively intact. The resident exhibited shortness of breath (SOB) or trouble breathing with exertion, at rest, and/or lying flat. He received Oxygen. The ADL Functional Rehabilitation Potential Care Area Assessment (CAA), dated 06/22/22, documentation did not include the address of his oxygen use and/or oxygen maintenance. The Care Plan, (CP), dated 07/05/22, directed staff the resident had [CONDITION(S)] with altered respiratory status and difficulty breathing. Staff should provide oxygen as ordered at four liters via nasal cannula when sleeping and as needed (prn) to keep oxygen saturations (the percentage of oxygen concentration in the blood) above 88 percent (%), related to acute respiratory failure, order started 02/03/2020. The physician orders, dated 06/22/22, included the following: 1. Humidified oxygen (O2), via nasal prongs (nasal cannula)/mask, two to four liters flow, as needed (prn,) to keep oxygen saturation above 88%. 2. Oxygen at 4 liters, per nasal cannula, when sleeping, and prn to keep saturation above 88%. On 08/10/22 at 09:27 AM, the resident's oxygen concentrator humidifier bottle was dated 07/17/22, a total of 24 days. The oxygen cannula and tubing laid directly on stacked linen in the seat of the resident's recliner. The area lacked a bag to store the cannula and tubing when not in use. On 08/10/22 at 09:30 AM , Certified Nurse Aide (CNA) M confirmed the resident used his oxygen. She stated the oxygen tubing and cannula should be stored in a bag when not in use to prevent the spread of infection. She reported the night shift staff were responsible for checking the oxygen equipment and changing the tubing weekly. She confirmed the dates on the humidifier bottles indicated the date they were last changed. On 08/15/22 at 12:03 PM, Licensed Nurse (LN) G reported the night shift nurse was responsible for changing the oxygen equipment and tubing weekly on Sunday nights. She reported the tubing and cannula should be stored in a bag when not in use to prevent cross contamination. The date labeled on the tubing and humidifier bottle indicated the date they were last changed. On 08/16/22 at 09:57 AM, Administrative nurse D verified the resident's oxygen tubing and cannula should be stored in a bag when not in use to prevent infection. She stated nursing staff should change and label the tubing, humidifier bottles, and cannula weekly on Sunday nights. Anytime the staff noted the resident's cannula and/or tubing on the floor or laying in direct contact with an unsanitized surface, staff should replace the oxygen equipment with new tubing to prevent infection. The facility's policy for Oxygen Administration, dated 6/20/21, lacked address of the maintenance, upkeep, storage, and routine changing of the oxygen cannula's, tubing and humidifier bottles to prevent infections. The facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice related to the storage and routine changing of oxygen tubing/cannula, and humidifier bottles for this resident, that required oxygen.

The facility reported a census of 31 residents with 13 residents selected for review, including six residents reviewed for unnecessary medications. Based on interview and record review the facility failed to obtain physician ordered lab for Resident (R)24, and failed to schedule an appointment, failed to check blood sugar levels as ordered, and failed to obtain lab as ordered for R16. Findings included: - The medical diagnosis tab located in the electronic medical record (EMR), for Resident (R)24 included diagnoses of [CONDITION(S)] (condition characterized by decreased activity of the [CONDITION(S)]) and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Care Plan dated 12/27/21, included R 24 had a diagnosis of [CONDITION(S)] and to obtain lab/diagnostic work as ordered, report results to the medical doctor, and follow up as indicated. The Order Review Report dated 06/30/22, included these orders: 1. On 12/19/21, [MEDICATION(S)] (insulin) pen-injector, inject 25 units, subcutaneously, every day, related to diabetes mellitus. 2. On 04/22/22, recheck the TSH ([CONDITION(S)] stimulating hormone-laboratory blood level used to measure levels of the hormone) in July 2022. 3. On 04/22/22, [MEDICATION(S)] (medication used to treat [CONDITION(S)]), 150 micrograms, orally, in the morning, for [CONDITION(S)]. 4. On 04/28/22, [MEDICATION(S)] (insulin) pen injector, subcutaneously, per sliding scale, before meals. 5. On 05/03/22, check a CMP (comprehensive metabolic profile-laboratory test that measures 14 different substances in the blood, including blood sugar levels) and a Hgb A1c (hemoglobin A1c-laboratory test used to measure average level of blood sugars over the past three months) every three months in April/July/October/January related to diabetes mellitus and [CONDITION(S)]. Review of the electronic record under the document tab lacked laboratory results for the CMP, TSH and HgbA1c for July 2022. On 08/15/22 at 02:27 PM, Licensed Nurse (LN) G stated staff place the lab orders in the EMR to show up on the lab tab and would display notifications for the time for staff to draw the blood. The laboratory staff would fax the results to the facility, then staff should fax the results to the doctor unless the lab result was critical, then staff should call the doctor. On 08/15/22 at 02:34 PM, Administrative Nurse D stated a form is sent to an outside laboratory and they do the lab draws. The facility should use that form to mark off the lab as the results returned. The nurses would give the form to Administrative Nurse D after they check and make sure the lab results were returned to the facility. Administrative Nurse D stated she was not able to locate the forms for July 2022. On 08/16/22 at 02:51 PM, Administrative Nurse D stated the facility did not draw the TSH, CMP and the HgbA1c due in July, as ordered by the physician. The facility's policy for Lab and Diagnostic Test Results - Clinical Guidelines effective 05/2022, revealed staff would process test requisitions and arrange for tests per community and contracted lab protocol. The facility failed to obtain physician ordered laboratory to assist to manage medications ordered for R24. - The medical diagnosis located in the electronic medical record (EMR) for Resident (R)16 included diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) [CONDITION(S)], and [CONDITION(S)]. The Care Plan dated 05/03/21 included R 16 had a nutritional risk related to weight fluctuations related to fluid and diagnosis of diabetes mellitus and [CONDITION(S)]. The staff were to administer medications as ordered: [MEDICATION(S)] (medication to help control blood sugar) and [MEDICATION(S)] (medication to help remove excess fluid in the body). The staff were to obtain laboratory as ordered every three months and report the results to the physician: HgbA1c (hemoglobin A1c- [laboratory blood test] measures average blood sugar level over the past three months) and a CMP (comprehensive metabolic profile-[laboratory blood test]measures the levels of 14 substances in the blood and could be useful in detecting diabetes and kidney disease). The Order Review Report dated 06/30/22 included these orders: 1. On 11/01/21, check fasting blood sugars weekly on Monday, and notify the primary care provider for results less than 60 or greater than 400 related to diabetes mellitus. 2. On 05/03/22, CMP and HgbA1c every three months in January, April, July, and October. The EMR lacked results for the HgbA1c due for July 2022. The CMP, drawn on 07/07/22 revealed a BUN (measures the amount of urea nitrogen in the blood- a high level may be a sign of decreased kidney function) level of 42 (normal range 9-20) and a [MEDICATION(S)] (measures how well the kidneys are filtering waste form your blood) level of 2.4 (normal range 0.7-1.3). The primary care provider responded to the lab results on 07/11/22 and wrote on the lab report Worsening renal function needs nephrology (specialist that concerns the study of the kidneys) consult if not already seeing one. The Progress Note dated 07/11/22 at 01:41 PM, revealed lab results back with primary care provider stating worsening renal function and needed a nephrology consult if not already seeing one. Staff notified the SSD (social service director). Furthermore, review of the Diabetic Monitoring Medication Administration Record (MAR), which included the weekly fasting blood sugars on Monday, for the month of April 2022, May 2022, June 2022, July 2022, and 08/01/22-08/15/22, revealed the facility failed to obtain fasting blood sugars for the following dates on nine occasions: 04/04/22, 04/11/22, 05/02/22, 05/09/22, 05/30/22, 06/06/22, 07/11/22, 07/18/22, and 08/15/22. On 08/15/22 at 11:35 AM LN G stated staff should check the resident's fasting blood sugars every Monday, usually by the night shift. LN G checked the MAR and confirmed the blood sugar was not done for 08/15/22 and stated they should be documented on the MAR when completed. On 08/15/22 at 02:19 PM, R16 stated he has not had an appointment with a nephrologist and was not aware if he had one scheduled. He reported the facility should let him know when he has appointments. On 08/15/22 at 02:27 PM, Licensed Nurse (LN) G stated she did not know if R20 had seen a nephrologist, and the appointment book was not at the desk. Social services should take care of the appointments. When a resident had a new appointment, nursing staff should let her know and she would schedule the appointments. LN G stated lab orders are placed in the EMR to show up on the lab tab and would display like medications do for when it was time for staff to draw the blood. The laboratory staff would fax the results to the facility, then staff would fax the results to the doctor. If the lab was critical, staff would call the doctor. On 08/15/22 at 02:34 PM, Administrative D stated the HgbA1c for July was not drawn. She stated an outside lab drew the lab and a form were sent to them, and the facility uses that form to mark off the lab as the results come back. The nurses give the form to Administrative Nurse D after they check and make sure the lab results were returned back to the facility. Administrative Staff D stated she was not able to locate the forms for July and would expect the staff to obtain the lab as ordered. On 08/16/22 at 10:36 AM, Social Service staff X stated R16's family does all of his appointments, she had no notes or was not notified of the need for a nephrology consult, and R16 did not have a nephrology consult appointment made. On 08/16/22 at 11:56 AM Administrative Nurse D stated the staff leave a note in the appointment book which is located at the nurse's desk or leave a note at the desk if someone has the book. Administrative Nurse D stated she would expect the staff to notify the SSD of needed appointments and the SSD to schedule appointments ordered by the primary care provider. In addition, when staff processed the order for the fasting blood sugar, staff placed the order under the diabetic Accucheck rather than the diabetic MAR in the EMR, so the order did not display correctly for the staff to obtain. She was unaware staff missed blood sugars, as ordered by the physician. The facility policy Lab and Diagnostic Test Results - Clinical Guidelines effective 05/2022, revealed the staff will process test requisitions and arrange for tests per community and contracted lab protocol. The facility lacked a policy regarding following physician orders. The facility failed to obtain laboratory as ordered by the physician, failed to schedule a nephrology consult as ordered by the physician, and failed to obtain a fasting blood sugar as ordered by the physician for nine of 20 opportunities for this resident.

The facility reported a census of 31 residents with 13 residents sampled, that included six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to act upon the pharmacist's recommendation in a timely manner, to resolve identified irregularities for two residents (R)17 related to potential duplicate therapy of respiratory treatment, dose reduction of medication used to treat pain and R 30 related to gradual dose reduction of psychoactive medication and obtaining lab recommendations. Findings included: - Review of Resident (R)17's Physician Orders, dated 06/22/22, revealed diagnoses which included, [CONDITION(S)] ([CONDITION(S)]- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), pulmonary embolism (blood clot in the lungs), acute pain due to trauma, chronic pain, low back pain, nondisplaced fracture (broken bone with alignment maintained) of right wrist, and pain in the left shoulder. The Significant Change in Status Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. She required extensive assistance with activities of daily living (ADLs). She received scheduled and prn pain medications and reported almost constant pain rated 10/10 which interfered with her sleep and day to day activities. She received opioids for seven days of the look back period. The resident experienced shortness of breath or trouble breathing with exertion, at rest, and when lying flat. She received oxygen. The Mood State, and Pain Care Area Assessment, (CAA), dated 12/09/21, respectively documented the resident has chronic pain which contributed to her ADL performance. She received routine pain medication and received as needed (prn) pain medication which she utilized often. The resident refused to take her medications at times which increased her risk for a further decline in mood state. She was at-risk related to adverse drug reaction to medications. The pain made it hard for her to sleep at night and that limited what she would do, because of the pain. She reported pain in her bilateral (both) wrists, knees, lower back, ankle and experienced frequent headaches. She had her [MEDICATION(S)] (pain medication) increased for one month. The CAA's lacked address of the use of respiratory inhalation treatments. The Care Plan, (CP), dated 8/2/22, directed staff the resident received breathing treatments which included [MEDICATION(S)] inhaler (inhalation medication used to treat wheezing and shortness of breath) every four to six hours as needed, for SOB/wheezing, initiated 06/30/21. Staff should monitor for difficulty breathing on exertion. Give breathing treatments as ordered and monitor for effectiveness of treatments. The resident had chronic pain. She receives multiple medications to treat pain. The facility staff would follow-up on the pharmacist's monthly medication regimen review and resulting recommendation as indicated. Review of the Physician's Orders, revealed the resident received medications which included the following: 1. [MEDICATION(S)] Tablet, 500 milligram (mg), two tablets, by mouth, every eight hours, as needed for muscle spasms, related to back pain, ordered 06/10/22. 2. [MEDICATION(S)] extended release (ER) tablet, 100 mg, one tablet by mouth, two times a day, for muscle spasms, ordered 04/02/2022. 3. [MEDICATION(S)] ([MEDICATION(S)]) 4 mg, one by mouth every 8 hours as needed for nausea, ordered 05/15/22. 4. Acetaminophen 500 mg, give two tablets, by mouth every four hours as needed for pain, ordered 04/02/22. 5. [MEDICATION(S)] (HCl), ([MEDICATION(S)]), give two tablets by mouth every six hours, as needed for pain for 30 days, ordered 08/03/22. 6. [MEDICATION(S)] Sulfate Nebulization Solution (2.5 MG/3ML) 0.083%, 3 milliliters (ml), inhale orally via nebulizer, every four hours as needed for Shortness of Breath, ordered 07/23/21. 7. [MEDICATION(S)] Aerosol Solution (rescue inhaler)108 (90 Base) MCG/ACT ([MEDICATION(S)] Sulfate HFA), give two puffs, inhale orally, every six hours, as needed for [CONDITION(S)]. The resident is able to keep at bedside and administer to self as needed, ordered 5/5/2016. Review of the pharmacist's Monthly Medication Regimen Review, revealed the following concerns: On 10/15/2021, Recommended the discontinuation of the prn order for [MEDICATION(S)] 8 mg. every 12 hours, prn, due to lack of use in previous 80 days. The physician responded on 11/05/21, 21 days following the pharmacist recommendation. Additionally, the pharmacist identified a potential for duplicate medication treatment related to the use of [MEDICATION(S)] Solution 2.5 mg/3 ml via nebulizer every four hours prn SOB and [MEDICATION(S)]-[MEDICATION(S)] solution via nebulizer, every eight hours prn asthma ordered. As well as [MEDICATION(S)] at bedside prn use. The physician responded on 11/03/21 (19 days later). On 04/16/2022, the pharmacist identified a potential for excessive dose medication treatment related to the use of an opioid, [MEDICATION(S)] 10-325(narcotic) three times daily, in combination with [MEDICATION(S)] (an atypical antipsychotic) 15 mg daily, and Orpheridrine (muscle relaxant) ER 100 mg twice daily. The pharmacist requested a dose reduction of for one of these medications if clinically appropriate. The physician responded on 06/16/22, 61 days later. On 08/10/22 at 09:57 AM, the resident transferred from her wheelchair to the be with the assistance of Certified Nurse Aide (CNA) P, CNA O, and CNA Q. The resident was short of breath and reported pain rated at 9/10. Licensed Nurse (LN) G gave the resident [MEDICATION(S)] two mg. The resident reported she tried to sit up in her wheelchair, but it hurt her back and the only relief was for her to lay down and get pain medication. On 08/15/22 at 01:40 PM, the resident was sat in her wheelchair leaning to the right. She reported she had just returned from the doctor and was tired and her back hurt. She requested to lay down. On 08/15/22 at 12:03 PM, LN G stated the resident would cry and get upset when she was in pain. She reported her pain level as 10/10. She has [MEDICATION(S)] two mg every six hours as needed for pain, as well as muscle relaxers. LN G stated she was not aware of the pharmacy medication regimen review nor the expected turn around on follow-up. She reported that was handled by the administrative nursing staff. On 08/16/22 at 09:57 AM, Administrative Nurse D stated the pharmacist does remote pharmacy reviews, and she sends the pharmacy recommendations to the physician and puts the pharmacy reviews for the physicians that round in the facility in a communication book to review when they come to the facility. Administrative Nurse D stated that timeliness of response by the physicians was an issue. She reported that the facility often had to refax physicians and physically go to their office to obtain a response which caused delays in the follow up to the pharmacist's recommendations. She stated the expectation for routine review and follow-up to the pharmacy recommendations was seven to ten days. She agreed the follow-up to the pharmacy recommendations was not timely. The facility policy for Medication Regimen Reviews F756, dated 05/22/22, documentation included, The Director of Nursing and the Consultant Pharmacist will agree on the process and steps to be taken to care once an irregularity has been identified. The facility failed to act upon the pharmacist recommendation to resolve identified irregularities for the resident related to duplicate therapy and dose reduction of multiple medication used to treat pain. - Review of Resident's (R)30's Physician Orders, dated 06/29/22, revealed diagnoses which included, [CONDITION(S)] disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), [CONDITION(S)] disorder (major mental illness that caused people to have episodes of severe high and low moods), hypertension (high blood pressure), major depressive disorder ( major mood disorder), [CONDITION(S)] (swelling due to accumulation of fluid), and acute kidney failure. The Annual Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. The resident reported little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, poor appetite or overeating, trouble concentrating on things, such as reading the newspaper or watching television during the look back period. He required extensive assistance of staff activities of daily living (ADL). He was always incontinent of bladder and which did not improve with attempted toileting program. The resident received injections, insulin, antidepressants, anticoagulants, diuretics and opioids for seven days of the look back period. The Urinary Incontinence and Indwelling Catheter, Mood State, and [CONDITION(S)] Drug Use, Care Area Assessment (CAA), dated 08/01/22, respective documentation included the resident required extensive assistance with toileting and was incontinent of bladder. He had a diagnosis of depression with depression indicator score of nine. Additional diagnoses included [CONDITION(S)] disorder, [CONDITION(S)] disorder and anxiety. The resident received [MEDICATION(S)] (antidepressant medication) daily. Staff should monitor for side effects of medications every shift. The pharmacist reviews the resident's medications and should make recommendations which include a gradual dose reduction (GDR), per policy. The Care Plan, (CP), dated 07/29/22, directed staff to administer medications as ordered. Ask the physician to review medication for possible dose reduction every three months. Monitor medications for side effects and adverse reactions to medications. Ensure labs are drawn as ordered. Follow-up on pharmacist's monthly medication regimen reviews and recommendations. Review of the Physician orders, documentation, dated 06/29/22, revealed the following medication orders: 1. [MEDICATION(S)], (medication to promote the formation and excretion of urine), two milligrams (mg), daily, related to congestive heart failure, ordered 08/05/21. 2. [MEDICATION(S)] [MEDICATION(S)] (HCL), 60 mg., give one capsule by mouth, daily, ordered 11/25/21, for major depressive disorder with psychotic features. Review of the Pharmacy Medication Regimen Review, revealed the following concerns: 1. On 10/15/2021, the pharmacist recommended a GDR for [MEDICATION(S)] 60 mg for depression related to [CONDITION(S)] disorder. The physician responded to the recommendation on 11/09/21, 24 days later to accept the recommendation. 2. On 02/20/22, the pharmacist recommended a decrease of [MEDICATION(S)] (medication to treat diabetes) from 1000 mg twice daily to 500 mg. due to elevated creatinine level (an indicator of decrease kidney function). The physician responded on 03/08/22,16 days later. 3. On 03/14/2022, the pharmacist recommended multiple labs due to previous abnormalities indicated worsening kidney function. The physician responded 39 days later with orders on 04/22/22, for multiple labs to monitor the resident for kidney function. Additionally, the facility did not obtain the labs ordered on 04/22/22 until 12 days after receiving the orders. Furthermore, on 05/12/22, seven days later, the physician discontinued the residents [MEDICATION(S)], [MEDICATION(S)], and decrease the resident's Aspirin dose, based on the results of the labs obtained on 05/04/22. On 08/10/22 at 09:32 AM, the resident noted to have [CONDITION(S)] with redness in both legs. On 08/15/22 at 12:13 PM, LN G stated the resident had depression. The Nurse Practitioner discontinued his [MEDICATION(S)]. She changed his diuretic form [MEDICATION(S)] to [MEDICATION(S)] due to his kidney function. Pharmacists makes recommendation. She was not aware of the pharmacy medication regimen review nor the expected turn around on the follow-up. She reported that was handled by the administrative nursing staff. On 08/16/22 at 09:57 AM, Administrative Nurse D stated the pharmacist did remote pharmacy reviews, and she sends the pharmacy recommendations to the physician and puts the pharmacy reviews for the physicians that round in the facility in a communication book to review when they come to the facility. Administrative Nurse D stated that timeliness of response by the physicians was an issue. She reported that the facility often had to refax physicians and physically go to their office to obtain a response which caused delays in the follow up to the pharmacist's recommendations. She stated the expectation for routine review and follow-up to the pharmacy recommendations was seven to ten days. She agreed the follow-up to the pharmacy recommendations was not timely. The facility policy for Medication Regimen Reviews F756, dated 05/22/22, documentation included, The Director of Nursing and the Consultant Pharmacist will agree on the process and steps to be taken to care once an irregularity has been identified. The facility failed to act upon the pharmacist recommendation to resolve identified irregularities for the resident related to this resident's diuretic therapy and antidepressant therapy.

The facility reported a census of 31 residents, with 13 residents sampled, including six residents sampled for unnecessary medications. Based on record review and interview, the facility failed to notify the primary care provider on 16 occasions from 06/05/22 through 08/07/22 when R29's blood sugar level was out of ordered parameters. Findings included: - The Order Summary Report dated 07/09/22 for Resident (R)29 included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] assessed R29 with a Brief Interview of Mental Status (BIMS) score of 15, indicating cognitively intact. The resident received a therapeutic diet and received insulin injections for seven days of the assessment period. The Nutritional Status Care Area assessment dated [DATE] revealed R29 was on a carbohydrate controlled/fortified/extra calorie with meals diet. She was an insulin dependent diabetic and took oral medication as well. The Care Plan dated 09/08/21, included R29 had diabetes and to call the physician for a blood sugar greater than 400. R29 also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Order tab located in the electronic medical record (EMR), included the following orders: 1. On 09/12/21, [MEDICATION(S)] Emergency Kit, one milligram, inject intramuscularly, as needed, for diabetes mellitus. Administer if blood glucose is less than 60 and not alert. Call the PCP. 2. On 01/13/22, [MEDICATION(S)] (insulin) pen solution cartridge, 100 units/milliliter (mL), inject subcutaneously, before meals and at bedtime, and only give at bedtime if blood sugar greater than 400. 3. On 01/14/21, [MEDICATION(S)] (insulin) solution 100 units/mL, inject subcutaneously, one time a day per sliding scale, and to call the primary care provider for a blood sugar greater than 400. The laboratory result, on 07/07/22, of the HgbA1c (laboratory test that measures average blood sugar levels over the past three months) was high at 8.3 (up from 7.5 on 04/07/22). The Diabetic Monitoring MAR (medication administration record) for June 2022, July 2022, and 08/01/22- 08/15/22 revealed these blood sugars greater than 400 that required primary care provider notification: 1. On 06/20/22 at 11:00 AM, the blood glucose level was 409. 2. On 06/30/22 at 05:00 PM, the blood glucose level was 463. 3. On 07/01/22 at 05:00 PM, the blood glucose level was 418. 4. On 07/02/22 at 11:00 AM, the blood glucose level was 479. 5. On 07/03/22 at 05:00 PM, the blood glucose level was 420. 6. On 07/05/22 at 05:00 PM, the blood glucose level was 426. 7. On 07/19/22 at 05:00 PM, the blood glucose level was 461. 8. On 08/02/22 at 09:00 PM, the blood glucose level was 407. Review of the progress notes in the EMR lacked documentation if the staff notified the primary care provider of the results greater than 400 on the above dates. The Diabetic Monitoring MAR for June 2022, July 2022, and 08/01/08/15/22 revealed these blood sugars greater less than 60 that required primary care provider notification as well as required [MEDICATION(S)] if not alert: 1. On 06/05/22 at 07:30 AM, the blood glucose level was 57. 2. On 06/07/22 at 11:00 AM, the blood glucose level was 57. 3. On 06/10/22 at 07:30 AM, the blood glucose level was 55. 4. On 06/14/22 at 07:30 AM, the blood glucose level was 56. 5. On 06/27/22 at 07:30 AM, the blood glucose level was 56. 6. On 07/26/22 at 09:00 PM, the blood glucose level was 58. 7. On 07/31/22 at 09:00 PM, the blood glucose level was 48. 8. On 08/07/22 at 07:30 AM, the blood glucose level was 58. The progress notes on 06/27/22 revealed breakfast given to the resident, and on 08/07/22 revealed staff administered orange juice, however, the progress notes lacked whether or not staff notified the physician. Review of the progress notes for the other eight occurrences lacked if the resident was alert and if staff notified the primary care provider of the results less than 60. On 08/10/22 at 02:16 PM, R29 stated this morning staff brought her a Glucerna supplement, she had been taking an Ensure supplement because her blood sugar would be low quite a bit of the time. R29 stated the staff check her blood sugar several times during the day and she was unable to tell when her blood sugar was low. On 08/16/22 at 09:23 AM, Licensed Nurse (LN) G stated staff should notify the physician when the blood sugar was out of parameters. Staff should document the results and notifications in the nurse's notes. When R29's blood sugar was low, staff should document it was low, even if staff were not required to give the [MEDICATION(S)] and the physician would still need to be notified. On 08/16/22 at 01:01 PM, Administrative Nurse D stated the EMR lacked documentation the staff notified the physician when the blood sugar levels were out of parameters, and she would expect them to notify the physician each time and document that notification in the progress notes. The facility's policy for Guidelines for Notifying Physicians of Clinical Problems effective 05/2022, included observations that might require physician action included for example significant fluctuations in blood sugar. The facility failed to notify the primary care provider on 16 occasions from 06/05/22 through 08/07/22 when R29's blood sugar level was out of ordered parameters.

The facility reported a census of 31 residents with 13 selected for review including six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure one of the sampled residents, Resident (R)1 was free unnecessary [CONDITION(S)] (class of medications capable of affecting the mind, emotions, and behavior) medications. Findings included: - The medical diagnosis tab, located in the electronic medical record (EMR) for Resident (R)1 included diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure) and dementia (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R1 as having a problem with short- and long-term memory, inattention, and disorganized thinking. R1 could rarely make herself understood and rarely understood others. She did not have any delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), hallucinations (sensing things while awake that appear to be real, but the mind created), behavior symptoms, or rejection of care. She received an antipsychotic (class of medications used to treat [CONDITION(S)] and other mental emotional conditions) medication seven days of the assessment period, and the last gradual dose reduction attempt of the antipsychotic medication was on 05/18/21 (four days after admission to the facility). A gradual dose reduction for the antipsychotic medication had not been documented by a physician as clinically contraindicated. The Annual MDS dated [DATE] had assessed R1 the same except for the physician documented a gradual dose reduction of the antipsychotic medication was clinically contraindicated. The [CONDITION(S)] Drug Use Care Area assessment dated [DATE] revealed R1 received [MEDICATION(S)] (antipsychotic medication), [MEDICATION(S)] (antidepressant medication), Trazadone (antidepressant medication), and [MEDICATION(S)] (antianxiety medication). R1's medications would be reviewed monthly and would have the appropriate gradual dose reductions if necessary and side effects would be monitored routinely. The last pharmacy consultant medication review was on 04/18/22. The Care Plan dated 05/24/21 revealed R1 had a behavior problem related to her disease process. Staff were to administer medications as ordered, monitor behavior episodes, and attempt to determine underlying cause, and document behavior and potential causes. R1 would become agitated when she was either in pain or needed to use the bathroom. The Care Plan included the medication [MEDICATION(S)] had a Black Box Warning, which revealed the medication had not been approved for the treatment of patients with dementia-related [CONDITION(S)] and elderly patients with dementia-related [CONDITION(S)] treated with antipsychotic drugs were at increased risk of death. Additionally, the Care Plan included a problem that R1 received antipsychotic, antidepressant, and antianxiety medication related to diagnosis of anxiety and Alzheimer's dementia. The staff were to monitor/record occurrence of target behavior symptoms of pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. The Order Review Report dated 06/06/22 included an order dated 05/14/21 for [MEDICATION(S)], 50 milligrams (mg), one tab, orally, three times a day for dementia without behavior disturbance. The Other section of the report lacked instructions for staff to monitor for side effects and behaviors related to the use of the medication. The monthly pharmacy Consultation Report dated 11/24/21 recommended to obtain a diagnosis of dementia with behaviors for the [MEDICATION(S)]. The facility contacted the physician on 11/26/21 and responded there was no supporting diagnosis available. The monthly pharmacy Consultation Report dated 04/18/22 recommended a gradual dose reduction to [MEDICATION(S)] to 50 mg twice daily. The physician declined the recommendation on 06/15/22. The monthly pharmacy Consultation Report dated 06/17/22 revealed an inappropriate diagnosis for [MEDICATION(S)], dementia without behavioral disturbance, and should be with behaviors. The facility faxed the physician on 06/22/22 with no response. The facility called the physician on 06/22/22 and reported she does not have that diagnosis at this time. The monthly pharmacy Consultation Report dated 07/16/22 revealed it was a repeated recommendation from 06/17/22. A note on the report included unable to find supporting diagnosis, awaiting information from previous History and Physical's prior to admission. On 08/10/22 at 09:43 AM, observed R1 being transferred by two staff into a recliner in the dining room. R1 was restless and verbally rambling. On 08/11/22 at 09:06 AM, observed R1 in her reclining wheelchair in the dining room, one leg crossed over the other and moving it up and down. She sat quietly and watched movement around her. On 08/11/22 at 10:08 AM, observed R1 fidgeting in the recliner, moving leg up and down, making occasional verbal sounds. On 08/11/22 at 10:15 AM, observed Certified Nurse Aide (CNA) N propel her from the dining room in the reclining chair, when asked if she needed to go to the bathroom, R 1 clearly answered Yes. On 08/11/22 at 10:55 AM, observed R1 rambling word salad, occasional fidgeting in her reclining wheelchair. She would be still and answer a few questions clearly, then would go back to rambling and fidgeting. 08/11/33 at 12:52 PM, observed R1 rambling and crying off and on and when CNA N questioned if she needed to go the bathroom R1 responded Yeah. On 08/15/22 at 10:25 AM, observed R1 in the recliner in the dining room facing the television making repetitive verbal noises, crossing her left leg over the right then uncrossing it, arms restless. R1 responded Hi there when name spoken and smiled, then went back to making repetitive verbal noises. On 08/15/22 at 02:06 PM, CNA O stated R1 required assistance with all of her ADL's (activities of daily living) and depending on her mood or anxiety she could follow commands. CNA O stated R1 talked a lot, moved around a lot, but did not seem to be having any pain. On 08/15/22 at 03:04 PM observed R1 resting on her bed, eyes closed, was not making any verbal noises, and was resting without any movements. On 08/16/22 at 11:58 AM Administrative Staff D stated that her primary care physician did not like to address those kinds of medications/diagnosis that he did not order, in regard to the [MEDICATION(S)]. Administrative Nurse D stated the EMR lacked monitoring of side effects for the [MEDICATION(S)] and monitoring of behaviors and should be in place. The facility policy Medication Regimen Reviews F 756 effective 05/2022 included the drug regimen review shall include at the minimum unnecessary drugs given without adequate monitoring. The facility failed to adequately monitor for side effects of the antipsychotic medication and monitor for behaviors present related to use of the medication to ensure R1 was free from unnecessary medication.

The facility reported a census of 34 residents with three residents sampled for accidents. Based on record review and interview, the facility failed to ensure appropriate and safe transfer of one of the three residents sampled, Resident (R) 1, who required a mechanical lift with a sling to move from surface to surface. On 06/21/21, staff used an inappropriate sized mechanical lift sling, rated to hold 250 pounds (lbs) when the resident weighed 422 lbs. Subsequently during the transfer, the straps of the sling broke and caused the resident to fall approximately 2-3 feet to the floor, landing on his back. The staff lacked the appropriate knowledge of how to read the labels correctly on the slings and assumed all slings in the facility held a maximum of 600 lbs. This deficient practice placed the resident in immediate jeopardy. Findings included: - R1's signed Physician Orders (PO), dated 04/01/21, documented the resident with diagnoses of obesity due to excess calories and generalized muscle weakness. The Annual Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. He was totally dependent on staff for transfers and used a wheelchair for mobility. The resident's weight was 383 pounds (lbs). The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 08/24/20, documented the resident was dependent on two staff members for transfer with a mechanical lift. The Quarterly MDS, dated [DATE], documented the resident with a BIMS score of 15, which indicated intact cognition. He required extensive assistance of two staff members for transfers and used a wheelchair for mobility. The resident's weight was 425 lbs. The Care Plan, revised 06/21/21, advised staff that the resident had a self-care deficit related to weakness and utilized a full mechanical lift for all transfers. An Event Note, dated 06/21/21 at 01:57 PM, revealed Certified Nurse Aide (CNA) M alerted Licensed Nurse (LN) G to come to R1's room. Upon entering the room, LN G saw the resident lying on the floor beneath the mechanical lift. The lift sling was hanging in place, but on one side all three hooks were ripped apart. The sling had a maximum of 600 lbs, was new, and without defaults. LN G assessed the resident, and he was able to talk to her and tell her what happened. He complained of pain in his left side from his shoulders to his toes. He could move his extremities and had no physical injuries. He had not hit his head. He bit his lip in the process of the fall and LN G noted a small amount of blood. LN G notified the physician. A Fall Questionnaire, dated 06/21/21, documented the resident had a fall at 01:30 PM during a mechanical lift transfer. The Root Cause Analysis documented the staff used the incorrect sized sling for the weight of the resident. The resident was too heavy for the sling utilized by the staff. A Witness Statement, dated 06/21/21, by CNA N, documented at around 01:30 PM, she went into the resident's room with CNA M to help the resident back to bed after lunch. The CNAs hooked the sling, which was laying underneath the resident, up to the lift. They started lifting him up in the air and the lift sheet snapped. The resident fell to the floor and landed on his back. The CNAs called for the charge nurse, LN G. The resident complained of his left side hurting. LN G assessed the resident, the CNAs got a different sling, and they lifted him up and put him in bed. LN G kept an eye on the resident. A Witness Statement, dated 06/21/21, by CNA M, documented at 01:30 PM, she went into the resident's room with CNA N to lay the resident down in bed after lunch. The CNAs hooked the sling up to the mechanical lift and raised him up in the air from his wheelchair. The sling broke and snapped, and the resident hit the floor. They asked the resident if he was okay and they sat him up to pull the legs of the lift out from underneath him. The CNAs laid him back on the floor and called for the charge nurse, LN G. The nurse assessed the resident and then staff assisted the resident off the floor and back into bed. Interview on 07/07/21 at 10:05 AM with Administrative Staff D, revealed before R1's fall, all the aides thought the slings in the building were rated at 600 lbs. The labels documented 600 lbs, but it was the amount the lift would handle and not the sling. The CNAs were mis-reading the labels. They had to provide education after R1's fall about how to read the labels. Slings were thrown away if they could not read the labels. They threw away the broken sling, that was rated at 250 lbs, that staff used when R1 fell . Interview on 07/07/21 at 12:40 PM with LN G, verified the Event Note documented above. The labels on the slings document the weight capacities. She stated that the sling broke and that was why he fell . The staff received education on how to read the labels properly and identify which sling was appropriate to use with each resident requiring the mechanical lift. Interview on 07/07/21 at 12:50 PM with Administrative Nurse D, revealed the staff informed her of the incident and she immediately went to the room to assist the staff. R1 was on his back when she entered the room. He could move all his extremities and denied pain at that time. He stated he just wanted off the floor. She assisted LN G to check his skin and complete his physical assessment and no physical injuries were found. They helped the resident back up into bed. CNA M and CNA N mis-read the label and used an inappropriate sling. Interview on 07/07/21 at 01:25 PM with CNA M, revealed she had nothing to add to her witness statement. She stated they used the wrong size lift sling and received education on how to read the labels properly, verify the correct mechanical lift sheet with the correct lift, and follow the proper guidelines. The facility's policy Safe Lifting and Movement of Residents, dated May of 2021, documented .In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .4. Staff responsible for direct care will be trained in the use of .mechanical lifting devices .9. Enough slings, in the sizes required by residents in need, will be available at all times .11. All equipment design and use will meet or exceed guidelines and regulations concerning resident safety . The facility failed to an ensure appropriate and safe transfer for Resident (R) 1, who required a mechanical lift with a sling to move from surface to surface. On 06/21/21, the staff used an inappropriate sized sling rated to hold 250 lbs when the resident weighed 422 lbs. Subsequently during the transfer, the straps of the sling broke and caused the resident to fall approximately 2-3 feet to the floor, landing on his back. The staff lacked the appropriate knowledge of how to read the labels correctly on the slings and assumed all slings in the facility held a maximum of 600 lbs. This deficient practice placed the resident in immediate jeopardy. This deficiency was cited as past non-compliance as the facility completed the following on 06/21/21: 1. At 02:10 PM, Administrative Nurse D instructed nursing staff and CNAs not to use the slings until she inspected all the slings in the facility with Administrative Staff A. All slings were gathered and inspected. 2. At 02:20 PM, Administrative Staff A, after determining weight limits for slings in the facility, called the company who made the slings for label clarification and notified the medical director for cause of the accident. She requested a Quality Assurance meeting to be held at 03:30 PM. 3. At 02:30 PM, Administrative Nurse D reviewed the Lift and Transfer assessments for each resident who required the use of the mechanical lift. Correct weight limit slings were available for these residents. 4. At 02:40 PM, Administrative Nurse D began education for all nurses and nurse aides about the use of the lifts and appropriate slings in the facility. All to be trained prior to working their next shift. 5. At 03:30 PM, Quality Assurance meeting was held. The DON and the administrator, or designee, will monitor mechanical lift transfers during rounds that will occur weekly for four weeks, then monthly for three months, then quarterly.

The facility reported a census of 34 residents. The facility identified 4 residents with pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and sampled 3 residents for review with pressure ulcers. Based on observation, interviews and record review, the facility failed to provide appropriate dressing changes, position changes and special boot placement to prevent additional pressure ulcers development and promote healing of previous pressure ulcers for 2 (#01 and #02) of the 3 sampled residents. Resident #1's coccyx (small triangular bone at the base of the spine) wound worsened from 5 by 2 cm (centimeters) to 7 by 9 cm, and new pressure ulcers developed on the resident's bilateral calves. Findings included: - The facility admitted resident #01 on 1/4/17. The physician listed [DIAGNOSES REDACTED]. The admission MDS (minimum data set) assessment, dated 1/13/17, documented the resident's BIMS (brief interview for mental status) scored an 8, indicating moderately impaired cognition. The resident demonstrated the need for extensive assistance of 2 staff with bed mobility, transfers, eating, dressing, toilet use and personal hygiene. The resident presented with one stage II pressure ulcer and one unstageable suspected deep tissue injury. The 12/16/17 annual MDS documented the resident with a BIMS score of 6, (severe cognitive impairment), totally dependent on 2 staff for all activities of daily living. and always incontinent of bowel and bladder. The resident had one stage II pressure ulcer. The 1/13/17 CAA (care area assessment) for cognition included: The resident was at risk for increased confusion, anxiety, falls, injuries related to decreased safety awareness. Maintain his/her current level of physical and mental function and endurance. Encourage the resident to verbalize preferred activity pattern and make reasonable accommodations. Provide the resident with the least restrictive environment. He/she scored an 8 on a BIMS and his/her cognitive status varied throughout the day. The 1/13/17 CAA for ADLs (activities of daily living) included: The resident was at risk for loss of dignity and independence related to ADL deficits. The resident was also at risk for falls, contractures, increased or unrelieved pain, decreased ROM (range of motion) and risk for depression. Provide therapy to improve the resident's level of function, dignity and independence. He/she had issues with pain and often hollered out when staff attempted to work with him/her. The resident was up in a wheelchair that staff pushed to desired locations. The 1/13/17 CAA for incontinence included: The resident was at risk for impaired skin integrity, loss of dignity, and infection. He/she was incontinent of bowel and bladder and staff used a hoyer lift (mechanical lift) for transfers. He/she admitted with a pressure ulcer to his/her coccyx. The 1/13/17 CAA for nutrition included: The resident admitted with a surgical wound, and multiple skin issues. He/she ate well and dietary supplements ([MEDICATION NAME] and Med Plus SF) and protocol were being initiated. The resident was on therapy services and they were assessing the wheelchair cushion and for proper bed pressure relieving interventions. The resident required extensive assistance of 1-2 staff for ADL's and was on a repositioning program. The 1/13/17 CAA for pressure ulcer included: The resident admitted with a surgical wound and pressure ulcer. He/she required extensive assistance with staff for ADL's and was on therapy services at this time, they were assessing the wheelchair cushion and for proper bed and positioning due to skin issues. The resident is on scheduled repositioning by staff. The care plan revised on 5/15/17 included: The resident had pressure ulcers of the coccyx related to impaired mobility. Interventions included: Float heels as much as possible. Monitor and document progress in wound healing on an ongoing basis. He/she attended the wound care clinic weekly. Use low loss air mattress and cushion in wheelchair or chair when sitting. Provide and serve a liberal diabetic diet, pureed texture. He/she needed cueing to total assistance with meals. The resident was incontinent and wears briefs. Check for incontinence every 2 hours. The resident was dependent on staff for bed mobility. Wound clinic documentation revealed the following: 1.) Review of hospital wound clinic notes, on 12/13/17, revealed the resident presented to the wound clinic with a [MEDICATION NAME] dressing to the coccyx. The previous order, dated 11/29/17, included cleanse the wound with normal saline, apply a foam adhesive dressing. Change the dressing daily and prn (as needed) for soiling. Notes revealed the resident missed his/her 12/6/17 appointment at the wound clinic. The wound notes on 12/13/17 acknowledged the resident's pressure wounds to the buttocks suddenly declined. On 12/13/17, the resident's coccyx area was an acute stage II pressure ulcer. The wound measured 5.0 cm (centimeters) by 2.0 cm by 0.5 cm depth. There was a moderate amount of sanguineous drainage (which is thin, watery, and pale red to pink in color) noted. The staff documented the wound as deteriorating. Directions from the wound clinic physician to the long term care facility, for the coccyx area, dated 12/13/17, included, apply foam adhesive dressing and change daily and as needed for soiling. Use mattress overlay or specialty mattress, turn every 2 hours and avoid position directing pressure to the wound site, lift the resident when moving him/her rather than pulling or sliding the resident. On 1/2/18 at 10:00 A.M., administrative staff A reported the facility experienced times when dressing supplies were not available due to not ordered in a timely manner or a delay in the delivery. On 1/2/18 at 10:40 A.M., certified nursing staff D verified dates were altered and foam dressing changes not completed on at least 2 days in the past. On 1/5/17 at 6:00 P.M., licensed nursing staff D acknowledged seeing changed dates on the coccyx dressing. 2). On 12/20/17 the wound clinic documentation revealed the following: The coccyx wound noted as worsening with measurements documented as 7.0 cm by 9.0 cm by 0.5 cm. The dressing was saturated with urine and not intact upon arrival at the clinic. On 1/2/18 at 10:20 A.M. observation revealed the air mattress appeared to be sunken in under the resident's back and buttock areas. Licensed nurse B reported the baffels (inside the mattress, the long tubes that hold the air) were not fully inflated and this had previously happened at least twice. The facility notified the mattress rental company. 3). The lateral left lower leg displayed an unstageable full-thickness skin and tissue loss pressure ulcer. Measurements were recorded at 2.5 cm x 3.5 cm x 0.3 cm in depth. The wound displayed a moderate amount of sero-sanguineous (which is thin, watery, and pale red to pink in color) drainage with a mild odor. The care plan documented the multi-podus boots (protective type boots for the heels/feet) initiated on 2/1/17. Observation, on 1/2/18 at 3:35 P.M., with licensed nurse B, revealed the multi-podus boots remained on the floor of the closet and not on the resident's lower extremities. Licensed nursing staff B verified the resident developed the pressure ulcer on the lateral left lower leg from the multi-podus boots rubbing. Observation with staff B at this time, revealed the resident's right outer leg now also displayed a pressure ulcer, which measured a discolored area 0.2 x 3.4 cm and a pressure ulcer within the discoloration which measured 0.9 x 0.8 cm. Nurse B reported this area was new since he/she worked on the nursing floor, 4 days ago. On 1/5/18 at 9:20 A.M., licensed nursing staff C explained a lack of the correct (wound clinic ordered) dressing, prior to observation of staff C changing the resident's coccyx dressing. Two gauze 4 x 4's were applied instead of the foam dressing ordered. Later, at 6:50 P.M., observation of the coccyx wound, with direct care staff G, revealed the wound uncovered and with the dressing hanging off. On 1/5/18 at 6:30 P.M. licensed nursing staff D verified staff used ABD (abdominal pads- for wounds requiring high absorbency) pads when the foam dressings were unavailable in the facility for this resident's coccyx wound treatment. Staff D reported he/she also noted that staff members changed the dates on the same dressings a few times, without ever changing the soiled dressing. The facility pressure ulcer policy, revised on 5/2013, included: Identify risk factors for pressure ulcer development. Verify there is a physician's orders [REDACTED]. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate. The facility pressure ulcer policy, dated 5/2013 included, document per community protocol. Report in accordance with facility policy and professional standards of practice. Professional standards of practice for pressure ulcers, per Mosby, forth edition, page 990. The facility failed to provide dressing changes and bilateral special protective boots per the physician wound clinic orders. The facility failed to prevent the development of an unstagable pressure injury to the resident's left leg and worsening of his/her coccyx wound from 5 by 2 cm to 7 by 9 cm. - Resident #02's hospital history and physical, dated 11/30/17, documented the resident admitted to the facility on [DATE]. The resident presented to the hospital from home with right and left buttock wounds due to remaining seated on the toilet seat for approximately 3 days without the ability to move. The admission MDS (minimum data set) assessment, dated 12/7/17, identified the resident with cognition intact. He/she required extensive assistant with bed mobility, transfers, dressing, toilet use and personal hygiene. The CAA (care area assessment) for ADLs (activity of daily living), dated 12/7/17 included: He/she is a new admit to this community, who previously lived at home. He/she became weak at home and was not able to lift self from the toilet. He/she requires extensive assist of 1-2 staff for bed mobility and transfers. He/she has pressure ulcers to the sacrum and posterior bilateral thighs. The CAA for Nutrition, dated 12/7/17 included: He/she admitted with 3, stage II pressure ulcers and a skin abrasion to the right arm. He/she is eating well on a regular diet and the registered dietician to review chart and makes recommendations. The CAA for Pressure ulcers, dated 12/7/17 included: He/she lived at home alone previously, is very weak and debilitated. When the resident was at home he/she became weak and could not get off the toilet, where he/she sat for 3 days developing pressure ulcers to the sacrum, and to the posterior thighs. The Care Plan dated 1/2/18 included: The resident admitted to this facility with 3 pressure ulcers related to Immobility and weakness. Assess/record/monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (medical doctor) and wound care. Avoid positioning the resident on his/her back for long periods of time. The resident is able to make significant changes in position per self. The resident attends a Wound Clinic weekly. Monitor dressing daily or with peri-care to ensure it is intact and adhering. Report lose dressing to Charge nurse/ Treatment nurse. Monitor nutritional status. Serve diet as ordered, monitor intake and record. The resident is on a regular diet with regular texture. The resident requires skin inspection weekly. Observe for redness, open areas, scratches, cuts, and bruises. On 12/28/17 instructions from the wound clinic physician included: 1). Seat lifts or shift position in the chair every 15 minutes. 2). Turn every 2 hours, avoid position directing pressure to wound site. On 1/2/18 observation revealed the resident seated in the wheelchair from 11:00 A.M. until 3:00 P.M. when he/she worked with the physical therapist. The resident remained without assistance to reposition from the wheelchair for at least 4 hours. On 1/5/17 at 10:30 A.M, the resident explained that he/she remained seated in the wheelchair since 7:00 to 8:00 A.M. At that time, (at least 2 and a half hours later), the resident acknowledged no one at the facility informed him/her to shift weight or to change position frequently. The facility pressure ulcer policy, dated 5/2013 included, document per community protocol. Report in accordance with facility policy and professional standards of practice. The facility failed to ensure this resident with pressure ulcers, received assistance as needed to reposition on 2 occasions for 2 and a half hours and again for 4 hours, to promote healing of his/her pressure ulcers.

The facility reported a census of 34 residents. The facility identified 1 resident with bilateral diabetic heel ulcers, included in the 3 residents sampled for review. Based on observation, interviews and record review, the facility failed to provide appropriate special boot placement as ordered to promote healing of the one sampled resident's (#01), bilateral diabetic heel ulcers, which worsened. Findings included: - The facility admitted resident #01 on 1/4/17. The physician listed [DIAGNOSES REDACTED]. The admission MDS (minimum data set) assessment, dated 1/13/17, documented the resident scored with moderately impaired cognition. The resident demonstrated the need for extensive assistance of 2 staff with bed mobility, transfers, eating, dressing, toilet use and personal hygiene. The resident presented with one stage II pressure ulcer and one unstageable suspected deep tissue injury. The 12/16/17 annual MDS documented the resident with a BIMS (brief interview for mental status) score of 6, (severe cognitive impairment), totally dependent on staff for all activities of daily living. and always incontinent of bowel and bladder. The resident had one stage II pressure ulcer and [MEDICAL CONDITION]. The 1/13/17 CAA (care area assessment) for cognition included: The resident is at risk for increased confusion, anxiety, falls, injuries related to decreased safety awareness. Maintain his/her current level of physical and mental function and endurance. Encourage the resident to verbalize preferred activity pattern and make reasonable accommodations. Provide the resident with the least restrictive environment. He/she scored an 8 on a BIMS and his/her cognitive status varies throughout the day. The 1/13/17 CAA for ADLs (activities of daily living) included: The resident was at risk for loss of dignity and independence related to ADL deficits. The resident is also at risk for falls, contractures, increased or unrelieved pain, decreased ROM (range of motion) and risk for depression. Provide therapy to improve the resident's level of function, dignity and independence. He/she had issues with pain and often hollered out when staff attempted to work with him/her. The resident had one stage II pressure ulcer and [MEDICAL CONDITION]. The 1/13/17 CAA for nutrition included: The resident admitted with a surgical wound, and multiple skin issues. He/she ate well and dietary supplements ([MEDICATION NAME] and Med Plus SF) and protocol were being initiated. The resident was on therapy services and they were assessing the wheelchair cushion and for proper bed pressure relieving interventions. The resident required extensive assistance of 1-2 staff for ADL's and was on a repositioning program. The 1/13/17 CAA for pressure ulcer included: The resident admitted with a surgical wound and pressure ulcer. He/she required extensive assistance with staff for ADL's and was on therapy services at this time, they were assessing the wheelchair cushion and for proper bed and positioning due to skin issues. The resident was on scheduled repositioning by staff. The care plan revised on 5/15/17 included: Resident had pressure ulcers (The physician identified these areas as diabetic ulcers), on bilateral heels related to impaired mobility. Interventions included: Float heels as much as possible. Monitor and document progress in wound healing on an ongoing basis. He/she attended the wound care clinic weekly. Multi-podus boots to bilateral heels. Provide and serve a liberal diabetic diet, pureed texture. He/she needed cueing to total assistance with meals. The resident is dependent on staff for bed mobility. On 1/2/18 at 11:20 A.M., licensed nursing staff B verified the staff documented weekly wound assessments in the resident's progress notes. Review of hospital wound clinic notes, on 12/13/17, revealed documentation that acknowledged the resident's bilateral heel wounds that suddenly declined. During this visit, the resident's left heel wound measured larger without evidence of infection. The left heel assessed as a chronic Wagner grade 4 (a grading scale with 4 - partial foot gangrene) diabetic ulcer. The wound measured 3.5 cm (centimeter) by 3.3 cm by 0.2 cm depth. There was a moderate amount of serosanguinous (a clear liquid mixed with blood, or pale red) drainage. Physician orders [REDACTED]. The right heal assessed as a chronic Wagner grade 4 diabetic ulcer. The wound measured 1.0 cm by 1.5 cm by 0.1 cm depth. Physician orders [REDACTED]. Pillows to the upper and lower portion of the right foot to stop the rotation out and relieve pressure to that area. Additional wound clinic instructions for the heels to the facility included, wounds must be kept covered and protected at all times to prevent infection. Elevation of the swollen limb will allow gravity to help reduce swelling. Multi-podus (protective) boots on at all times. On 12/20/17 the wound clinic documentation revealed the following: The left heel assessed as larger at 5 .0 cm by 2.5 cm by 0.2 cm in depth. The right heel assessed as larger as 4.0 cm by 2.0 cm by 0.5 cm depth. On 1/2/18 at 10:00 A.M., administrative staff A explained that the facility did experience times when dressing supplies were not ordered or delivered in a timely manner, so the facility staff did not always have the dressing supplies as ordered by the physician. On 1/2/18 at 10:20 A.M., observation revealed the resident's feet lacked the multi-podus (protective) boots in place as ordered. Licensed nursing staff B verified the resident developed a wound on the lateral left lower leg from the multi-podus boots and the staff failed to pad the boots and failed to apply the boots as ordered. On 1/2/18 at 12:30 P.M. direct care staff H acknowledged the lack of the physician ordered bilateral protective boots were not on the resident as ordered. Observation, on 1/2/18 at 3:35 P.M., revealed the resident's protective multi-podus boots remained on the floor of the closet and not on the resident's feet. At this time, licensed nurse B being present verified the staff failed to place the protective boots on the resident's heels. The facility wound care policy, revised on 5/2013, included: Identify risk factors for pressure ulcer development. Verify there is a physician's orders [REDACTED]. The facility pressure ulcer policy, dated 5/2013 included, document per community protocol. Report in accordance with facility policy and professional standards of practice. The facility failed to provide the physician ordered protective special boots remained on the resident's bilateral feet, per the wound clinic instructions and the resident's bilateral heel wounds worsened with increase in size.

The facility reported a census of 34 residents. The sample included 3 residents selected for medication review. Based on observation, interview, and record review, the facility failed to ensure that 1 (#1) resident was free of any significant medication errors, evidenced by not having received his/her [MEDICATION NAME] (a generic medication for [MEDICATION NAME], an antipsychotic (medication for the treatment of [REDACTED]. The lack of the resident not having received his/her medication for a period of 7 days, and then administered the medication without physician direction, resulted in the resident experiencing hallucinations and [MEDICAL CONDITION], and an allergic reaction (tongue tip swollen and protruding), with the resident transferred to the hospital, without physician notification, which placed this resident in immediate jeopardy. Findings included: - Resident #1 ' s signed physician orders, dated 12/21/16, documented the resident admitted on [DATE], with a [DIAGNOSES REDACTED]. The significant change MDS (minimum data set), dated 2/12/16, revealed the resident had a BIMS (brief interview for mental status) score of 12, indicating moderately impaired cognition, without [MEDICAL CONDITION] or behaviors. The resident received an antipsychotic medication. The [MEDICAL CONDITION] medication CAA (care area assessment), dated 2/16/16, documented the resident received an antipsychotic medication to treat his/her [MEDICAL CONDITION]. The quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 9, indicating moderately impaired cognition. Otherwise, the assessment remained the same as the 2/12/16 assessment. The care plan, reviewed on 12/14/16, advised the resident received a [MEDICAL CONDITION] ([MEDICATION NAME]) medication related to the [DIAGNOSES REDACTED]. Furthermore, during treatment, the resident must have a regular ANC (absolute [DIAGNOSES REDACTED] count), found in a CBC (complete blood count) a laboratory parameter for monitoring patients for [MEDICATION NAME]-induced [DIAGNOSES REDACTED] (the presence of abnormally small numbers of [DIAGNOSES REDACTED]s (a mature white blood cell) in the circulating blood), which could lead to serious infection and death. Because of the risk of severe [DIAGNOSES REDACTED], [MEDICATION NAME] is available only through a restricted program under a Risk Evaluation Mitigation Strategy (REMS) called the [MEDICATION NAME] REMS Program. The resident also had hallucinations and paranoia. The resident ' s hallucination and delusions generally manifest as him/her talking to people and objects that are not there. The staff was to administer the medication as ordered and monitor for side effects and effectiveness. The physician ordered, on 4/19/15, [MEDICATION NAME], 100 mg (milligrams), give 4 tablets by mouth one time a day at bedtime for schizophreniform disorder. Give 4 tablets to equal 400 mg. The physician ordered on, 12/9/15, a CBC (complete blood count) with auto differential every 25 days. A CBC must be obtained and faxed to the pharmacy before [MEDICATION NAME] may be refilled. Review of the CBC obtained, on 10/10/16, the resident had an ANC of 4,800/ul. The normal range for an ANC is 1500/ul (unit per liter) of above The CBC obtained on11/9/16, 30 days later, revealed an ANC of 4,600/ul. The CBC obtained on 12/7/16, 28 days later, revealed an ANC of 4,600/ul. On 12/29/16, the laboratory received from physician staff G, an order for [REDACTED]. Review of the residents December 2016 MAR (medication review record) revealed the resident's [MEDICATION NAME] was not given on 9th, 10th, and 11th. Furthermore, review of the resident's progress notes revealed the physician was not notified of the resident not having received his/her medication. Review of the January 2017 MAR indicated [REDACTED]. The CBC obtained on 1/11/17, 35 days later, after the last ANC test, revealed an ANC of 5,800/ul. The progress notes, dated 1/13/17 at 1:55 PM, documented a late entry for 1/11/17, which evidenced the lab results faxed to the PCP (primary care physician). The progress notes, dated 1/13/17 at 7:42 PM, documented a fax received from the PCP asking for an updated MAR. The progress notes dated 1/15/17 at 7:57 AM, revealed the resident confided that he/she had been angry and upset because he/she had not received his/her medication [MEDICATION NAME]. The resident understood that he/she may need to titrate (start at a low dose), and gradually work back to his/her effective dose. The progress notes, dated 1/15/17 at 8:44 AM, revealed supporting lab (CBC) faxed to the facility pharmacy for medications along with the request for refilling the [MEDICATION NAME]. The progress notes, dated 1/16/17 at 3:42 PM, documented direct care staff L received verbal report from staff members that this resident appeared agitated and restless throughout the week-end of 1/14/17 and 1/15/17 and had also been unable to sleep at night. Direct care staff L spoke with this resident and he/she stated that he/she was psychotic as hell because they (the staff) were not giving him/her medicine. Direct care staff L noted that the resident's face appeared flushed and his/her speech was brisk and loud. Direct care staff L spoke with administrative staff A to report the resident's status. The progress notes, dated 1/17/17 at 12:35 AM, documented at 7:45 PM (on 1/16/17) this nurse went to administer a breathing treatment to the resident. The resident was barely responsive. The resident's respirations were 24, pulse of 95 beats per minute, and his/her blood pressure was 61/33 mmHg (hypotensive, low blood pressure)).The resident's tongue was swollen and protruding from his/her mouth and lower lip appeared swollen. The resident would answer questions, however his/her speech slurred and he/she uttered only one word responses. The resident was barely conscious. Licensed nursing staff S was told by direct care staff M that he/she had given the resident his/her regular dose of [MEDICATION NAME] (400 mg) when it arrived, per instruction of the previous charge nurse. The nurse notified physician F and the physician instructed the staff to send the resident to the hospital. On 1/16/17, the hospital emergency room discharge instructions documented the resident had a reaction to [MEDICATION NAME] and to contact the prescribing physician tomorrow for a new dosing of the [MEDICATION NAME]. The progress notes, dated1/17/17 at 6:30 AM, revealed the resident returned to the facility, and continued to be groggy but was more responsive. Observation, on 2/1/17 at 9:50 AM, revealed the resident was alert and oriented and answered questions appropriately. The resident was in a good mood and stated, at that time, he/she was doing fine. The resident reported he/she did not receive his/her medication for a while and he/she had really needed it, but he/she had receivied his/her medications now. Observation on 2/2/17 at 8:00 AM, revealed the resident was alert, oriented, and in good spirits discussing that today was the resident ' s birthday and he/she was going out to eat with family. Interview, on 2/1/17 at 1:45 PM, administrative staff A stated the staff failed to notify the physician of the medication not being available for 7 days until the night the resident went to the hospital, after obtaining the medication, and administering it. Interview, on 2/1/17 at 12:11 PM, direct care staff N stated he/she passed medications on the January 14, 2017, and realized the resident was out of his/her [MEDICATION NAME], and told administrative nursing staff C. If a medication was not given, staff N would put his/her initials in the box, then circle the box, write on the back of the MAR indicated [REDACTED]. Interview, on 2/1/17 at 1:44 PM, direct care staff M stated he/she had worked a 16 hour shift, on January 16, 2017. The [MEDICATION NAME] came in about 30 minutes before he/she gave the [MEDICATION NAME]. Direct care staff M stated he/she asked the charge nurse if he/she wanted the resident to have his/her medication now or later at bedtime as ordered, and the charge nurse told him/her give it now. Interview, on 1/1/17 at 2:29 PM, direct care staff O stated there was some confusion with the laboratory and staff failed to ensure the CBC was drawn timely, due to staff confusion as to what lab was to be drawn. The physician ordered the CBC to be drawn every 25 days. On 2/1/17 at 3:37 PM, direct care staff P stated the resident ran out of his/her [MEDICATION NAME] for a couple of days in December 2016, and he/she gave the resident his/her [MEDICATION NAME] on December 12, 2016, when it came in. During the 7 days in January 2017 (the 9th, 10th, 11th, 12th, 13th, 14th, 15th), the resident did not receive his/her [MEDICATION NAME], and was the only time he/she noticed the resident acted differently. On 2/2/17 at 2:00 PM, direct care staff O stated the laboratory informed him/her that physician F's standing orders were outdated (12/16) and the laboratory would not accept the orders until the physician signed new standing orders. Staff O discussed with physician staff G the concern with the standing orders and physician staff G went back to his/her office and wrote an order for [REDACTED]. On 2/1/17 at 11:53 AM, licensed nursing staff Q stated a circle with initials means the [MEDICATION NAME] was not given (December 2016 and January 2017). The labs are drawn on the day shift and the technician would leave a note as to which resident and what lab test was to be drawn. Staff Q stated he/she was told the medication was not here and to fax the resident's CBC results to the pharmacy. Staff Q stated he/she sent the lab results to the wrong pharmacy. Staff should notify the physician of any changes with the resident. Furthermore, he/she would have faxed the physician, if he/she was aware the resident missed a couple of doses of his/her [MEDICATION NAME]. On 2/2/17 at 7:29 AM, licensed nursing staff J stated he/she was aware the medication was being held because the resident was out of the [MEDICATION NAME]. One of the problems with receiving the [MEDICATION NAME] was because the medication would be filled by the pharmacy in town and not the facility pharmacy. The nurses were faxing the CBC results to the facility pharmacy, which did not let the facility know they did not fill the resident's [MEDICATION NAME]. Staff R stated he/she thought the CBC was drawn monthly, not every 25 days. Staff R was not aware the resident's medication was out until a couple of days before the resident was sent to the hospital, and told the day shift nurse was to take care of it. On 2/2/17 at 9:25 AM, licensed nursing staff K stated he/she had been off work and came back on the January 12, 2017, and staff informed him/her that the resident did not have his/her [MEDICATION NAME]. Two days later, he/she found out the pharmacy needed the CBC results for the medication to be filled. He/she then came back to work on January 15, 2017, and noted the resident with agitation and having hallucinations. He/she found out the staff faxed the pharmacy the CBC results the day before. He/she called the resident ' s pharmacy that morning and was told they would fill the [MEDICATION NAME]. He/she called the pharmacy numerous times and when they called back, the pharmacy staff told him/her the CBC results were 5 days old, and staff K explained the results had been sent to the wrong pharmacy. Staff K did not think to ask if the [MEDICATION NAME] should be given since the resident had not received the medication for 7 days, however he/she kept telling the pharmacist the resident had not received the [MEDICATION NAME] for 7 days. Staff K stated he/she did instruct the medication aide to give the [MEDICATION NAME] since the resident was having hallucinations. On 2/2/17 at 5:00 PM, administrative staff B stated the resident did not receive his/her [MEDICATION NAME] in December 2016, for the three days. On 2/2/17 at 7:57 AM, administrative nursing staff C stated the facilitydiscovered the systems in place for laboratory testing was not being done correctly and therefore the physician ordered labs were not being obtained timely. The doctor ordered the CBC to be drawn every 25 days. Staff C was not sure why the [MEDICATION NAME] was circled, but would assume the medication was held. With this situation, he/she was not aware the resident used 2 pharmacies ([MEDICATION NAME] ordered from the in-town pharmacy, and all other medications from out of town pharmacy), and he/she faxed the CBC to the wrong pharmacy. The nurses should have notified the physician the [MEDICATION NAME] was not given for 7 days and get direction as to if the resident should have received 400 mg dose of the [MEDICATION NAME]. On 2/1/17 at 2:50 PM, pharmacy consultant H stated he/she noticed the labs were not being done when ordered, and did send a pharmacist consult letter to the physician. If a resident had not received his/her [MEDICATION NAME] for the 7 days, he/she would recommend doing a titration, starting with a low dose and increase slowly. On 2/6/17 at 12:20 PM, pharmacist staff I stated he/she filled the resident's [MEDICATION NAME] for 28 days on November 11, 2016 and would last until around December 7, 2016. In December 2016, the CBC was drawn on December 7, 2016, however he/she did not receive the results of the CBC until December 11, 2017, and he/she filled the [MEDICATION NAME] for 28 days on December 12, 2016. The [MEDICATION NAME] filled in December 2016 would have lasted until approximately January 9, 2017. The resident's [MEDICATION NAME] could only be filled for 28 days at a time per the program. Based on his/her records, the resident would have been out of the [MEDICATION NAME] on January 9, 2017. The next CBC had been drawn on 1/11/17 and he/she received the CBC results on January 16, 2017, and filled the [MEDICATION NAME] on that day. He/she did not realize the resident had not been receiving the medication for 7 days prior to dispensing the [MEDICATION NAME] in January 2017. He/she had not been having difficulty receiving the CBC until the last 3-5 months. On 2/1/17 at 3:15 PM, physician D stated he/she had not been notified the resident had not received the [MEDICATION NAME] for 7 days until after he/she went to the hospital. Since the resident did not receive his/her [MEDICATION NAME] for 7 days, the resident was hallucinating, and someone without instruction ordered the medication to be given at the 400 mg dose. Physician D stated he/she would have ordered the [MEDICATION NAME] to be titrated from a low dose up. Furthermore, physician D stated he/she did not know the resident did not receive his/her [MEDICATION NAME] in December 2016, because physician D was not involved with the resident's care, at that time. On 2/2/17 at 1:45 AM, physician F stated the facility notified him/her when the resident was crashing (blood pressure very low) at the facility. At that time, staff also informed him/her the resident was given his/her normal dose of [MEDICATION NAME], 400 mg. If the facility called him/her before giving the [MEDICATION NAME], physician F stated he/she would have ordered the facility to give a lower dose of the [MEDICATION NAME] because it could cause the resident to become hypotensive (low blood pressure). Whenever a resident missed their antipsychotic medication, the facility should notify the doctor. The facility did not notify physician F regarding the residents 3 missed doses of his/her [MEDICATION NAME] in December 2016. The facility policy for identifying and managing medication errors and adverse consequences, dated 4/07, documented the staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur. The staff shall report clinically significant adverse medication consequences and medication errors with adverse clinical consequences to the resident's attending physician immediately. The facility policy for Pharmacy services, dated 11/16, documented the facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the services of a licensed pharmacist. Also help the facility assure that medications are requested, received, and administered in a timely manner as ordered by the authorized prescribers. To help develop procedures and guidance regarding when to contact a prescriber about a medication issue. The facility policy for administering medications, dated 4/10, advised medications must be administered in accordance with the orders, including any required time frame. The director of nursing services will supervise and direct all nursing personnel who administer medications and/or have related functions. The facility failed to ensure this resident was free of significant medication errors, and placed the resident in immediate jeopardy for harm related to being given antipsychotic medication the resident had not taken for 7 days, causing hallucinations, a hypotensive adverse reaction and allergic reaction, which resulted in the resident having to be transported to the hospital for treatment. The investigation revealed the facility was in past-noncompliance as of 01/19/17, as the facility: 1.) All licensed nursing staff was educated on medication administration, physician notification, where to verify the residents' pharmacy of choice on the resident face sheet, and on lab procedure within the community from January 17 to 19th, 2017. 2.) Follow-up and monitoring will be reviewed by staff delivering medication by verifying when a medication is low or out that the medication is on the Medication Concern Log. If a medication was not available it is considered a stop and take action situation. Medical records/designee will monitor labs every Thursday morning.

The facility identified a census of 29 residents with a sample of 5 residents, which included the one resident with a urinary indwelling catheter reviewed. Based on observation, interview and record review, the facility failed to ensure the one sampled resident (#1) with an indwelling catheter had a valid medical justification for the use of the catheter and failed to provide appropriate services to prevent urethral trauma, penile tearing, and catheter-related pain. Findings included: - The electronic medical record documented Resident #1 [DIAGNOSES REDACTED]. The Admission MDS (minimum data set), dated 11/10/14, documented the resident ' s BIMS (brief interview for mental status) score of 11, indicating moderately impaired cognition. The MDS documented the resident was totally dependent on 2 staff for ADLs (activities of daily living) and had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag). Review of the Care Area Assessments for admission, dated 11/10/14, documented the resident was a new admit, post hospitalization , with a [DIAGNOSES REDACTED]. The resident also came to the facility with a severe UTI that was being treated at the hospital. After the UTI, and with the history of being unable to void without a catheter, the hospital decided the resident was in need of a chronic Foley catheter. The resident was at risk for further complications and infections related to the Foley catheter use. The care plan, dated 11/16/14, directed staff with the following interventions: dependent on staff for all catheter care; store collection bag inside a protective dignity pouch; report UTI; position the bag below the level of the bladder; obtain UA (urinalysis) for suspected UTI; manipulate tubing as little as possible during care; keep the catheter system as a closed system as much as possible; irrigate catheter only if an obstruction is suspected; do not allow tubing or any part of the drainage system to touch the floor; change Foley catheter every month and as needed , 16 French with 10 ml (milliliter) balloon; change catheter bag every week; avoid obstructions in the drainage; avoid lying on top of the tubing; assess drainage and administer [MEDICATION NAME] 0.4 mg daily. Additions included: On 12/16/14, the urologist ordered staff to apply Vaseline or any inert cream on the external meatus twice daily and suggested to tape (anchor) the catheter tubing, and continue present management. The physician's orders [REDACTED]. The physician's order [REDACTED]. In addition, the care plan updated on 1/12/15, documented follow up to be scheduled for urology to assess the continued need for the indwelling catheter; on 1/25/15 the urologist does not feel comfortable doing a supra-pubic catheter, and would like to remove the indwelling catheter due to the tearing of the meatus. The physician ordered staff to remove the catheter after the infection had cleared. The physician ordered IV (intravenous) antibiotics in a last attempt to treat the UTI. 2/11/15 the urologist suggested intermittent catheterizations 2 to 3 times a day, however, the resident and family refused. On 2/23/15, the tip of the resident ' s penis was torn and draining a copious (abundant) amount of pus (white/yellow drainage, a sign of infection). The resident stated that it was very painful. The catheter was not putting out any urine. Along with this, the resident is also having respiratory issues. The physician ordered the resident to be transferred to the emergency room where the resident was admitted for acute care. Furthermore, the care plan addition on 2/19/15, documented the resident was not participating in the restorative range of motion (ROM) program as much as anticipated due to pain from the split meatus (lacerated urethra) at the tip of the penis. The resident would participate in ROM in the upper extremities but would not allow ROM to the lower extremities at this time. The nurse ' s note, dated 11/07/2014 at 8:50 PM, documented the resident required assist of 2 staff for ADLs and transfers via Hoyer lift. The Foley catheter was patent, draining dark yellow/blood tinged urine. The resident stated "When they got me up this morning, they pulled on the catheter, it hurt really bad." The nurse ' s note, dated 12/06/2014 at 6:38 PM, documented at approximately 5:45 PM, CNA (certified nursing assistant) called for this nurse and stated that the resident ' s catheter was twisted around the left leg under his/her pants. While transferring the resident, staff inadvertently pulled on the catheter tubing. The urethral opening of the penis tore from the bottom of the opening to the base of the penis. A small amount of bleeding noted and 4x4 gauze pads and pressure applied to the penis. The resident complained of pain when the catheter or penis is touched. The catheter was in place at this time. The resident transferred via ambulance to the emergency room . The nurse ' s note, dated 12/07/2014 at 12:39 PM, documented the Foley catheter was in place and draining yellow urine. The resident stated the insertion site was sore, so staff administered PRN (as needed) [MEDICATION NAME] (an opioid pain medication used to treat moderate to moderately severe pain) this morning. The nurse ' s note, dated 12/08/2014 at 10:36 PM, documented the resident ' s penis was swollen. The nurse ' s note, dated 12/18/2014 at 2:54 PM, documented the resident complained of penile pain, and rated the pain at 8 on 0-10 pain scale. Staff administered [MEDICATION NAME] orders. The nurse ' s note, dated 01/22/2015 at 9:58 AM, documented staff reported to this nurse that the resident had no urine output and that blood was in the catheter tubing. When asked if the catheter had been pulled, staff stated, " a little " . Upon assessment, the 16FR Foley was found lying in the brief, with the balloon still filled. The resident stated that staff pulled it out while transferring him/her with the Hoyer lift. The resident had complaints of urethral pain, and rated the pain at 10 on 0-10 pain scale. Staff administered PRN [MEDICATION NAME]. A small amount of blood noted to the penis. Staff cleansed the resident and inserted a new 16 French Foley catheter at this time. The resident voiced complaints of pain and discomfort on insertion of the catheter. The nurse ' s note, dated 01/30/2015 at 9:44 AM, documented the resident voiced complaints of discomfort to the meatus due to the previous trauma from the catheter being pulled out. The nurse ' s note, dated 02/15/2015 at 1:30 AM, documented the CNA staff called this nurse to the resident ' s room to observe the resident ' s penis. The shaft of the penis tear seemed to be larger. Vaseline therapy and care continued to be done with the resident. The nurse ' s note, dated 02/23/2015 at 12:00 PM, documented the urethra was split open to the left, right, and downward at this time with yellow/white drainage. The nurse ' s note, dated 02/23/2015 at 12:57 PM, documented staff was unable to successfully flush the catheter without discomfort, and the resident had no urinary output at this time. The resident had other non-related symptoms as well and transferred to the emergency room at this time. The nurse ' s note, dated 02/27/2015 at 4:19 PM, documented the resident returned to the facility at this time with complaints of penile pain, and rated the pain at a "9" on the 0-10 pain rating scale. Staff administered PRN [MEDICATION NAME] at this time. The hospital discharge summary, dated 2/27/15, documented the resident had sustained some traumatic accidental Foley catheter removals and sustained some penis trauma. The resident had begun having supra-pubic pain and non-draining of the Foley catheter and was sent to the emergency department for evaluation. On evaluation there, the Foley catheter had to be removed secondary to obstruction. On replacement of the Foley, a very dark urine and sediment drained out and was sent for urinalysis and culture. The resident had an acute complicated urinary tract infection with indwelling Foley and started IV (intravenous) antibiotics. The resident also had signs [MEDICAL CONDITION] (a severe blood infection that can lead to organ failure and death) from the infection and was started on IV fluids for fluid resuscitation with [MEDICAL CONDITION]. [MEDICATION NAME] jelly was provided for penis pain relief. Observation of the resident, on 3/12/15 at 7:12 AM, revealed Direct Care Staff C and Licensed Nursing Staff D, entered the resident ' s room to get him/her up for the day. Staff D cleaned the glans of the penis, used wipes, and then treated the tear on the glans of the penis, noted to be approximately ½ inch in length, with [MEDICATION NAME] gel for pain control, which the resident rated at 7 out of 10 at this time. The catheter drained to a dependent drainage bag and hung on the edge of the bed, with no anchor on the tubing. During observation of the resident, on 3/12/15 at 7:46 AM, Licensed Nursing Staff D entered the room with an anchor for the catheter tubing, and while opening it, stated to the resident, " I ' ve never used one like this, I ' m not sure I know how. " Staff rubbed skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) onto the right thigh of the resident, and placed the anchor, and continued to state, " I just don ' t see how this thing works. " Staff D later observed that the anchor was for a PICC (peripherally inserted central catheter - used for intravenous access) line, not a urinary catheter. Staff D then removed the anchor from the resident ' s leg, telling the resident he/she was sorry. Staff then stated he/she was going to go see if there were any urinary catheter anchors in the building, stating he/she knew the facility did not have any before, but maybe they did now. The resident, on 3/12/15 at 9:19 AM, reported he/she could not remember all of the details about all of the times staff pulled on the catheter or when the catheter got pulled out, but knows there were many times. The resident stated that the staff during transfer of the resident with the Hoyer lift, the tubing got caught up and pulled by the lift all the way out, which hurt really bad. But, before that, it also had been pulled on and tore the tip of the penis. When that happened, staff told the resident the catheter tubing had gotten all wrapped around the resident ' s leg, which pulled on the catheter so bad it just ripped the resident ' s penis wide open. The resident stated staff never used an anchor for the catheter tubing, and staff told the resident the facility did not have any of them. The resident reported that when he/she went to the hospital, the hospital put and anchor on the resident ' s leg for the catheter tubing, but when the resident came back to the facility, staff removed the anchor and the resident reported he/she had not had an anchor again since then. On 3/12/15 at 9:43 AM, Direct Care Staff E reported the resident ' s catheter tubing is not anchored to the leg. On 3/12/15 at 10:10 AM, Direct Care Staff F reported the staff do not use a leg strap for the resident ' s catheter tubing, and staff never had. On 3/12/15 on 10:51 AM, Licensed Nursing Staff D reported a urinary catheter anchor holds the catheter tubing in place to keep it from pulling on the urethra and decreases catheter pain. Staff D then confirmed the resident was without an anchor for the catheter tubing and stated staff D was not sure why the facility does not have any anchors available. Staff D recalled the night the direct care staff approached him/her and reported the resident was bleeding from the penis. The CNA ' s had told Staff D when they transferred the resident they pulled too hard on the catheter and the bleeding started. Staff D sent the resident to the emergency room and they said the resident needed to see the specialist. Staff D reported that on assessments prior to this night, the tear was there, but not as bad as it was after that night. Staff D recalled on January 22, 2015, working and the CNA ' s reported the resident had no output form the catheter. Staff D went to assess the resident and the catheter had been pulled out. Staff D found the catheter in the resident ' s brief with the balloon still inflated and a small amount of blood coming out of the resident ' s penis. The CNA ' s said they were using the Hoyer to transfer the resident; there was no anchor on the catheter tubing. The tubing caught and pulled the catheter out. At that time, the facility had no anchors for the catheter tubing. The resident rated pain at 10 out of 10 and staff gave him/her [MEDICATION NAME] for the pain. Staff D reported that physician orders [REDACTED]. On 3/12/15 at 2:26 PM, Administrative Nursing Staff B reported the expectation for catheters was that facility staff always use a catheter tubing anchor/stabilizer and confirmed that staff was not using one for this resident. Staff B reported the facility did have two incidents with the resident ' s catheter; one where the catheter was pulled, causing trauma and bleeding to the resident ' s penis and the second time, where the catheter was pulled all the way out of the penis with the balloon still inflated. The last time it caused the resident ' s penis to tear more. Staff B confirmed that for both of these incidents, a catheter tubing anchor was not being used. Staff B confirmed the record lacked a proper [DIAGNOSES REDACTED]. The facility provided policy for Catheters/Urinary/Catheter Care, dated 02/2012, documented to minimize trauma to the urethra, secure the catheter with a catheter clip in order to allow the catheter tubing to be freed for manipulation when necessary. The facility failed to ensure the resident received appropriate catheter care, remained free of injury while providing care with the failure to anchor this resident ' s catheter tubing and the resident received tearing of the urethra requiring two hospitalization s and the facility failed to ensure valid medical justification for the resident ' s use of the catheter.