Every finding on record at Palm Garden of Gainesville

Based on observation, interview, and record review the facility failed to maintain complete and accurately documented medical records for 5 of 8 residents, Residents #28, #32, #62, #97, and #119 reviewed for medication management, 2 of 6 residents, Residents #99 and #111 reviewed for mood and behavior, 1 of 3 residents, Resident #103 reviewed for intravenous therapy, and 1 of 3 residents, Resident #136, reviewed for discharge. Findings include: 1) Review of Resident #97's physician order dated 5/5/2025 read, Basaglar Kwikpen Solution Pen-Injector 100 UNIT/ML [milliliter] [insulin Glargine] inject 10 unit subcutaneously in the morning for diabetes. Review of Resident #97's physician order dated 5/5/2025 read, Insulin Lispro [NAME] KwiwPen Subcutaneous solution Pen-Injector 100 UNIT/ML [Insulin Lispro] inject as per sliding scale: If 0-150= 0 units, 151-200=2 units, 201-250= 4 units, 251-300= 6 units, 301-350=6 units, 351-400=10 units; 401+ Notify MD [Medical Doctor] subcutaneously before meals for diabetes. Review of Resident #97's Medication Administration Record (MAR) for the Month of May 2025 for Insulin Lispro revealed a blank entry on 5/04/2025 at 0630 [6:30AM]. Review of Resident #97 MAR for the Month of May 2025 for Basaglar Kwikpen 10 units revealed blank entries on 5/9/2025 and 5/13/2025. During an interview on 5/29/2025 at 12:00 PM the Director of Nursing (DON) stated, I spoke to [Staff F, Registered Nurse's name (RN)] and she stated [Resident 97's name] refused the insulin coverage due to the blood glucose level but she forgot to document it in the medication administration record. I also spoke to [Staff G, License Practical Nurse's name (LPN)] and [Resident #97's name] was running less than 150 and did not need coverage but does not know why she did not document it. During an interview on 5/29/2025 at 1:38PM Staff F, RN stated, The blood sugar was low and [Resident #97's name] refused both days on 5/9/2025 and on 5/13/2025 the blood sugar was low. I called the doctor to notify him, and I did not give the insulin. I forgot to write a progress note normally I will write a note in the system. During an interview on 5/29/2025 at 1:33 PM Staff G, LPN stated, I forgot to document that day. [Resident #97's name] was running low I cannot remember the blood sugar level but it was less than 150. [Resident #97's name] did not require insulin coverage normally she runs low. I went to get her a snack and in the exchange forgot to document. 2) Review of Resident #119's physician order dated 2/24/2025 read, Insulin Aspart 100 UNIT/ML inject 11 units subcutaneously three times a day for DM2 [Diabetes Mellitus Type 2] hold for glucose less than 100. Review of Resident #119's MAR for the month of May 2025 documented on 5/10/2025 for Insulin Aspart at 7:30 AM no blood glucose value was documented. Coded as 9 at 2100 [9:00 PM] was checked off as given but no blood glucose value was documented. On 5/14/2025 at 2100 [9:00 PM] blood glucose value was documented as 94 and the insulin was checked off as administered. Review of Resident #119's physician order dated 5/11/2025 read, Insulin Glargine Subcutaneous Solution [Insulin Glargine] Inject 50 units subcutaneously at bedtime for DM. Review of Resident #119's MAR for the month of May 2025 documented for Insulin Glargine 50 units documented on 5/17/2025 HS [hour of sleep] coded 5. During an interview on 5/29/2025 at 4:52 PM Staff R, LPN, stated, The system will not allow you to move forward if you don't document. I might have been quick to click to check it off, but she [Resident #119] did not get the insulin. I always follow the parameters. During an interview on 5/29/2025 at 4:50 PM Staff S, LPN, stated, I don't recall if I held it or not [the insulin]. Normally I would call the provider if I have a question or concern with medication. 3) Review of Resident #28's physician order dated 5/14/2025 read, Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 UNIT/ML [Insulin Degludec] Inject 10 unit subcutaneously in the morning for DM2. Review of Resident #28's MAR for the month of May 2025 documented on 5/2/2205 at HS coded 9. Review of Resident #28's progress noted dated 5/2025 read, bg [Blood Glucose] was 63. During an interview on 5/30/2025 at 1:09 PM the Advance Practice Registered Nurse #1 (APRN #1) stated, Normally staff will contact me if they have a question regarding insulin administration or blood sugars. I have no concerns regarding staff holding medication when they should. I get many calls, and I am not able to remember specific dates. 4) Review of Resident #62's physician order dated 4/17/2025 read, Oxycodone HCL [hydrochloride] capsule 5 mg [milligrams] give 1 tablet by mouth every 6 hours as needed for moderate to severe pain level 6-10. Review of Resident #62's MAR for the month of May 2025 for Oxycodone 5 mg documented medication was given on 5/5/2025 at 2015 [8:20 PM] for a pain level of 4, 5/11/2025 at 2054 [8:54 PM] for a pain level of 4, 5/12/2025 at 2032 [8:32 PM] pain level of 5, on 5/14/2025 at 1411 [2:11 PM], and at 2249 [10:49 PM] pain level of 5, and on 5/15/2025 at 2201 [10:01 PM] pain level of 5. During an interview on 5/30/2025 at 9:29 AM Staff H, RN stated, [Resident #62's name] is always in pain. His pain is never lower than 9 or 10. It was a typo when entering the pain level in the record. During an interview on 5/30/2025 at 11:00 AM the DON stated, I am glad the nurses remember [Resident #62's name] pain levels, but I believe it was more a human error and typing to fast in the key board. During an interview on 5/30/2025 at 2:10 PM Staff L, LPN, stated, Usually his pain is 6 or 7 could have been I entered the wrong pain level. It could have been a distraction, I do not recall. Review of the policy and procedure titled General Dose Preparation and Medication Administration with a last review date of 1/31/2025 read, Procedure: .5.2 Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record .6. After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 6.1 Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN [as needed] medications, application site) on appropriate forms. Review of the policy and procedure titled, Charting and Documentation with a last review date of 1/31/2025 read, Purpose: The purpose of this procedure is to provide a complete, accurate, readily accessible and systematically organized medical record. The medical record will reflect a resident's progress toward achieving their person-center plan of care objectives, goals, and improvement and/or maintenance of their clinical functional, mental and psychosocial status. Guidelines, Effective Documentation practices include but are not limited to: use only appropriate terminology and abbreviations. 49846 5) Review of resident #32's physician orders dated 12/05/24 read, Midodrine HCL oral tablet 2.5 mg one tablet by mouth two times a day/Hold if systolic Blood Pressure is over 120. Record review of resident #32's MAR for the month of May 2025 for Midodrine HCL 2.5 mg documented the medication was administered for the evening hour on 05/01/25 - BP [blood pressure] 128/80, early hour on 5/03/25 BP - 138/76, evening hour 05/09/25 - BP 144/86, early hour 5/11/25 BP - 130/76, evening on 05/14/25 - BP 131/77, evening hour 5/19/25 - BP 156/88, blank entry for the early hour on 5/24/25, early hour 5/25/25 - BP 145/77, evening 5/26/25 - BP 125/74. During a telephone interview on 05/29/25 at 02:15 PM Staff O, LPN stated, I did not give the medication the last time, I do not recall giving the medication on May 3, 2025. During a phone interview on 05/30/25 at 09:57 AM with Staff P, LPN regarding Midodrine HCL oral tablet 2.5 mg. Staff P stated, If I signed the medication as given it was signed in error, I always take her blood pressure and I know the parameters. During an interview on 05/30/25 at 12:25 PM Medical Doctor #2 stated, If medication was given out of parameter, it would not have a negative effect on the patient due to this drug is short active. I do think I will change the parameter from 120, to hold over 140. During a telephone interview on 05/30/25 at 12:46 PM Staff Q who stated, I did sign the medication out and there should be no blanks on the medication MAR. I know there are parameters and depending on what it was I either gave it or not I just can't remember what the blood pressure was. 50123 6) Review of Resident #99's physician order dated 3/18/2025 read Aripiprazole Oral Tablet 5 mg give 10 mg by mouth at bedtime for schizophrenia. Review of Resident #99's physician order dated 2/23/2024 read Divalproex Sodium Tablet Delayed Release 250 mg give 1 tablet by mouth two times a day for Bipolar. Review of Resident #99's physician order dated 7/22/2024 read Sertraline HCl Tablet 100 mg give 1 tablet by mouth in the morning for major depressive disorder. Review of Resident #99's physician order dated 10/18/2022 read monitor and document behavior concerns using codes provided. Behavior code: 0-no behavior, 1-fear/panic, 2-anger, 3-scream/yell, 4-danger/self/others, 5-delusions, 6-hallucinations, 7-sad/tearful, 8-emotion/act withdrawal, 9-other (describe). Interventions: 1-redirect, 2-1 on 1, 3-Ambulate, 4-Activity, 5-Return to room, 6-Toilet, 7-Give food, 8-Give fluids, 9-Change position, 10-Encourage to rest, 11-Back rub, 12-PRN med. Outcome: I-Improved, S-Same, W-Worse. Side Effects: 0-None, 1-EPS [Extrapyramidal Symptoms], 2-Tardive Dyskinesia, 3-Hypotension, 4-Inc. Review of Resident #99's Treatment Administration Record for March 2025 for behavior monitoring showed staff documented code NA (Not Applicable) on 3/7/2025, 3/9/2025, 3/21/2025, and 3/24/2025 during the 7-3 shift; on 3/5/2027 and 3/22/2025 on the 3-11 shift; on 3/21/2025 during the 11-7 shift. Review of Resident #99's Treatment Administration Record for April 2025 for behavior monitoring showed staff documented code NA on 4/7/2025, 4/8/2025, 4/10/2025, 4/14/2025 and 4/15/2025 during the 7-3 shift; on 4/7/2025, 4/9/2025, 4/14/2025, and 4/23/2025 during the 3-11 shift. Review of Resident #99's Treatment Administration Record for May 2025 for behavior monitoring showed staff documented code NA on 5/8/2025, 5/16/2025, 5/22/2025 and 5/24/2025 on the 7-3 shift. During an interview on 5/30/2025 at 10:00 AM Staff S, LPN stated, You should document 0 if there are no behaviors. N/A is not appropriate. Review of Resident #111's physician order dated 1/17/2025 read Monitor and document behavior concerns using codes provided Behavior code:0 no behavior, 1 Fear/panic, 2 Anger, 3 Scream/yell, 4 Danger/self/others, 5 Delusions, 6 Hallucinations, 7 Sad/tearful, 8 Emotion/Act Withdrawal, 9 other(describe) Interventions:,1 Redirect, 2- 1 on 1, 3 Ambulate, 4 Activity, 5 Return to room, 6 Toilet, 7 Give food, 8 Give fluids, 9 Change position, 10 Encourage to rest ,11 Back rub, 12-PRN med. Outcome: I-Improved, S-Same, W-Worse. Side Effects: 0-None, 1-EPS, 2-Tardive Dys, 3-Hypotension, 4-Inc. Review of Resident #111's physician order dated 1/18/2025 read Amitriptyline HCl oral tablet 25 MG. Give 25 mg by mouth at bedtime for depression. Review of Resident #111's MAR for 04/01/2025 through 04/30/2025 documented NA for the Day Hours on 04/7/2025, 04/08/2025, 04/10/2025, 04/14/2025, 04/15/2025, and 04/17/2025. The Evening Hours on 04/07/2025, 04/08/2025, 04/14/2025, 04/23/2025, and 04/30/2025. Review of Resident #111's MAR for 05/01/2025 through 05/31/2025 documented NA for the Day Hours on 05/08/2025, 05/16/2025, 05/22/2025, and 05/25/2025. During an interview on 5/30/2025 at 2:00 PM, Staff S, LPN stated, If they don't have any behaviors, you document 0 for no occurrences. You should never document NA. During an interview on 5/30/2025 at 12:00 PM, the DON stated, They should always document according to the legend. NA is not on the legend for that section 50695 7) During an observation on 5/27/25 at 2:11 PM, Resident #103 had a dual lumen, central venous catheter on his right upper chest with a dressing dated 5/1/25. (Photographic evidence obtained) During an interview on 5/27/25 at 2:11 PM, Resident #103 stated, The last time he was in the hospital they put in the catheter for antibiotics. Since my return to the facility, a nurse had said that the dressing needed to be changed, but that the dressing had not been changed. Review of Resident #103's Census Data documented the resident was initially admitted on [DATE] and most recently readmitted on [DATE]. Review of Resident #103's medical diagnoses included the following relevant information: pneumonia, unspecified organism; methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere; dependence on renal dialysis During an interview on 5/29/25 at 9:39 AM, the Medical Director stated, I do not recall being contacted on or around 5/1/25 regarding [Resident #103's name] orders upon readmission from the hospital. I was aware that the resident had a central vascular catheter and IV [intravenous] antibiotics, but I don't recall the nurse discussing any orders for the IV catheter. During an interview on 5/28/25 at 3:17 PM, Staff A, LPN stated, I have flushed [Resident #103's name] central venous catheter, as it was ordered to be done daily. I was not sure whether [Resident #103's name] had an order for a dressing change for his central venous catheter, and an order did not pop up in the computer to complete [a dressing change]. I didn't have time to investigate [for an order]. The admitting nurse should have identified whether there was an IV catheter and that it needed an order for a dressing change. During an interview on 5/29/25 at 9:55 AM the DON stated, When a resident is admitted the nurse completes an admission packet. The nurse would enter the medications and call the doctor to confirm the orders. A head-to-toe assessment would be expected to be done, which includes documentation of a skin check and documentation of any IVs, tubes, or drains. The nurse is expected to review the discharge summary from the hospital and would look to see if a specific type of IV line is mentioned. Review of Resident #103's Evaluation revealed a Clinical Admission form dated 5/1/25. In the section for IV catheters/access, there was no documentation of a central venous catheter. The section for antibiotics did not contain documentation. Review of the policy and procedures titled, Charting and Documentation, with an effective date of October 2024, and last reviewed 1/31/25, read, Purpose: F 842 - The purpose of this procedure is to provide a complete, accurate, readily accessible and systematically organized medical record. The medical record will reflect a resident's progress toward achieving their person-centered plan of care objectives, goals and improvement and/or maintenance of their clinical, functional, mental and psychosocial status . Overview: . Clinical admission evaluation is initiated upon admission and completed within 24 hours . 48708 8) Review of Resident #136's nurses note dated 2/28/25 read, Resident discharged home with husband and home health care. Review of physician orders did not provide for documentation of an order for Resident #136 discharge. During interview on 5/29/25 the DON stated, I received a verbal order for the resident to discharge [Resident #136] and it was written in her progress note not in orders. During interview on 5/30/25 Staff N, LPN, Unit Manager stated, Social Services starts the process of a discharge. The order is obtained from the physician and put in the orders section of the chart. Review of the policy and procedure titled, Transfer and Discharge Requirements F622 and F 623 last review date of 1/31/25 read, Purpose: To ensure that the center follows the requirements under which a guest/resident may be transferred or discharged from the center, the documentation that is required to be included in the medical record, who is responsible for the documentation and the information that is required to be provided to the receiving provider for a transfer or discharge. Procedure: d. The resident's attending physician or the medical director of the center must sign any notice indicating a medical reason for transfer or discharge. i. ARNP or PA [Physician Assistant] may sign. ii. Fax signature is acceptable.

Based on record review and interview the facility failed to ensure a recapitulation summary was documented for 1 of 3 residents, Resident #136, reviewed for discharge. Findings include: Review of resident #136's medical record did not contain documentation of the recapitulation of stay for the resident. During an interview on 5/30/25 at approximately 10:00 AM Staff L, LPN (Licensed Practical Nurse) on the Short Term Rehabilitation hall stated, Once an order is obtained in the chart for discharge, Social Services starts the process of filling out a Discharge Summary/Recapitulation packet for the resident's discharge. This packet goes home with the resident/representative and a copy goes to medical records. The packet is signed and dated by the resident/responsible party and staff member. A copy will go to Medical Records. During interview on 5/30/25 at approximately 10:30 AM Staff K, Health Information Specialist stated, I am unable to locate a copy of [Resident #136's name] discharge summary. Review of the policy and procedure titled, Policy Transfer and Discharge Effective date: March 2015, last review date of 1/31/25 read, Risk Management/Social Service Policy and Procedure Manual. Policy: The Social Services team members, as a member of the Interdisciplinary Care Planning Team, will participate in the development of a discharge summary when a resident is discharged to a private residence, another nursing health care center or another type of residential health care center according to the following timeframes and center guidelines. 1. Nursing Center Resident. A. Non-skilled: before or at time of discharge. B. Skilled: before or at time of discharge. 2. Sub-acute Resident. A. Before or at time of discharge. Procedure: 1. The discharge summary provides for a recapitulation of the resident's stay and the status at the time of discharge to assure continuity of care.

Based on observation, interview, and record reviews the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 3 of 8 residents, Residents #73, #103, and #87, reviewed for MDS assessments. Findings include: 1) Review of Resident #73's physician order dated 5/3/2025 read, NPO [Nothing by Mouth] diet, Not applicable texture, NPO consistency. Review of Resident #73's speech therapy evaluation dated 5/8/2025 read Clinical Bedside Assessment of Swallowing: Dysphagia: Pt [patient] requiring suctioning of oral secretions. Unable to elicit volitional or reflexive swallow. At this time, not appropriate for PO [oral] trials due to poor oral manipulation, control of ability to initiate a swallow. Review of Resident #73's MDS admitted d 5/9/2025 read Section K0100. Swallowing Disorder, Check all that apply. No areas under this section were marked to acknowledge Resident #73 suffered a swallowing disorder. Review of Resident #73's physician order dated 5/5/2025 read provide suction every 1 hours as needed for retained oral secretions 5/5/2025. Review of Resident #73's electronic medical record dated 5/3/2025, documented by Advanced Practitioner Registered Nurse #1 read Order placed for bedside suction per daughter's request. Review of Resident #73's MDS admitted d 5/9/2025 read, Section O0110.D1. Suctioning: there was no entry documented/marked for suctioning. During an interview on 5/29/2025 at 11:00 AM, Staff B, Licensed Practical Nurse/Minimum Data Set Coordinator (LPN/MDSC) stated, It [suctioning] wasn't marked on the MAR [Medication Administration Record], so I didn't mark it. During an interview on 5/29/2025 at 3:00 PM the Registered Dietician (RD) stated, It [swallowing disorder] should have been marked. I usually wait until Speech has completed their evaluation, but their evaluation was complete on 5/8/2025. During an interview on 5/29/2025 at 2:00 PM, the Director of Nursing stated, I expect the MDS and care plans to be accurate and complete. 50695 2) Review of Resident #87's MDS Evaluation dated 4/24/25 documented the following, Section C - BIMS [Brief Interview for Mental Status] Score - 03 [severe cognitive impairment]. Section N - N0415. High-Risk Drug Classes: Use and Indication: Antipsychotic the response was marked Yes. Review of Resident #87's medical diagnoses documented the following, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; Other: seizures. During an interview on 5/30/25 at 2:00 PM, Staff B, Licensed Practical Nurse (LPN) - Care Plan Specialist, stated, I don't see that [Resident #87's name] was currently or previously receiving an antipsychotic medication. I marked that in error. During an interview on 5/30/25 at 2:45 PM the DON stated, Accuracy for the MDS evaluations is important. Having [Resident #87's name] MDS Evaluation marked 'yes' for receiving antipsychotic medications was another human error. I expect the correct medications and diagnoses to be documented. 3) During an observation on 5/27/25 at 2:11 PM, Resident #103 had a dual lumen, central venous catheter in his right upper chest. (Photographic evidence obtained) Review of Resident #103's medical diagnoses included the following, pneumonia, unspecified organism; methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere; dependence on renal dialysis. Review of Resident #103's MDS Evaluation dated 5/8/25 documented the following, Section C - BIMS 13, (cognition intact). Section I - I1700. Multidrug-Resistant Organism (MDRO) - the documented response was No, and I2000. Pneumonia - the documented response was, No. Section N - High risk medications: antibiotic. Section O - O0110-Special Treatments, Procedures, and Programs: documented No for A.2 - IV [intravenous]; No for H.1 - IV Medications; No for O1. IV Access; and No for O4. - Central. During an interview on 5/29/25 at 10:51 AM Staff B, LPN, Care Plan Specialist stated, We utilized the RAI [Resident Assessment Instrument] Manual as our policy for completing MDS evaluations. The reason pneumonia was marked as 'no' for [Resident #103'sname] during the MDS evaluation conducted on 5/8/25 was that he was not actively receiving treatment for it, and that the reason antibiotics were marked as a 'no' was because he was not ordered to receive them in the facility when he was admitted . The 'Central' in the section regarding IV access should have been marked 'yes,' and there is not an explanation for why multi-drug-resistant organisms (MDRO) was marked 'no.' During an interview on 5/29/25 at 2:00 PM, the DON stated, All newly admitted residents are reviewed at the Morning Meeting the following day, and the review includes the residents' orders and any new diagnoses. The MDS staff attend the Morning Meetings to hear the information in order to complete the MDS evaluations. The omission of [Resident #103's name] having a central venous catheter and the diagnosis of MRSA [methicillin-resistant Staphylococcus aureus]; MRSA is considered a MDRO [multidrug-resistant organism] and the mistake was due to human error.

Based on interviews and record review, the facility failed to comply with the development and implementation of a comprehensive care plan regarding suctioning in 1 out of 3 residents. Resident #73. Findings include: Review of Resident #73's physician order dated 5/5/2025 showed to read provide suction every 1 hours as needed for retained oral secretions 5/5/2025. Review of Resident #73's electronic medical record dated 5/3/2025, by Advanced Practitioner Registered Nurse #1 showed to read Order placed for bedside suction per daughter's request. During an interview on 5/29/2025 at 11:00 AM, Staff B, Licensed Practical Nurse/Minimum Data Set Coordinator, (LPN/MDS) stated if he [Resident #73] was receiving suctioning, it should have been care planned. During an interview on 5/29/2025 at 2:00pm, the Director of Nursing stated I expect the MDS' [Minimum Data Set] and care plans to be accurate and complete.

Based on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain appropriate grooming and personal hygiene for 1 of 3 residents, Resident #61, reviewed for Activities of Daily Living. Findings include: During an interview on 05/27/25 at 11:47 AM, Resident #61 stated, My shower days are Tuesdays, Thursdays, and Saturdays, but that I'm lucky to get a shower once a week. My preference is to have showers on my scheduled shower days. Review of Resident #61's Task List documentation for the period of 5/1/25 through 5/29/25 documented Resident #61 received showers on 5/1/25, 5/24/25, and 5/29/25, with no documentation of other bath or shower provided for the 30 days. During an interview on 5/30/25 at 9:05 AM Staff U, CNA (Certified Nursing Assistant) stated, We try to get each resident up and to the shower at least once a week. I'm not sure how often [Resident #61's name] receives a shower. We are supposed to document it in POC and in the shower book when the resident is bathed. I sometimes forget to document in one or the other location. During an interview on 5/30/25 at 9:20 AM Staff V, LPN stated, I changed the shower schedule for [Resident #61's name] from the 3-11 shift to the 7-3 shift because she [Resident #61] was not always getting her showers as scheduled. [Resident #61's name] was scheduled to receive a shower on Tuesday, Thursday, and Saturday. The Task List documentation was reviewed with Staff V, LPN for Resident #61. Staff V, LPN confirmed there was documentation of only three showers for Resident #61 in the last 30 days. The dates of the showers were confirmed to be documented on 5/1/25, 5/24/25, and 5/29/25. Review on 5/30/25 of the Documentation Survey Report for Resident #61, specifically for the Intervention/Task of Bathing/Showering, for May 2025, documented nine instances of missed opportunities for the administration of a bath or shower per Resident #61's preference and scheduled days for a shower. Review of Resident #61's MDS [Minimum Data Set] Evaluation dated 4/8/25 documented Section C: BIMS (Brief Interview for Mental Status) Score 14 (cognition intact). Section E: No behaviors were documented. Section F: C. F0400. Interview for Daily Preferences: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? The response was documented as Very important; F0600. Daily and Activity Preferences Primary Respondent: Indicate primary respondent for Daily and Activity Preferences (F0400 and F0500) - The response was documented as, 1. Resident Section GG: GG0115. Functional Limitation in Range of Motion: Upper body extremities and Lower body extremities - the response is documented as, No impairment. All self-care activities are documented as, Independent, with the exception of shower/bathe self, which is documented as, Supervision or touching assistance. Review of Resident #61's Care Plan documented the following, Focus - Activities of Daily Living (ADL) Self-Care and/or mobility deficit. Needs assistance with ADL's; At risk of developing complications associated with decreased ADL self-performance related to: hypertension (HTN), generalized weakness, fatigue, decreased appetite, shortness of breath Date Initiated: 04/13/2023; Revision on: 04/13/2023. Goal - Will maintain ADL self performance levels as evidenced by no decline in current level of functioning through next review date. Date Initiated: 04/13/2023; Revision on: 04/17/2025; Target Date: 07/15/2025 Will have all ADL's complete by staff as needed. Date Initiated: 04/13/2023; Revision on: 04/17/2025; Target Date: 07/15/2025 Shower/bath-Supervision or touching assistance Date Initiated: 04/13/2023; Revision on: 04/15/2025. Review of the policy and procedure titled, Shower issued 7/2023, last reviewed 1/31/25, read, Purpose: To clean the skin and shampoo hair (as needed). To increase circulation. To exercise body parts/provide range of motion. To reduce tension. To promote comfort while maintaining safety and dignity. Procedure: . 28. Document any observations made during bathing. Observations may include, but are not limited to: Refusal of all or part of shower . 29. Provide the guest/resident with the opportunity to bathe according to guest/resident preference. 30. Document shower in the electronic medical record .

Based on observation, interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for a central venous catheter for 1 of 3 residents, Resident #103, observed for intravenous (IV) catheter care and medication administration practices. Findings include: During an observation on 5/27/25 at 2:11 PM, Resident #103 had a dual lumen, central venous catheter in his right upper chest with a dressing dated 5/1/25. The catheter insertion site was visible, the dressing was clean, dry, and intact. (Photographic evidence obtained) During an interview on 5/27/25 at 2:11 PM, Resident #103 stated, The last time I was in the hospital they put in the catheter for antibiotics. Since I've returned to the facility, a nurse had said that the dressing needed to be changed, but the dressing has not been changed. Review of Resident #103's medical record documented the resident was most recently admitted on [DATE] with medical diagnosis to include pneumonia, unspecified organism; methicillin resistant staphylococcus aureus Infection as the cause of diseases classified elsewhere; dependence on renal dialysis Review of Resident #103's physician orders did not have documentation of an order for central IV-line dressing changes. Review of Resident #103's Initial Plan of Care Summary (PIC/IPOC), dated 5/1/25, documented that the resident had a percutaneously inserted central catheter (PICC) line. During an interview on 5/28/25 at 3:17 PM, Staff A, LPN stated, I have flushed [Resident #103's name] central venous catheter, as it was ordered to be done daily. I was not sure whether [Resident #103's name] had an order for a dressing change for his central venous catheter, and an order did not pop up in the computer to complete [a dressing change]. I didn't have time to investigate [for an order]. The admitting nurse should have identified whether there was an IV catheter and that it needed an order for a dressing change. During an interview on 5/29/25 at 9:24 AM, Staff B, LPN stated, I worked with [Resident #103's name] on the 11p-7a shift [11:00 PM - 7:00 AM] on 5/26/25. I have been giving his IV Vancomycin on the 3-11 shift [3:00 PM to 11:00 PM]. I looked at the IV site and spoke with the resident about it. I recall that the dressing had a five on it, but I don't recall the full date. I believe the policy for IV dressing changes was for them to be done every seven days. If I identified a dressing was older than seven days, I would go back and check the orders [for frequency of dressing changes], and if it is supposed to be changed, I would report it to my supervisor and contact the doctor for orders. During an interview on 5/29/25 at 9:39 AM, the Medical Director stated, I don't recall being contacted on or around 5/1/25 regarding [Resident #103's name] orders upon readmission from the hospital. I was aware that the resident had a central vascular catheter and intravenous (IV) antibiotics, but I don't recall the nurse discussing any orders for the IV catheter. When residents come back from a hospitalization I usually discuss the medications with the nurse and the orders for IV catheters, such as dressing changes, are in the nursing realm, as IV dressing changes are a nursing standard. During an interview on 5/29/25 at 9:50 AM, Staff C, LPN stated, I am familiar with [Resident #103's name]. I worked with him within the past two to three weeks, but I can't recall the dates. I didn't administer anything to [Resident #103's name] through a central intravenous catheter and I don't recall whether he had a central IV catheter. I believe the policy for IV dressing changes was every seven days, and that as an LPN I would not change the dressing. If I observed that the dressing had been in place for greater than seven days, I would be expected to report it [to her supervisor]. During an interview on 5/29/25 at 9:55 AM the Director of Nursing (DON) When a resident is admitted the nurse completes an admission packet. The nurse would enter the medications and call the doctor to confirm the orders. A head-to-toe assessment would be expected to be done, which includes documentation of a skin check and documentation of any IVs, tubes, or drains. The nurse is expected to review the discharge summary from the hospital and would look to see if a specific type of IV line is mentioned. The expectation is the nurse who admitted [Resident #103's name] would have obtained dressing change orders, and that IV dressings were changed weekly, or more often if the dressing had lifted, was torn, or was soiled. Review of Resident #103's Care Plan, updated on 5/2/25, documented Focus - IV therapy/potential for complications related to PICC line. Date Initiated: 05/02/2025. Goal - IV site will remain free from S/S [signs/symptoms] of infection. Date Initiated: 5/02/2025 Target Date: 06/04/2025. Interventions - Change dressing to IV site per orders/facility policy. Date Initiated: 05/02/2025 Review of Resident #103's evaluation documented on the Clinical Admission form dated 5/1/25 under the section for IV catheters/access, there was no documentation of a central venous catheter. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008) provided to the facility from the discharging hospital documented, Section V. Treatment Devices, IV/PICC/Portacath Access - Date Inserted 5/1/25. Type: powerline. Review of the policy and procedure titled, Central Vascular Access Device (CVAD) Dressing Change, with an effective date of 10/2005, read, Considerations - 1. Central vascular access devices (CVADs) include: . 1.4 Implanted venous ports. 2. The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection . Guidance - 1. Perform sterile dressing changes using Aseptic Non Touch Technique (ANTT): 1.1 Upon admission 1.1.1 If transparent dressing is dated. clean, dry, and intact, the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label . 1.2 At least weekly .

Based on interview and record review, the facility failed to ensure documentation of physician/prescriber's rationale for declination of pharmacist's recommendations for 3 of 5 residents, Residents #99, #111, and #62, reviewed for unnecessary medications. Findings include: 1) Review of the Medication Regimen Review recommendations for Resident #99 dated 4/22/2025 read [Resident #99's name] 's PRN [as needed] orders below have not been used within the previous 60 days: 1. Artificial. Tears 2. Loperamide 3. Ondansetron 4. Tramadol. Recommendation: Please consider discontinuing due to lack of use. Physician's Response: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. The rationale for declining the recommendations was not documented in the resident's record. 2) Review of Medication Regimen Review recommendations for Resident #111 dated 2/26/2025 read, Recommendation: Please decrease citalopram to 20 mg [milligrams] daily or consider alternative therapy. Physician's Response: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below: Psych follows was documented by the physician 3/4/2025. There was no follow up psych documentation for the rationale for declining the recommendations documented in the resident's record. Review of the Medication Regimen Review recommendations for Resident #111 dated 2/26/2025 read Recommendation: Please discontinue Amitriptyline. Physician's Response: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below: Psych follows was documented by the physician 3/4/2025. There was no follow up psych documentation for the rationale for declining the recommendations documented in the resident's record. During an interview on 5/29/2025 at 1:30 PM, the Director of Clinical Services (DCS) stated The process is the MRR [Medication Regimen Review] is printed out by medical records and given to the DCS, who forwards them to the Unit Managers. The Unit Managers give them to the physicians to directly address the issues and then we review them. The physician should always document the rationale on the form and in the resident record. During an interview on 5/30/2025 at 11:00 AM, Medical Doctor #2 stated Just because they recommend to discontinue something because it hasn't been used in 60 days doesn't mean he won't need it eventually. I'm not going to discontinue it and turn around and have to re-order it because he needs it. I'll document that on the form from now on. During an interview on 5/30/2025 at 1:00 PM, Advanced Practitioner Registered Nurse (APRN) #1, stated If there is anything involving psych, they have GDR meetings weekly, so all pharmacy recommendations involving psych medication management should be addressed by the Director of Clinical Services, nursing and psychiatric services. Review of the policy and procedure titled, Medication Regimen Review with a last review date of 1/31/2025, read 9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. 9.1 For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected, as outlined in the State Operations Manual Appendix PP. 9.2. The attending physician should document in the resident's health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 9.2.1. If the attending physician/prescriber has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record. 46523 2) Review of Resident #62 Omnicare Consultation Report dated 4/18/2025 read, Recommendation: Please attempt a gradual dose reduction to Abilify 1 mg once daily. The consultation report did not have a physician signature, or a rationale only documented MD [Medical Doctor] refused. Review of Resident #62 physician order dated 4/17/2025 read, Aripiprazole Tablet 2 mg give 1 tablet by mouth in the morning for depression. During an interview on 5/29/2025 at 3:53 PM Medical Doctor #1 stated, [Resident #62's name] has severe depression and is doing fairly well with the medication. After talking to the resident, we decided to keep the medication. Sometimes the facility requires a rationale, but it is typically more complicated. Usually, the nurses will drop the recommendation in my book, and I will review them. During an interview on 5/30/2025 at 2:51 PM the Director of Nursing stated, [Resident #62 name] consultation report should have been signed and a rationale should have been provided.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principle for 1 of 3 hallways reviewed for secured medication. Findings include: 1) During an observation on 5/27/2025 at 10:17 AM of Resident #71 it showed the resident was lying in bed. CeraVe itch relief moisturizing cream, vapor rub, Benadryl extra strength cream, and arthritis cream which contained 10% Trolamine Salicylate was on top of the nightstand. (Photographic evidence obtained) Review of Resident #71's medical record did not document an order or an assessment the resident was safe to self-administer medications. 2) During an observation on 5/27/2025 at 10:28 AM of Resident #53 it showed the resident was lying in bed. Nystatin Cream was observed on top of the nightstand. (Photographic evidence obtained) Review of Resident #53's medical record did not document an order or an assessment the resident was safe to self-administer medications. 3) During an observation on 5/27/2025 at 10:41 AM of Resident #99 it showed the resident was lying in bed. There was a bottle of Clear Eyes, eye drops on top of the bedside table. (Photographic evidence obtained) During an interview on 5/27/2025 at 10:41 AM Resident #99 stated, I do that [pointing to the bottle of eye drops] twice a day, the nurses are supposed to do it for me. Review of Resident #99's medical record did not document an order or an assessment the resident was safe to self-administer medications. During an interview on 5/30/2025 at 9:59 AM Staff M License Practical Nurse stated, [Resident #71's name], [Resident #53's name], and [Resident #99's name] do not have orders for self-administration. Medication should not be left in their rooms unattended. I know that [Resident #71's name] family will bring medications often and leave them in the room. During an interview on 5/30/2025 at 11:01 AM the Director of Nursing (DON) stated, Medication should not be unattended. There should be an assessment but [Resident #53's name], [Resident #71's name], and [Resident #99's name] do not have one at this time. Review of the policy and procedure titled Self Administration of Medications with a last review date of 1/31/2025 read, Procedure: 1. Facility should comply with facility policy, applicable law and the State Operations Manual with respect to resident self-administration of medications. 9. Facility should provide a secure compartment for storage of such medications in accordance with facility policy. 9.1 The medication storage compartments should be located in the resident's room so that another resident is not able to access the medications. 9.2 The storage compartment should be locked when not in use. 50695 4) During an observation on 5/29/25 at approximately 4:05 PM, Staff E, Licensed Practical Nurse (LPN) attempted to administer three oral medications to Resident #107, but the resident refused the medications. Staff E, LPN set the medication cup containing the three pills on the medication cart and walked away from the cart, leaving the medications unattended. During an interview on 5/29/25 at 4:10 PM, Staff F, Registered Nurse, (RN) stated, She [Staff E, LPN] should have at least locked them [the three medications] in the med cart until she had time to deal with them. During an interview on 5/29/25 at approximately 5:20 PM Staff E, LPN stated, I was flustered by answering questions [asked by this writer] and that was what caused me to leave [Resident #107's name] medications unattended. I know I should not have left the medication unattended. Review of the policy and procedure titled, 5.3 - Storage and Expiration Dating of Medications and Biologicals, with an effective date of 12/1/07, and last reviewed 1/2025, read, Applicability: Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes, and needles. Procedure . 5. Facility should ensure all medication and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible to residents and visitors .

Based on observation, interview, and record review, the facility failed to maintain appropriate infection prevention and control practices during medication administration for 2 of 15 residents, Residents #78 and #338) reviewed for medication administration practices, and failed to ensure appropriate infection control barriers were applied for residents with orders for isolation for 1 of 2 residents, Resident #129, reviewed for infection control. Findings include: 1) During an observation on 5/29/25 at 11:09 AM, Staff D, Licensed Practical Nurse (LPN), donned gloves, and cleaned Resident #78's glucometer. After cleaning the glucometer, and removing her gloves, she dropped the gloves on the ground, picked them up and disposed of them. Staff D then donned a new pair of gloves, without performing hand hygiene, and removed Resident #78's insulin pen [a device used to administer insulin injections] from the medication cart and then removed and disposed of her gloves. Staff D donned a new pair of gloves without performing hand hygiene and entered Resident #78's room and performed a finger stick [a medical procedure where a small amount of blood is collected from the fingertip, typically by pricking the skin with a sterile lancet]; Staff D removed and disposed of her gloves before exiting Resident #78's room. Staff D donned a new pair of gloves without performing hand hygiene and administered the dosage of insulin ordered to Resident #78, via subcutaneous injection. During an interview on 5/29/25 at approximately 11:15 AM, Staff D, LPN stated, I had performed hand hygiene before I started cleaning the glucometer; I should have performed hand hygiene each time I changed my gloves. 2) During an observation on 5/29/25 at approximately 4:20 PM, Staff E, LPN donned gloves as the only form of personal protective equipment (PPE) and administered 10 milliliters of Sodium Chloride Solution 0.9% (normal saline) as ordered to flush Resident #338's PICC (peripherally inserted central catheter which is a long, thin catheter inserted into a vein in the arm and threaded up to a large vein in the chest, near the heart) line. During an interview on 5/29/25 at approximately 4:25 PM, Staff E, LPN stated, Residents [Resident #338] are on EBP [Enhanced Barrier Precautions] for reasons such as intravenous catheters (IVs). Depending on the reason for the EBP the staff are to wear gloves, gowns, and masks, and that those items would be put on in the resident's room, before care, and removed in the resident's room after care. Review of the policy and procedure titled, Enhanced Barrier Precautions, implemented on 8/16/22, and last reviewed 1/31/25, read, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for . those at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Policy Explanation and Compliance Guideline: . 4. High-contact resident care activities include: . g. Device care or use: central lines . 7. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical device is removed. Review of the policy and procedure titled, Infection Prevention and Control Program, with an effective date of 12/2020, and last reviewed 1/31/25, read, Mission of Program: The primary mission is to establish and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infection. Policy: It is the policy that this facility's Infection Prevention and Control Program (IPCP), is based upon information from the facility assessment including the infection control risk assessment and follows the national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. The infection prevention and control program includes: 1. A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to regulatory requirements and following accepted national standards. 2. Written standards, policies, and the procedures for the program, which include: . f. The hand hygiene procedures . Review of the policy and procedure titled, 6.0 General Dose Preparation and Medication Administration, with an effective date of 12/1/07, and last reviewed on 1/31/25, read Applicability - This Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the state operations manual (SOM) when administering medications. Procedure 1. Prior to administering medications, authorized and competent facility staff should follow facility's infection control policy. 1.1 Appropriate hand hygiene should be performed before and after direct resident contact. 51447 3) During an observation on 5/27/2025 at 10:10 AM, Resident #129 had an Enhanced Barrier Precaution sign posted on the door. The back of the sign noted gowns and gloves are required when entering the resident's room. During an interview on 5/27/2025 at 10:16 AM Staff W stated, [Resident #129's name] is supposed to be on contact precautions not enhanced barrier precautions. Review of Resident #129 physician orders dated 5/16/2025 read, Contact precautions every shift for pseudomonas to LLE [left lower extremity] surgical wound. Review of the policy and procedure titled, Transmission Based Precautions, reviewed on 1/31/2025 read, Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. See Nurse Sign: posting will be on resident rooms alerting HCW's (healthcare workers), residents and visitors that they must see the nurse before entering room. The reverse side of the sign will note the type of precaution, method of acceptable hand disinfection and PPE to be utilized. The nurse will provide resident's specific precaution instructions.

Based on interview and record review, the facility failed to ensure resident records were complete and accurate for 1 of 3 residents, Resident #2, reviewed for wound care. Findings include: Review of Resident #2's clinical records doucmented Resident #2 had diagnoses to include pressure ulcer of left buttock, stage 3 (full-thickness skin loss, where the wound extends into the subcutaneous tissue). Review of Resident #2's physician's orders dated 4/1/25 read, Wound Care: left buttock, pressure; clean with soap & water, pat dry, apply honey to calcium alginate and cover open area. Cover with optifoam dsg [dressing], T/Th/Sat [Tuesday/Thursday/Saturday] and PRN [as needed] every evening shift every Tue, Thu, Sat [Tuesday/Thursday/Saturday] for left buttock, pressure, S3 [Stage 3] and as needed for left buttock, pressure, S3 [Stage 3]; heel protectors to bilateral heels while in bed as tolerated every shift for wound prevention; Wound Care: right lateral heel, pressure; skin prep daily to lateral heel every evening shift for right lateral heel; pressure, S1 [Stage 1] and Wound Care: left heel, pressure; skin prep daily to lateral heel; every evening shift for left heel, pressure, S1 [Stage 1]. Review of Resident #2's treatment administration record, dated 4/1/2025 - 4/30/2025, failed to provide documentaiton of Resident #2's ordered treatment for left buttock on 4/10/2025 and 4/12/2025, ordered treatment for the left heel was not documented on 4/4/2025, the ordered treatment for his right lateral heel was not documented on 4/4/2025, and his ordered intervention for bilateral heel protectors was not documented on 4/4/2025. During an interview on 4/14/2025 at 12:50 PM, the Director of Nursing stated audits had been completed and had been focused audits to ensure wound treatments were completed as ordered. The verification audits were not focused on determining whether wound treatments had been documented when completed. She confirmed Resident #2's wound care interventions had not been documented completed as ordered on the April, 2025 treatment administration record.

Based on observation, interview, and record review, the facility failed to prevent the possible spread of infection when failing to perform hand hygiene or use appropriate personal protective equipment (PPE) when performing care for 1 (Resident #1) of 3 residents on Enhanced Barrier Precautions. Findings include: Review of the admission record for Resident #1 documented the resident was readmitted to the facility on [DATE] with diagnoses including a pressure ulcer of the sacral region, Stage 4 [a wound on the lower back that extends through all layers of skin, exposing underlying muscle, tendons, and bone and requires extensive and prolonged treatment], schizophrenia [a disorder that affects a person's ability to think, feel, and behave clearly], major depressive disorder, difficulty in walking, and urinary tract infection. Review of the physician's order dated 11/12/2024 for Resident #1 read, Enhanced Barrier Precautions - Wound/Catheter every shift for Stage 4/catheter. Review of the physician's order dated 11/25/2024 for Resident #1 read, Indwelling [urinary] Catheter #18 FR [French] per 10ml [milliliters]. DX [diagnosis]: Stage IV [four] wound to sacrum. During an observation on 12/27/2024 at 10:02 AM there was an Enhanced Barrier Precautions (EBP) sign on Resident #1's door. There was a blue storage unit hung on the door containing Personal Protective Equipment (PPE) including gowns, gloves, and masks. At 10:05 AM Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA entered Resident #1's room and without performing hand hygiene, Staff A and Staff B donned gloves and proceeded to the resident's bedside. Without wearing gowns, Staff A stood at the right side and Staff B stood at the left side of Resident #1's bed. Staff B, CNA pulled down the resident's top blanket, unfastened the front of Resident #1's incontinence brief, grabbed a package of disposable wet wipes, used for cleaning the resident's skin, and cleaned the skin around the resident's urinary catheter. Staff A and Staff B, without wearing gowns, pulled Resident #1 onto her right side. Staff B, CNA cleaned the stool off from the resident's buttock area using the wet wipes, threw the soiled incontinence brief into the trash beside the resident's bed, and placed a clean incontinence brief under the resident. Staff A, CNA and Staff B, CNA then rolled the resident partially onto her back and Staff B pulled up the clean incontinence brief over the foley catheter and fastened the brief at the resident's waist. Staff A, CNA removed the stool soiled reusable blue absorbent under pad from under Resident #1's bottom and tossed the under pad on the floor against the wall at the foot of the bed. Staff B removed his gloves and without performing hand hygiene, re-opened the package of hygiene wipes and wiped Resident #1's face. Staff A, CNA removed his gloves, and without performing hand hygiene, exited the room at 10:12 AM. At 10:13 AM Staff A, CNA re-entered Resident #1's room with a clear plastic bag, and without performing hand hygiene or wearing gloves, picked up the stool soiled blue under pad from the floor and placed it the bag, and without performing hand hygiene, exited the room. After wiping Resident #1's face with the hygiene wipes and without performing hand hygiene, Staff B, CNA opened and closed the drawers of Resident #1's nightstand, grabbed a tube of facial moisturizer from the top of the stand, and applied the moisturizer cream to Resident #1's face. At 10:15 AM, without performing hand hygiene, Staff B, CNA picked up the clear bag of trash from the trash can, exited Resident #1's room, proceeded down the hallway to the dirty utility room, punched the keypad code, opened the door, and entered the room. During an interview on 12/27/2024 at 10:16 AM, Staff B, Certified Nursing Assistant stated, She (Resident #1) is on Enhanced Barrier Precautions because she has a foley catheter. I should have worn a gown when cleaning her and changing her brief. I should have performed hand hygiene before I put on my gloves and after I took my gloves off before I did any other care with her. During an interview on 12/27/2024 at 11:13 AM, Staff A, Certified Nursing Assistant stated, I didn't wear a gown, but I wore gloves when caring for (Resident #1's name). I didn't think I needed to wear a gown. She has a catheter, but I was just helping with care. I put her dirty under pad on the floor because I didn't have a bag. I shouldn't have done that. I washed my hands before I came in the room. I should have washed my hands after I removed my gloves, but I didn't. I didn't wear gloves when I picked up the dirty pad of the floor either. During an interview on 12/27/2024 at 11:15 AM, the Administrator in Training stated, Staff needs to perform hand hygiene before they go in the room, before they put on and after they take off their gloves. We never place anything dirty on the floor. The staff need to wear a gown and gloves for residents on Enhanced Barrier Precautions when performing care. That includes foley catheters and wounds. During an interview on 12/27/2024 at 1:48 PM, the Director of Clinical Services confirmed that the staff should have been wearing a gown when performing incontinence care for Resident #1 because she had an indwelling urinary catheter device. The Director of Clinical Services stated, The expectation is to wear a gown and gloves for anyone with a line, tube, or drain. Staff should perform hand hygiene when entering the room, before putting on their gloves, when changing their gloves, when going from dirty to clean areas of the body, and after resident care. Review of the signage, by the U.S. Department of Health and Human Services Centers for Disease Control and Prevention, posted on Resident #1's door read, Enhanced Barrier Precautions: Everyone MUST perform hand hygiene with alcohol-based hand rub (ABHR) or soap and water before entering and exiting. Wear gloves and a gown for the following high-contact resident care activities: Transferring, Bathing/Showering, Changing Linens, Providing Hygiene, Changing briefs/assisting with toileting, and Device care or use: Central line, urinary catheter .Wound Care. Review of the policy titled, Enhanced Barrier Precautions, implemented 08/16/2022 read, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced Barrier Precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with MDRO (multidrug-resistant organisms) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices. Policy Explanation and Compliance Guidelines: c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. 2. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters .even if the resident is not known to be infected or colonized with a MDRO. 4. High-contact resident care activities include: e. Changing linens, f. changing briefs or assisting with toileting, g. Device care or use: central lines, urinary catheters . Review of the U.S. Centers for Disease Control and Prevention website titled, Clinical Safety: Hand Hygiene for Healthcare Workers, last updated 2/27/2024, read, Know when to clean your hands: Immediately before touching a patient, before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal. Know when to wear (and change) gloves: Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings. Always clean your hands after removing gloves. When to wear gloves: When you anticipate that you will come in contact with blood or other infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment). When to change gloves and clean hands: If gloves become soiled with blood or body fluids after a task. If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs. Before exiting a patient room. https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html

Based on observation and interview, the facility failed to provide a clean and homelike environment. Findings include: During an observation on 11/7/2024 beginning at 10:30 AM, there were multiple circular spots of a black substances on the vents of the air conditioner units in the rooms of Residents #6, #7, #8, #9, #10, and #12. During an interview on 11/7/2024 at 11:45 AM, the Environmental Director stated that the environmental services was responsible for cleaning the vents of the air conditioner units daily with a cloth and surface cleaner. The Environmental Director observed the black circular spots on the vents and stated, They should be cleaned daily and those don't look like they were clean, when the environmental staff cannot adequately get to the harder areas to reach on the vents, they are supposed to notify maintenance. During an interview on 11/7/2024 at 11:52 AM, the Maintenance Director observed the air conditioner vents and stated, They are not clean and should be wiped down. During an interview on 11/7/2024 at 11:55 AM, Resident #8 stated that the spots of a black substance on his air conditioner vents would be dangerous to his health. During an interview on 11/7/2024 at 11:58 AM, Resident #9 stated, I have asthma, and it would be very bad for it. During an interview on 11/7/2024 around 1:00 PM, the Director of Clinical Services confirmed that the conditions of the vents were not acceptable.

Based on interview and record review, the facility failed to provide Medicare coverage and liability notice to resident representative for 1 of 3 residents reviewed for notice of Medicare non coverage, Resident #1. Findings include: Review of Resident #1's admission record showed Resident #1's daughter as the responsible party, with the power of attorney for financial affairs, healthcare Surrogate, and care conference person. Review of Resident #1's medical records showed Health Care Surrogate signed by Resident #1 on 4/11/2005, appointing Resident #1's Daughter as health care surrogate. Review of Resident #1's care plan initiated on 1/23/2024 showed a focus for impaired cognition as evidence by decision making problem, short term memory deficit, long term memory deficit, and problems understanding others. Review of Resident #1's MDS (Minimum Data Set) dated 1/29/2024 showed BIMS (Brief Interview for Mental Status) score of 5 (severe cognitive impairment) under Section C. Cognitive Patterns. Review of Resident #1's Determination of Incapacity form dated 12/18/2023, showed the resident lacked the capacity to give informed consent to make medical decisions. Review of Resident #1's Transaction Report for the period from 2/1/2024 through 3/31/2024 showed a total due from Medicare A- Coinsurance Private of $4080.00 under Medicare A- Coinsurance Private from 2/1/2024 to 2/19/2024. Review of Resident #1's Insurance Explanation Courtesy Letter dated 1/22/2024, read, This year's rate is $204.00 per day. We have verified your Medicare Supplement Insurance benefits and will bill this copay to your insurance as a courtesy after Medicare has paid their portion. Your insurance company has stated that they will pay the below percentage of this copay until your benefits are exhausted. Your portion will be billed to you on a weekly basis and will be due upon receipt. Please note, if we have not received payment from your insurance company within 45 days of billing, payment in full will be expected from you or your loved one. Date Copay Begins: 01/22/2024 . Days of Copay: 9. Review of Resident #1's Activity Report showed financial statements generated on 2/6/2024 with a balance of $1,224.00, on 2/16/2024 with a balance of $3,264.00, and on 2/23/2024 with a balance of $4,488.00. During an interview on 4/18/2024 at 11:55 AM, the Business Manager stated, All financial documents would have been delivered to the room. [Resident #1's name] BIMS score is low that was an error in our part. The daughter may not have been aware of the financial responsibility. When I spoke to her on the 2/16/2024, it was only in regard to the NOMNC [Notice of Medicare Non-Coverage] did not mention the past due amounts. The business office is responsible for checking the BIMS scores and delivering the financial information accordingly. During an interview on 4/18/2024 at 1:35 PM, the Director of Nursing stated, If [Resident #1's Daughter's name] would have called and notified us, the Administrator would have written the outstanding amount off, but she did not reach out to the facility Administrator. Review of the facility's Admission Agreement read, Payment . 3. [NAME] and Rate Changes: We shall provide you with monthly statements itemizing all charges incurred by you. We shall provide you with at least sixty (60) days written notice of any increase in the basic daily rate or increase in rates for non-covered services or items provided by our center . Benefits and Third-Party Payors . In the event you fail to pay for your care or services, we will notify you and a person you designate of such delinquency.

Based on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, and failed to ensure the equipment was cleaned in the areas of the kitchen and nourishment rooms. Findings include: A walk-through tour of the kitchen was conducted on 2/26/2024 at 9:16 AM with the Certified Dietary Manager (CDM). There were twelve large containers in the walk-in cooler that did not have identifying labels. There were eleven sandwiches and fourteen swirl cups in the reach-in cooler with no identifying labels. There was a pan of chicken noodle soup on the tray line at 9:22 AM with lunch times being 11:20 AM- 12:25 PM. During an interview on 2/26/2024 at 9:20 AM, the CDM stated that the containers did not have identifying labels and all leftover foods should be covered, labeled, and dated according to standards of practice. The CDM identified the twelve leftover food items in the walk-in cooler as pans of Salisbury steak, cabbage casserole, turkey, sweet potatoes, Italian sausages, hot dogs, gravy, ham, tomato soup, roast beef, beets, and marinara sauce. The CDM identified the eleven sandwiches as eight egg salad and three chicken salad sandwiches, and also identified eight swirl cups as chicken salad and six swirl cups as cottage cheese. During the follow-up tour of the kitchen on 2/27/2024 at 6:00 AM with the CDM, the drip tray on the gas stove had a buildup of black and tan grease and food debris, the microwave oven had food particles and rusty colored stains on the interior of the microwave, there were items opened and wrapped tightly on the spice tray with no identifying label, there was a large buildup of dust on the top of the reach-in cooler and reach-in freezer on the condenser motor and cords, and there was an opened bag of bread mix that was not properly closed or dated when opened in the dry storage. During an interview on 2/27/2024 at 6:00 AM, the CDM stated, The drip tray should have a new liner changed out weekly, the microwave should be cleaned daily, and maintenance department should be notified when cleaning is needed for the coils on top of reach-in cooler. I am not sure of what content in the wrapped item on the spice tray. The CDM unwrapped the item and found it to be chocolate chip cookies. The CDM stated that the wrapped item should have the date and identifying label and the mix in the dry storage room should have been properly closed and dated when opened. During an observation of nourishment rooms on 2/28/2024 at 8:00 AM, 2 of 3 nourishment rooms had microwaves that had a large buildup of food debris of tan, black, gold, and brown splotches and splatters on the interior sides and top of the microwaves. During an interview on 2/28/2024 at 8:10 AM, the CDM confirmed the microwave ovens were dirty with a buildup of food debris. Review of the document titled Kitchen Sanitation dated April 2017 and revised September 2018 read, Policy: The Culinary staff shall maintain the sanitation of the Dietary Department through compliance with the posted comprehensive cleaning schedules.

Based on record review and interview, the facility failed to ensure that resident assessments were transmitted in a timely manner for 2 of 3 residents sampled, Residents #44 and #46. Findings include: Review of Resident #44's Minimum Data Set (MDS) Discharge Return Anticipated Assessment showed the assessment status was exported on 1/29/2024. Resident #44's assessment did not have a status of accepted. Review of Resident #46's Minimum Data Set (MDS) Discharge Return Not Anticipated Assessment status was exported on 1/30/2024. Review of Resident #46's assessment did not have a status of accepted. During an interview on 2/29/2024 at 10:06 AM, the MDS Coordinator stated, Those assessments [Resident #44's and Resident #46's] were done but did not transmit. We [the facility] do not have a policy for transmitting assessments but followed the MDS manual.

Based on observation, interview, and record review, the facility failed to provide surgical wound care and treatment in accordance with professional standards of practice for 1 of 4 residents reviewed for skin conditions, Resident #77 (Photographic evidence obtained). Findings include: During an interview on 2/26/2024 at 10:08 AM, Resident #77 stated, I had a mole removed last Thursday [2/22/2024]. On Saturday, the CNA [Certified Nursing Assistant] covered my site with gauze and transparent dressing. I don't think I'm supposed to have a dressing on there. During an observation on 2/26/2024 at 10:14 AM, Resident #77 had a transparent dressing with gauze under a transparent dressing on his right forearm. There was a dime sized circular area on the gauze of brownish drainage. Review of Resident #77's admission record revealed the resident had diagnoses including hypertension, osteoarthritis, heart failure, and stage 3 kidney disease (chronic). Review of Resident #77's dermatology visit note dated 12/28/2023 read, Impression/Plan: Neoplasm of Uncertain Behavior . Ddx [differential diagnosis] includes: Squamous Cell Carcinoma. Review of Resident #77's medical records revealed no physician order or treatment administration record entry for wound care on right forearm surgical site. During an interview on 2/27/2024 at 8:39 AM, Resident #77 stated, The CNA put it [the gauze and transparent dressing] on before my shower on Saturday [2/24/2024)], so I didn't get the sutures wet. No one has checked it at all. I don't think I'm supposed to have a dressing on there. During an observation on 2/27/2024 at 2:12 PM, Resident #77's right forearm had a tan colored large adhesive bandage covering the surgical site. During an interview on 2/27/2024 at 2:19 PM, Staff D, Licensed Practical Nurse (LPN), stated, I changed the dressing this morning because he [Resident #77] took the other one off. I cleansed it with normal saline, applied antibiotic ointment, then covered it with the dressing. During an interview on 2/28/2024 at 9:58 AM, Staff D, LPN, stated, I don't have a physician's order for [Resident #77's name] wound care, but it's basically the same thing as the other orders. I should have orders for wound care. There are no orders for care of his wound. During an interview on 2/28/2024 at 10:18 AM, the Director of Nursing (DON) stated, The expectation is that staff should review doctor's orders for wound care and treatment. If the dermatology office didn't give instructions for post-operative care, then the expectation is that staff call the dermatology office or the facility provider and get clarification. The nurse did not have orders for the care and should have. Review of the facility policy and procedure titled Skin Care & Wound Management with an approval date of 1/30/2024 read, Policy: As part of an ongoing Quality Assurance process, skin care and wound management guidelines are to provide necessary treatment and services to promote healing, prevent infection, control pain and prevent development of pressure injury(s) unless the resident's clinical condition demonstrates that they were unavoidable . Procedure . Guidelines for Skin Care and Wound Management include . Skin inspection on a regular and ongoing basis to provide documentation and prompt interventions of any changes noted. Manage wound care using guidelines based upon current standards of practice . Inspection and Wound Management . The Skin Grid-Other will be completed upon identification of impaired skin at admission, at hospital return, at the time of a surgical wound, venous stasis wound, diabetic wound, burn, skin tear, laceration, abrasion, rash, MAD (moisture associated dermatitis) or any other significant skin condition is found . Current standards of practice will be used for skin and wound management. Appropriate treatment protocols will be based upon Palm Garden skin and Wound Care Guidelines and Lower Extremity Wound Care Guidelines in addition to Physician treatment orders. Physician treatment orders obtained and documented on the TAR (Treatment Administration Record).

Based on observation, interview, and record review, the facility failed to administer oxygen per physician order and according to professional standards of practice for 2 of 3 residents reviewed for respiratory care, Residents #36 and #112. Findings include: 1. Review of Resident #36's admission record revealed the resident was admitted with the diagnoses including end stage renal disease, hypertensive heart and chronic kidney disease without heart failure with stage 5 chronic kidney disease, type 2 diabetes mellitus without complications, cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, unspecified atrial fibrillation, essential primary hypertension, and major depressive disorder. Review of Resident #36's physician order dated 8/16/2023 read, Oxygen at 2 LPM [liters per minute] via N/C [nasal cannula] or mask every shift . Oxygen Continuously every shift. During an observation on 2/26/2024 at 10:10 AM, Resident #36 was receiving oxygen at 3 liters per minute via nasal cannula. During an observation on 2/28/2024 at 8:17 AM, Resident #36 was receiving oxygen at 3 liters per minute via nasal cannula. During an interview on 2/28/2024 at 8:17 AM, Resident #36 stated, I don't change that [the oxygen]. I can't reach it. During an interview on 2/28/2024 at 8:55 AM, Staff B, Registered Nurse (RN), confirmed that the oxygen was running at 3 liters per minute for Resident #36 and stated, All oxygen should be administered according to doctor's orders. During an interview on 2/28/2024 at 11:10 AM, the Director of Nursing (DON) stated, It is my expectation that nurses check oxygen daily and make sure it is running correctly. They should follow doctor's orders for running oxygen. 2. Review of Resident #112's admission record revealed the resident was admitted with the diagnoses including unspecified heart failure, essential primary hypertension and type 2 diabetes mellitus without complications. Review of Resident #112's physician order dated 12/5/2023 read, Oxygen at 3 LPM via N/C at bedtime for low sats [oxygen saturation] and as needed for low O2 [oxygen] sats < [less than] 90 during the day. During an observation on 2/26/2024 at 10:16 AM, Resident #112 was resting quietly in bed, receiving oxygen at 4 liters per minute. During an observation on 2/27/2024 at 8:10 AM, Resident #112 was resting in bed, receiving oxygen at 4 liters per minute. During an observation on 2/28/2024 at 7:43 AM, Resident #112 was resting in bed, receiving oxygen at 4 liters per minute. During an interview on 2/28/2024 at 8:55 AM, Staff B, RN, stated, It is at 4 liters and should be at 3 liters. We should check when we give meds [medications]. Review of the facility policy and procedures titled Oxygen Administration with the last approval date of 1/30/2024 read, Procedure: 1. Verify physician's order to include, but not be limited to: flow rate, duration of use (PRN [as needed], continuous, etc.), parameters for monitoring oxygen saturation, as indicated . 14. Monitor oxygen flow rate and oxygen saturation, as ordered.

Based on observation and interview, the facility failed to ensure nurse staffing information was posted daily. Findings include: During an observation on 2/26/2024 at 8:56 AM, the posted nurse staffing was dated 2/23/2024 (Photographic evidence obtained). During an interview on 2/28/2024 at 8:23 AM, the Director of Nursing stated, It is the responsibility of the weekend supervisor to post the staffing report daily. I was not aware the staffing report had not been posted daily. The facility does not have a policy for posting the staff report, but they follow the regulations.

Based on observation, interview, and record review, the facility failed to ensure medications were securely stored in 1 of 3 residential units, Unit 300. Findings include: 1. During an observation on 2/26/2024 at 9:14 AM, Resident #55 was in her bed. A tube of Zinc Oxide Ointment was on Resident #55's bedside table. There was no nurse or other facility staff present in the resident's room. During an interview on 2/26/2024 at 9:14 AM, Resident #55 stated, I had bed sores and the cream is used for my bed sores. During an observation on 2/27/2024 at 8:03 AM, a tube of zinc oxide was on Resident #55's bedside table. There was no nurse or other facility staff present in the resident's room. Review of Resident #55's physician order dated 1/10/2024 read, Wound care to bilateral buttocks; apply zinc after each incontinent episode, every day and evening for prevention . Order Status: Active. Start Date: 1/10/2024. Review of Resident #55's physician orders revealed no order to self-administer medications. Review of Resident #55's Self Administration of Medication Consent Form dated 12/9/2023 and initialed by Resident #55, showed the resident had indicated, No, I do not want to exercise my right to self-administer by [Sic.] medications. During an interview on 2/28/2024 at 8:27 AM, the Director of Nursing stated that to her knowledge Resident #55 had not been assessed for self-administration of medication. She stated that Resident #55 had indicated she did not wish to self-administer medications on the self-administration of medication consent form dated 12/9/2023. During an interview on 2/28/2024 at 9:01 AM, Staff A, Licensed Practical Nurse/Unit Manager, stated the zinc oxide ointment found on Resident #55's bedside table should have been secured in the treatment cart and labeled for Resident #55. 2. During an observation on 2/27/2024 at 8:08 AM, Resident #344 was in her room. Resident #344 was holding two boxes of tubes of Nystatin External Cream 100000 unit/gram antifungal cream. There was no nurse or other facility staff present in Resident #344's room. During an interview on 2/27/2024 at 8:08 AM, Resident #344 stated the doctor had given her the cream to use on her buttocks. Review of Resident #344's physician order dated 2/27/2024 read, Nystatin External Cream 100000 unit/gm [gram] (Nystatin Topical), apply to periarea topically every shift for redness apply until healed; may use home supply . Order Status: Active. Start Date: 2/27/2024. Review of Resident #344's physician orders revealed no order to self-administer medications. Review of Resident #344's Self Administration of Medication Consent Form dated 2/19/2024 and initialed by Resident #344, showed the resident had indicated, Yes, I would like to exercise my right to self-administer my medications. I understand that this right is subject to the results of the assessment of the care plan team. Review of Resident #344's care plan dated 2/19/2024 revealed no resident assessment for self-administration of medications. During an interview on 2/28/2024 at 9:07 AM, Staff A, Licensed Practical Nurse/Unit Manager, stated, [Resident #344's name] family brought the antifungal cream into the facility. I removed two tubes of the antifungal cream from [Resident #344's name] room but later discovered [Resident #344's name] had four tubes of the antifungal cream. I think her family probably brought it in the night before. [Resident #344's name] should not have the cream at beside, and it should have been in the cart. Staff A confirmed that Resident #344 had not been assessed for self-administration of medication. Review of Resident #344's progress note dated 2/28/2024 showed the progress note read, Self-Administration of Medication Notes: Medications found at bedside and removed. At this time, MD [Medical Doctor] prefers that resident not have Nystatin cream and powder at bedside due to overuse. Nursing will document the times resident requests the medication for 72 hours and then reevaluate to ensure proper use. Self-Administration Plan: Resident is not approved for self-administration of medications. Resident may not keep meds [medications] at bedside. Review of the facility policy and procedures titled Medications, Storage of with the last review date of 1/30/2024, showed the policy read, Purpose: The purpose of this procedure is to ensure the medications are stored in a safe, secure, and orderly manner. General Guidelines . 6. Compartments containing medications are locked when not in use. Trays or carts used to transport such items are not left unattended. (Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes.) Review of the facility policy and procedures titled Administration of Drugs with the last review date of 1/30/2024, showed the policy read, Key Procedural Points . 20. Medications should not be left at the bedside. Review of Self Administration of Medication Consent Form provided by the facility showed the consent form read, It is the policy of this facility that the resident has the right to self administer his or her own medication if the interdisciplinary team has determined that the practice is safe. The following criteria must be met: 1. Physician's orders for administration of medication must be on file at the facility (may be all or a specific drug); 2. The resident has signed a document stating his/her desire to self medicate; 3. The level of ability to identify medication, dosage, time, and to store properly has been determined as safe by the interdisciplinary team; 4. A safe storage place, plan for documentation and a method of accountability have been established; 5. If at any time the interdisciplinary team determines the practice is unsafe, the resident and physician will be notified.

Based on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for 1 of 2 residents reviewed for insulin administration out of a total of 6 residents reviewed for medications, Resident #104. Findings include: Review of Resident #104's admission record showed the resident was initially admitted on [DATE] with the diagnoses including type 2 diabetes mellitus, cerebral infarction (a stroke), and atrial fibrillation (an irregular heartbeat). Review of Resident #104's physician order dated 8/10/2022 read, Insulin Regular Human Solution Pen-injector 100 unit/ml [milliliter] inject s per sliding scale. Review of Resident #104's physician order dated 6/5/2023 read, Levemir FlexPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir), Inject 20 units subcutaneously in the morning for DM [diabetes mellitus]. Review of Resident #104's Medication Administration Record (MAR) for January 2024 revealed no documentation of blood sugar level and administration of insulin on 1/9/2024 at 6:30 AM and on 1/23/2024 at 6:30 AM. Review of Resident #104's MAR for February 2024 revealed no documentation of blood sugar level and administration of insulin on 2/18/2024 at 6:30 AM. Further review revealed code 13 documented on 2/8/2024 for Levemir FlexPen 20 units subcutaneously. Review of the medication administration chart codes read, 13= does not require sliding scale insulin. During an interview on 2/27/2024 at 3:07 PM, Staff C, Licensed Practical Nurse (LPN), stated, I really don't think that I held this medication. I think that really is a documentation error. I would always give long-acting insulin and would check with the physician before I held a long-acting insulin. Yes, this was definitely a documentation mistake. During an interview on 2/28/2024 at 11:15 AM, the Director of Nursing (DON) stated, It was documented by mistake. I do expect accurate documentation for all medications. Nurses do not hold long-acting insulin for the short acting parameters. There are no parameters on the long acting insulins. I expect the nurses to follow our policies and document accurately when they give medications. There should be no blanks on the MAR. Review of the facility policy and procedures titled Administration of Drugs with the last review date of 1/30/2024 read, Policy: Residents shall receive their medications on a timely basis and in accordance with our established policies. Key Procedural Points . 7. Medications must be documented by the person administering the drugs immediately following the administration. The date, time administered, dosage, etc., must be documented in the electronic medical record and signed by the person administering the medication . Reporting and Documentation: 1. Document the following: date, time and initials.

Based on observation, interview, and record review, the facility failed to ensure proper transfer procedures by not providing adequate supervision and assistance devices to prevent accidents resulting in a humeral fracture to the right upper arm for 1 of 4 residents, Resident #1 reviewed for proper transfer procedures. Findings include: Review of Resident #1's records showed the resident was admitted to the facility on [DATE]. The resident's medical [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) assessment, completed on 01/20/2020, indicated that the resident's functional status for Activities of Daily Living (ADL), assistance for transfers, was classified as Requires extensive assistance (one-person physical assist). Review of Resident #1's progress note dated 01/25/2020 at 10:52 PM read, Nurse tech was lifting the patient up in bed when the tech (heard) a loud pop on patient's right shoulder. Patient is in severe discomfort reporting pain level of 8/10. Advised to order x-ray of the right shoulder. Review of Resident #1's progress note dated 01/26/2020 at 3:32 AM read, Resident status [REDACTED]. According to nursing staff equal pulses and bilateral upper extremities. Difficult to have an x-ray performed of the right upper extremity, however x-ray tech was able to perform one view which showed a humeral fracture. Plan: sent to the emergency department for orthopedic surgery involvement. Review of the facility's investigation of the incident involved Resident #1 showed during the investigation, written statements were obtained from the two involved employees, Staff A, Certified Nursing Assistant (CNA), and Staff B, CNA. Staff A wrote in his statement, I placed one leg forward and requested she place her arms on my shoulders. Staff A stated that instead, Resident #1 wrapped her arms around his neck, and he requested again that she place her arms on his shoulders and notify him when she was ready to count down from three to be transferred. According to Staff A, Resident #1 said, Okay, one, two, three (rapidly) and hurried through the transfer. A loud pop was heard, and he requested Staff B to get assistance. Staff B wrote in her statement, He (Staff A) began to transfer (Resident #1's name) using the 1-assist pivot method from her wheelchair to her bed. He (Staff A) prompted (Resident #1's name) to place her hands on his shoulder, he counted to three and in mid-pivot (Resident #1's) shoulder sounded off with a cracking noise. He (Staff A) immediately placed her back into her chair. During an interview on 11/04/2020 at 1:08 PM, the Director of Nursing confirmed that both Staff A and Staff B told her that Staff A was not using a gait belt while performing the transfer with Resident #1. The Director of Nursing stated that Staff A had told her that he had instructed Resident #1 to hold onto his upper arms for support during the transfer. During an interview on 11/04/2020 at 5:05 PM, the Administrator stated that a plan of correction was completed following this incident. The Administrator stated that it had been discovered that Resident #1's care data did not include information about how to transfer the resident. The Administrator stated that she viewed this as the root cause of the incident, not the actions of Staff A. Review of the facility's transfer procedure, Nursing- Moving a resident, bed to chair/chair to bed, effective October 2014, read, 10. If moving a resident from chair to bed: . d. Instruct the resident to place both hands on the arms of the chair and slide forward. e. If the resident cannot stand alone, two persons (one on each side) should lock arms with the resident, gently stand and turn the resident and sit him or her on the edge of the bed. f. If the resident can assist in this procedure, stand on the resident's weak side. (Note: Encourage the resident to use his or her strong side and to assist in the procedure as much as possible). g. Support the resident by placing a belt around the resident's waist for you to hold and steady the resident. h. Instruct the resident to place his or her hands on the arms of the chair for support.

Based on record review and interview, the skilled nursing facility failed to ensure that 1 (#1) of 8 sampled residents received the necessary care and services for pain management and timely transfer to a facility of higher care. Resident #1 was identified to have complaints of mouth pain on 03/23/13. An x-ray on 03/26/13 revealed a fractured jaw of unknown origin; however, the resident was not transferred out to the hospital until 03/28/13 for treatment. The resident expressed significant mouth pain throughout the 5 days prior to transfer to the hospital. Findings: Record review for Resident #1 revealed that the resident was admitted to the skilled nursing facility on 3/18/13 after a hospital stay. The resident's admitting [DIAGNOSES REDACTED]. On 3/22/13 9:00 PM, the nurse noted that resident #1's lower lip appeared swollen. The physician's assistant (PA) was notified and [MEDICATION NAME] 12.5 milligrams (mg) was ordered and given for possible food/medication allergy. The nurse indicated that the lip continues to appear swollen. On 3/23/13 at 5:30 AM, the resident was found on the floor sitting on her buttocks between the bed and the chair. She reported that her arms and leg were hurting. The nurse noted that there was an abrasion on her back and bruises on her right and left shoulder. On 3/23/13 at 8:29 AM, the resident was complaining of mouth pain. Her lips were red and swollen. The PA examined the resident and found that she had a half-dollar sized knot on her right lower jaw which was warm to the touch. He ordered Tylenol 325 mg two tablets every 6 hours, as needed for pain, and [MEDICATION NAME] 50 mg one tablet every 6 hours as needed for pain. On 3/23/13 at 1:15 PM, the PA was notified that the resident's condition was worsening. The right side of her face was swollen and her bottom lip was swollen. On 3/23/13 at 1:40 PM, the PA examined the resident and diagnosed her with a dental abscess. He ordered [MEDICATION NAME] 250 mg, three times a day, for 7 days and [MEDICATION NAME] twice a day for 10 days. On 3/24/13 to 3/25/13, the notes indicate that the resident continued to have jaw swelling and complaints of pain. She continues to receive her antibiotics and pain medications as ordered. On 3/26/13 at 9:25 AM, the PA visited the resident and ordered an x-ray of the mandible. The x-ray revealed that the resident had a "comminuted [MEDICAL CONDITION] mandible for which further evaluation was suggested. " On 3/28/13 at 8:30 AM the resident was transferred by Emergency Medical Services (EMS) to an area hospital. Review of the As needed (PRN) pain Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] On 3/23/13 at 8:40 AM- [MEDICATION NAME] 50 mg by mouth was given for right jaw pain of " 7 out of 10 " . After 30 minutes, the pain is documented as " 6 out of 10. " After 1 hour, the pain is documented as " 3 out of 10. " On 3/23/13 at 1:40 PM -Tylenol 650 mg by mouth for right jaw pain of " 4 out of 10 " . After 30 minutes, the pain is documented as " 3 out of 10. " After 1 hour, the pain is documented as " 1 out of 10. " On 3/23/13 at 6 PM- [MEDICATION NAME] 50 mg by mouth was given for right jaw pain of " 6 out of 10 " . After 30 minutes, the pain is documented as " 3 out of 10. " After 1 hour, the pain is documented as " 1 out of 10. " On 3/24/13 at 7:50 AM -Tylenol 650 mg by mouth for right jaw pain of " 4 out of 10 " . After 30 minutes, the pain is documented as " 3 out of 10. " After 1 hour, the pain is documented as " 1 out of 10. " On 3/24/13 at 12 PM- Tylenol 650 mg by mouth for right jaw pain of " 7 out of 10 " . After 30 minutes, the pain is documented as " 5 out of 10. " After 1 hour, the pain is documented as " 2 out of 10. " On 3/24/13 at 12 PM- [MEDICATION NAME] 50 mg by mouth was given for right jaw pain of " 7 out of 10 " . After 30 minutes, the pain is documented as " 5 out of 10. " After 1 hour, the pain is documented as " 2 out of 10. " On 3/24/13 at 6 PM- [MEDICATION NAME] 50 mg by mouth was given for right jaw pain of " 8 out of 10 " . After 30 minutes, the pain is documented as " 2 out of 10. " After 1 hour, the pain is documented as " 1 out of 10. " On 3/24/13 at 9:30 PM- Tylenol 650 mg by mouth for right jaw pain of " 8 out of 10 " . After 30 minutes, the pain is documented as " 2 out of 10. " After 1, hour the pain is documented as " 1 out of 10. " On 3/25/13 at 4:18 AM- [MEDICATION NAME] 50 mg by mouth for right jaw pain of " 8 out of 10 " . After 30 minutes, the pain is documented as " 6 out of 10. " After 1 hour, the pain is documented as " 5 out of 10. " On 3/25/13 at 10:30 AM- [MEDICATION NAME] 50 mg by mouth for right jaw pain of " 8 out of 10 " . There was no documentation noted for intensity of pain for 30 minutes and for 1 hour after intervention. On 3/26/13 at 7:25 AM- [MEDICATION NAME] 50 mg by mouth for right jaw pain of " 6 out of 10 " . After 30 minutes, the pain is documented as " 5 out of 10. " After 1 hour, the pain is documented as " 2 out of 10. " On 3/26/13 at 7:25 AM -Tylenol 650 mg by mouth for right jaw pain of " 6 out of 10 " . After 30 minutes, the pain is documented as " 5 out of 10. " After 1 hour, the pain is documented as " 2 out of 10. " Late entry: On 3/26/13 at 1:10 AM [MEDICATION NAME] 50 mg by mouth for right jaw pain of " 9 out of 10 " . After 30 minutes, the pain is documented as " 6 out of 10. " After 1 hour, the pain is documented as " 4 out of 10. " On 3/27/13 at 7:10 AM- [MEDICATION NAME] 50 mg by mouth for right jaw pain of " 5 out of 10 " . After 30 minutes, the pain is documented as " 4 out of 10. " After 1 hour, the pain is documented as " 2 out of 10. " On 3/27/13 at 3:30 PM- [MEDICATION NAME] 50 mg by mouth for right jaw pain of " 8 out of 10 " . After 30 minutes, the pain is documented as " 8 out of 10. " After 1 hour, the pain is documented as " 7 out of 10. " On 3/27/13 at 6 PM- [MEDICATION NAME] 2 mg subcutaneous injection for right jaw pain of " 7 out of 10 " . After 30 minutes, the pain is documented as " 3 out of 10. " After 1 hour the pain, is documented as " 0 out of 10. " There is no documentation of pain medication being administered between 3/27/13 at 6 PM until EMS arrived on 3/28/13 at 8:36 AM. Interview with the Risk Manager on 4/4/13 at 1:00 PM revealed that Resident #1 was initially sent to the hospital for evaluation because she was not eating; not as a result of the fall. On 4/4/13 at 1:30 PM, the Administrator stated that nurse caring for Resident #1 was unavailable for interview on the day of the survey. She also stated that the PA involved in Resident #1's care was out of the country. She stated that she placed a call to the resident's physician, who is also the facility's medical director, but he has not returned her calls. Telephone interview on 4/16/13 at 7:44 AM with the daughter (Power of Attorney) of Resident #1 confirmed that she is the medical POA (Power of Attorney) for the resident. She stated that she is listed on the skilled nursing facility paperwork to call as the primary contact. She stated that she was notified that her mother fell at the skilled nursing facility. She stated that she and her family alerted the skilled nursing facility that her mother's face and lips were swollen and inverted. She stated that the nurses alerted the PA of the family's concerns each time an issue was brought to their attention. She stated that her sister questioned the PA as to how her mother could have an abscessed tooth when she did not have any teeth. She stated that once the x-ray results returned the PA told her that her mother's jaw was "cracked. " She stated that he was attempting pain management. She stated that she was not given any other treatment options. No one spoke with her concerning [DEVICE] placement as the resident was not eating. She stated that she does not know why the skilled nursing facility or the PA waited two additional days after identification of the jaw fracture (3/26/13) to transfer her mother to the hospital when she was not able to eat during this time and she was in pain. She stated that the hospital physicians had to stabilize her mother's blood pressure prior to repairing her jaw fracture. She stated that since her mother has been in the hospital she has had 2 surgeries. One surgery was to repair the fracture by placing 2 metal plates and screws to each side of her lower jaw. The other surgery was to place a [DEVICE] for nourishment. Review of the EMS record of Resident #1 revealed that on 3/28/13 at 8:46 AM EMS arrived to the skilled nursing facility to transport the resident to the hospital. The skilled nursing facility staff informed EMS that Resident #1 fell out of bed on 3/22/13. The staff informed the EMS that the resident had a fractured jaw and was not eating or taking her medications for the past 2 days. They also told EMS that they contacted Resident #1's physician and he wanted her evaluated for not eating or taking her medication. EMS administered 5 mg [MEDICATION NAME] sulfate intramuscularly to the resident's right deltoid muscle for complaints of pain of " 8 out of 10 " upon arrival to the skilled nursing facility. Review of the hospital record for Resident #1 revealed that the patient was admitted to the hospital on [DATE] at 9:12 AM with a [DIAGNOSES REDACTED]. The physician documented that Resident #1 was alert, incoherent, mumbling, but it was clear that she was in pain. Review of the operative report revealed that on 4/1/13 Resident #1 had an open reduction internal fixation of bilateral mandibular body fractures using a matrix 8-hole plate with 6 bicortical locking screws and 2 positional screws. Review of the consultation reports revealed that Resident #1 also had an [MEDICATION NAME] feeding tube placement.