Every finding on record at Park Manor of Conroe

Based on observation, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen reviewed for kitchen compliance. 1. Dietary staff failed to ensure all dishes and silverware were properly cleaned before utilizing during meal services. 2. Dietary staff failed to properly label/date dry storage items stored inside their pantry. 3. Dietary staff failed to properly seal dry storage items inside their pantry. 4. Dietary staff failed to utilize the chlorine sanitizer test strips and accurately document the results during each shift. 5. Dietary staff failed to document dishwashing temperatures daily. This failure could place residents at risk of contracting a foodborne illness and a diminished quality of life. Findings Included:During an interview on 10/09/25 at 10:18 a.m., DM A informed the surveyor that it was her third day in that role and she was trying to revamp the kitchen. The health department visited the facility's kitchen on 10/08/25 for an impromptu inspection due to a call for a foodborne outbreak at the facility and she could provide the documentation of their passing score. She stated she could tell the previous manager did not focus on checking temperatures of the food before meal service labeling items in the kitchen. In an observation on 10/09/25 at 10:20 a.m. inside of the dry storage inside the kitchen, the following items were found not dated or incorrectly sealed:4 bags of cornflakes (amount not specified) not dated6 bags of rice puffs (name not specified) were on the shelf and not dated. Packaged boxes of dry food in the middle of the floor were not dated. box of condiments not dated 2 boxes of 12lb sugar packets not dated2 62.9fl oz of caramel not dated1lb of celery salt not dated1lb vegetable seasoning not dated1lb hot cereal quick grits not dated5.75lb of mashed potatoes with vitamin c were not dated. 10lb bag of various classic durum wheat dried pasta shells. There was a hole in the bag and it was not sealed properly. The top was cut off and the bag was folded over once and sat on the shelf.10lb bag of noodles was left out on the shelf and folded over. Not secured or packaged in a way that maintained freshness. Dated 8-20.2 10lb bags of tri color pasta were not dated on the shelf.5 boxes of lasagna 1lb pasta boxes not dated. 2 packs 12 count hamburger buns not dated. pack of wheat bread that felt stale to the touch sat next to the buns, 13 slices of bread not dated. Crispy feel when touched. In an observation on 10/09/25 at 10:40 a.m., stacked on a rack by the sink were green and black acrylic drink mugs. Two of the mugs were dirty and sat upright with brown splatters, brown dripping liquid, and a leftover ring from a drink. The investigator smelled inside the mugs and confirmed that the brown splatters were from coffee. Another black cup had a cream-colored residue of a leftover food substance inside. On the same row of mugs, two green mugs also had leftover splatters of black coffee inside. In an observation and interview on 10/09/25 at 10:47 a.m. with TA F, he stated that he had been working there since the middle of September, but he was previously employed at the facility. He explained that his job responsibilities were to keep the dishwashing room clean, get the trays out, and wash the dishes. When the dishes came back after meal service, he would load them and run them through the dishwasher. He explained that each load of dishes got washed for about 5 minutes and all the clean dishes would be stacked and placed on trays by another kitchen staff. When asked what type of dishwasher he used, he stated that he did not know and he could not locate the type on the machine. The temperature log was hung on the wall and TA F stated that he checked the temperature every day. When asked how, he stuttered and began to look around the dishwasher. DM A walked by and he asked her how to check the dishwasher's temperature, and she asked him where the temperature gauge was, and he could not answer. DM A asked TA F where his test strips were and he stated he did not have any and she gave him a pack of chlorine sanitizer test strips and a quaternary test kit (strips used to test sanitizer solution strength) that expired on 02/01/23. TA F took one of the strips out of the quaternary test kit and attempted to test the water by dipping the strip into the water inside the dishwasher. The strip did not change colors. He grabbed another strip out of the chlorine sanitizer test strip and dipped it in the water again. He stated it's purple and walked quickly to the trashcan without sharing the results. The surveyor asked him to let her see and he replied oh. TA F grabbed another chlorine test strip out of the bottle and dipped it inside the water of the dishwasher again. It did not change color to reflect the strength of the sanitizer in the water and he asked it's supposed to change colors isn't it?. Referring to the temperature log, TA F was asked how he documented the temperature daily if he could not locate the thermometer. He responded that the lady who worked there before (DM B) would usually fill in the temperatures on the log. He said he knew that he told the surveyor that he checked and documented the water temperatures everyday but instead he would rewrite whatever was written down the previous day. In an interview on 10/09/25 at 11:02 a.m. with [NAME] D, he stated that he had been working at the facility for 1 month and his responsibilities were to cook, wash dishes, and store delivered items in the freezer. He stated that he did not stack the dishes that sat behind him on the rack and that the tray aides usually stacked their dishes after they washed them. He called out to TA F and they agreed that the night shift must have stacked the dirty dishes on the rack. When he was told that the dishes were still wet, [NAME] D stated that some of them must have been stacked that morning. [NAME] D explained that when a new shipment of food came in, the kitchen staff on shift at the time were to check that they received everything that was ordered, write the date it was delivered on the product, push the older stuff to the front, and the first shift would put up the frozen items and second shift would unpack the dry storage products. After the items were unboxed, the DM would go back and check to make sure everything was labeled. When asked how he checked the temperature of the kitchen sink, he replied that he used the little stick thing (referencing the chlorine sanitizer test strips) and stick it in the water but he had run out. In an interview on 10/09/25 at 11:17 a.m., DA G stated that he had been working at the facility for 2 months and some of his responsibilities were to wash dishes and help the cook read out tickets during serving times. He stated that the second aide was someone who was supposed to help the TA by checking the dishes to make sure they were clean and if they were dirty, they were supposed to put them to the side to be rewashed in the dishwasher. In an interview on 10/09/25 at 11:25 a.m. with DM A, she was informed about the dirty dishes found during the kitchen observation and she stated that she had dirty dishes on her list of things to talk to staff about. She explained that earlier that morning, she received a complaint that a resident had dried spinach on her drinking cup and she knew it was from the day before based off the fact that they did not have any breakfast items containing spinach. DM A was asked to provide the food handler certifications for her 9 staff members. She explained that the kitchen staff were contracted through a third-party company and she was only able to provide the certifications for 3 of the 5 kitchen staff currently on shift, but she would make copies once the others were found. She was also informed that [NAME] D and TA F did not know how to check the temperature of the kitchen sink or use the chlorine test strips. She stated that they would have to be retrained. In an interview on 10/10/25 at 10:20 a.m. with the AD, she stated that she had worked at the facility for over 20 years. She oversaw the resident council that met every 3rd Tuesday of the month. During the last resident council meeting, she had several complaints regarding the food was served on dirty plates accompanied by dirty silverware. In an interview on 10/09/25 at 12:01 p.m. with Resident #1 she stated in the last 4 months she had received 31 pieces of filthy silverware from the kitchen. She stated that she had informed the ADM about her kitchen concerns and felt she did not care because the staff were contracted with a different company. In an interview on 10/10/25 at 12:42 p.m. with DM B, she stated she was the Dietary Manager at the facility from 06/30/25 until she was termed on 10/06/25. She stated that prior to employment, her predecessor was well liked by everyone in the facility, and it was a hard task coming behind her and she probably was not a good fit. DM B explained that she received several grievances regarding dirty silverware. She felt that some of the complaints she received were valid and some of the grievances came from chronic complainers who were hard to please. She explained that during her employment, there were several dietary staff members who worked in the kitchen without their food handler's certification. She explained that in her 20 years of working in dietary, she had never received so many grievances. Some of the grievances she felt were valid like the ones who came from Resident #1. She explained that when she arrived to work on 9/26/25, she received about 9 or 10 grievances regarding the meal service from the night before and in-services were given to herself and the dietary staff regarding the proper storage of food items, chain of command, and food temperatures. DM B stated that the facility was a really tough building to work in. In an interview with the ADM on 10/10/25 at 2:16 p.m., she stated that she sat in on the Resident Council Meeting in August and she was concerned about all the complaints she received regarding the dietary department. This prompted her to begin a QAPI and start in-services to her staff. The facility tried to coach DM B, but her attitude made her difficult to work with and receive feedback, ultimately leading to her termination. Record review of the facility's dietary staffing list revealed that there were 9 employees who worked in the kitchen. Record review of the dietary staff food handler's certification records revealed that 6 out of 9 staff members had active certifications. TA A's certification was not submitted during this investigation. Record review of the facility's grievance and complaint log for August showed that on 8/20/25, there were 13 grievances directed towards the dietary department. Record review of the grievances for September 2025 documented 15 complaints directed towards the dietary department. Record review of the Resident Council Meeting minutes conducted on 9/16/25 at 2:00 p.m. revealed several complaints about receiving dirty silverware and dishes during mealtimes. Record review of DM B's employee file reflected that on 10/06/25, DM B received a 90-day performance review that stated that while coaching and feedback were consistently provided, the outcomes have not met the expectations for a food service manager at [name] company. Her areas of concern included the resident dissatisfaction regarding meal services, defensiveness or blame shifting when receiving feedback, raised tones and dismissive behavior towards staff that resulted in low morale and workplace tensions, and low progress to coaching sessions. She was effectively demoted on 10/06/25 to the position as a cook. DM B refused to sign this document and her employment with the facility and the contracted dietary company was terminated. Record review of a letter written by the ADM to whom it may concern from the contracted dietary company on 10/06/25 read that: Despite repeated attempts to address these issues through one-on-one discussions, progress has been limited. A primary barrier to resolution appears to be [DM B's] overall attitude and approach. She frequently became defensive or agitated when concerns were raised, often providing excuses or shifting blame rather than working towards solutions. Additionally, she had been observed raising her voice at her staff and had demonstrated dismissive or uncooperative behavior when approached by her nursing or administrative team members in collaboration. Given the continued complaints, the influence of grievances, and the lack of meaningful improvement, it appears to be the best interest of the facility to move forward and parting ways with [DM B] at this time. Record review of the contracted dietary company's policy titled Ware washing Policy and Procedure (not dated, received 10/10/25) displayed that: We prioritize the cleanliness and sanitation of all dishware, service ware, and utensils to uphold the highest health and safety standards.Procedures1. Training and Handling: Our Dietary Services staff undergo comprehensive training to proficiently operate dishwashing machinery and handle clean dishware, ensuring strict adherence to sanitary protocols.2. Machine Temperature Management: We regulate the temperature of dishwashing machine water according to the specifications provided by the manufacturer, whether utilizing high-temperature or low-temperature cleaning systems.3. Record Keeping: Meticulous logs are maintained to track either temperature or sanitizer concentration, depending on the type of machine, always guaranteeing compliance with sanitation standards.4. Drying and Storage: Cleaned dishware is air dried and stored appropriately to prevent any potential contamination prior to use, maintaining the integrity of our sanitary practices.Required Documentation: Dish Machine Log. Record review of the contracted dietary company's policy titled Dry Goods Storage Policy and Procedure (not dated, received 10/10/25) displayed that:5. Condition of Stored Items: All packaged and canned foods must be maintained in a clean, dry state and properly sealed to preserve their integrity.6. Organization: Storage areas shall be organized and maintained in a manner that allows for easy identification and access to items, with all goods appropriately dated.

Based on interview and record review, the facility failed to provide food and drink that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for food service safety. On 09/25/25, dietary served cold grilled cheese sandwiches and tomato soup during the dinner meal service.In September and August 2025, the facility received 28 grievances to the dietary department regarding cold and overcooked food served during meals.] This failure could place residents at risk of contracting a foodborne illness and a diminished quality of life. Findings included: Record review of Resident #1's facesheet revealed an eighty-one-year-old female who was admitted to the facility on [DATE]. Her admitting diagnoses were Type 2 Diabetes, GERD, hypertension (high blood pressure), gout (a form of arthritis), and anxiety disorder. Record review of Resident #1's care plan revealed that she was on a therapeutic CCD regular diet with regular consistency. Interventions listed were to alert the NP/MD and document resident's inability to consume diet, offer supplements and alternatives if less than 50% of the meal is consumed or resident does not like the meal, and provide diet as MD order. In relation to her Type 2 Diabetes, the intervention listed was to observe compliance with diet and document any problems. Record review of Resident #1's change in condition progress note dated 9/25/25 at 1:13 p.m. electronically signed by LVN A recorded that Resident #1 had diarrhea. The NP was notified and she was prescribed 2 tablets of Imodium 2mg every 4 hours as needed. Record review of Resident #1's nutrition progress note dated 9/09/25 at 11:06 am documented that Resident #1 stopped the dietician and requested supplements and no gravy on food. Record review of the facility's dietary staffing list revealed that there were 9 employees who worked in the kitchen. During an interview on 10/09/25 at 10:18 a.m., DM A informed the surveyor that it was her third day in that role and she was trying to revamp the kitchen. The health department visited the facility's kitchen on 10/08/25 for an impromptu inspection due to a call for a foodborne outbreak at the facility and she could provide the documentation of their passing score. She stated she could tell the previous manager did not focus on checking temperatures In an interview on 10/10/25 at 10:20 a.m. with the AD, she stated that she had worked at the facility for over 20 years. She oversaw the resident council that met every 3rd Tuesday of the month. During the last resident council meeting, she had several complaints regarding the food not being good. In an interview on 10/10/25 at 10:31 a.m. with LVN A, she stated that she had been working at the facility for 6 months. She stated that she remembered Resident #1 having diarrhea because she read it in her progress notes, but it was not reported to her because it may have happened overnight. She explained that in the past few weeks, there had been an upturn of complaints regarding the kitchen. These complaints concerned food being burnt, cold, and coming out late. In an interview on 10/10/25 at 11:03 a.m. with LVN C, he stated that he remembered Resident #1 having diarrhea on 09/25/25. He did not remember why she had it but Resident #1 often had episodes of nausea that she attributed to the food at the facility. He received complaints about the food a couple of times a week, stating that the food was not good and residents did not like it. In an interview on 10/10/25 at 12:01 p.m. with Resident #1, she stated that since she has been at the facility over the past couple of years, the food has gone from bad to worse. She stated that she had really bad acid reflux and she started experiencing increased episodes of diarrhea that led to her doctor increasing her medication dosage to provide some relief. Resident #1 stated that she constantly had to tell the kitchen staff and DM B that she did not like sausage, but they constantly placed it on her plate every morning during breakfast. She expressed that she hated sausage and seeing it on her tray made her want to throw up. Everyday her breakfast ticket said no sausage but staff would still place it on her plate because they were not reading the tickets. She also received meals covered in gravy after she listed that she did not like gravy. She stated that she had informed the ADM about her kitchen concerns and felt she did not care because the staff were contracted with a different company. In an interview on 10/10/25 at 12:42 p.m. with DM B, she stated she was the dietary manager at the facility from 06/30/25 until she was termed on 10/06/25. She stated that prior to employment, her predecessor was well liked by everyone in the facility, and it was a hard task coming behind her and she probably was not a good fit. DM B explained that she received several grievances regarding the menu and food being cold. She felt that some of the complaints she received were valid and some of the grievances came from chronic complainers who were hard to please. She explained that during her employment, there were several dietary staff members who worked in the kitchen without their food handler's certification. She explained that in her 20 years of working in dietary, she had never received so many grievances. Some of the grievances she felt were valid like the ones who came from Resident #1. She knew that Resident #1 did not like gravy on her food and staff continued to do it because they were not slowing down and reading the tickets. She explained that when she arrived to work on 9/26/25, she received about 9 or 10 grievances regarding the meal service from the night before and in-services were given to herself and the dietary staff regarding storage of proper food items, chain of command, and food temperatures. She did remember some complaints regarding diarrhea that stemmed from the cold grilled cheese sandwiches and tomato soup that was served during dinner on 09/25/25, but she was off that day. [NAME] E prepared the meal that night and she explained that she had made the grilled cheese sandwiches ahead of the service. DM B stated that she had to do a corrective action for [NAME] E and concluded that the facility was a really tough building to work in. She stated [NAME] E was terminated from this role shortly after. In an interview with the ADM on 10/10/25 at 2:16 p.m., she stated that she sat in on the Resident Council Meeting in August and she was concerned about all the complaints she received regarding the dietary department. This prompted her to begin a QAPI and start in-services to her staff. The facility tried to coach with DM B but her attitude made her difficult to work with and receive feedback, ultimately leading to her termination. Record review of the facility's grievance and complaint log for August showed that on 8/20/25, there were 13 grievances directed towards the dietary department. Record review of the grievances for September 2025 documented 15 complaints directed towards the dietary department. Record review of the Resident Council Meeting minutes conducted on 9/16/25 at 2:00 p.m. revealed that complaints were made regarding food being served cold, overcooked, and failure by kitchen staff to follow meal preferences. Resident #1 stated that her breakfast was served cold that morning and her waffles were still frozen. Resident #1 stated that she did not want any sausage on her breakfast tray but she still received sausage on her tray every time it was served. She also stated that she received two bowls of oatmeal that morning for breakfast instead of the bowl of dry cereal with milk and cranberry juice she requested. Record review of an in-service dated on 09/15/25 revealed that the ADM educated all nursing staff on mealtimes and stated the goal was to deliver warm food with a great presentation. Record review of an in-service titled Food temperatures dated on 09/26/25 with the dietary staff highlighted the purpose of the in-service was to ensure all dietary staff understood proper food temperature control and how it directly impacted resident satisfaction, safety, and compliance. This in-service documented that it was used as a learning opportunity to reinforce the standards and prevent recurrence of the recent incident in which grilled cheese sandwiches and tomato soups were served cold. Best practices indicated to take and document food temps before service begins, after transport, and on the line. Always use a calibrated food thermometer. Label and cover trays to retain heat and coordinate closely with nursing or dining teams to time delivery properly. Lastly, never guess temperatures based on feel or appearance. Record review of an in-service dated 09/29/25 revealed that the ADM educated all nursing staff on resident rights, abuse and neglect, and the policy on meal pass times and temperatures. Record review of DM B's employee file reflected that on 10/6/25, DM B received a 90-day performance review that stated that while coaching and feedback were consistently provided, the outcomes have not met the expectations for a food service manager at [name] company. Her areas of concern included the resident dissatisfaction regarding meal services, defensiveness or blame shifting when receiving feedback, raised tones and dismissive behavior towards staff that resulted in low morale and workplace tensions, and low progress to coaching sessions. She was effectively demoted on 10/6/25 to the position as a cook. DM B refused to sign this document and her employment with the facility and the contracted dietary company was terminated. Record review of a letter written by the ADM to whom it may concern from the contracted dietary company on 10/6/25 read that: Despite repeated attempts to address these issues through one-on-one discussions, progress has been limited. A primary barrier to resolution appears to be [DM B's] overall attitude and approach. She frequently became defensive or agitated when concerns were raised, often providing excuses or shifting blame rather than working towards solutions. Additionally, she had been observed raising her voice at her staff and had demonstrated dismissive or uncooperative behavior when approached by her nursing or administrative team members in collaboration. Given the continued complaints, the influence of grievances, and the lack of meaningful improvement, it appears to be the best interest of the facility to move forward and parting ways with [DM B] at this time.

Based on interview and record review, the facility failed to ensure each resident received and was provided food that accommodated resident allergies, intolerances, and preferences for 1 (Resident #1) of 5 residents reviewed for meal preferences. Resident #1 received sausage for breakfast and gravy on her food during mealtimes after she consistently requested the removal of these items from her plate. This failure could lead to a diminished quality of life. Findings included: Record review of Resident #1's facesheet revealed an eighty-one-year-old female who was admitted to the facility on [DATE]. Her admitting diagnoses were Type 2 Diabetes, GERD, hypertension (high blood pressure), gout (a form of arthritis), and anxiety disorder. Record review of Resident #1's care plan revealed that she was on a therapeutic CCD regular diet with regular consistency. Interventions listed were to alert the NP/MD and document residents' inability to consume diet, offer supplements and alternatives if less than 50% of the meal is consumed or resident does not like the meal, and provide diet as MD order. In relation to her Type 2 Diabetes, the intervention listed was to observe compliance with diet and document any problems. Record review of Resident #1's nutrition progress note dated 9/09/25 at 11:06 am documented that Resident #1 stopped the dietician and requested supplements and no gravy on food. Record review of the facility's dietary staffing list revealed that there were 9 employees who worked in the kitchen. During an interview on 10/09/25 at 10:18 a.m., DM A informed the surveyor that it was her third day in that role, and she was trying to revamp the kitchen. The health department visited the facility's kitchen on 10/08/25 for an impromptu inspection due to a call for a foodborne outbreak at the facility and she could provide the documentation of their passing score. She stated she could tell the previous manager did not focus on checking temperatures In an interview on 10/10/25 at 10:20 a.m. with the AD, she stated that she had worked at the facility for over 20 years. She oversaw the resident council that met every 3rd Tuesday of the month. During the last resident council meeting, she had several complaints regarding the food not being good. In an interview on 10/10/25 at 12:01 p.m. with Resident #1, she stated that since she has been at the facility over the past couple of years, the food has gone from bad to worse. Resident #1 stated that she constantly had to tell the kitchen staff and DM B that she did not like sausage, but they constantly placed it on her plate every morning during breakfast. She expressed that she hated sausage and seeing it on her tray made her want to throw up. Everyday her breakfast ticket said no sausage but staff would still place it on her plate because they were not reading the tickets. She also received meals covered in gravy after she listed that she did not like gravy. She stated that she had informed the ADM about her kitchen concerns and felt she did not care because the staff were contracted with a different company. In an interview on 10/10/25 at 12:42 p.m. with DM B, she stated she was the dietary manager at the facility from 06/30/25 until she was termed on 10/06/25. She stated that prior to employment, her predecessor was well liked by everyone in the facility, and it was a hard task coming behind her and she probably was not a good fit. DM B explained that she received several grievances regarding the menu and food being cold. She felt that some of the complaints she received were valid and some of the grievances came from chronic complainers who were hard to please. She explained that during her employment, there were several dietary staff members who worked in the kitchen without their food handler's certification. She explained that in her 20 years of working in dietary, she had never received so many grievances. Some of the grievances she felt were valid like the ones who came from Resident #1. She knew that Resident #1 did not like gravy on her food and staff continued to do it because they were not slowing down and reading the tickets. In an interview with the ADM on 10/10/25 at 2:16 p.m., she stated that she sat in on the Resident Council Meeting in August and she was concerned about all of the complaints she received regarding the dietary department. This prompted her to begin a QAPI and start in-services to her staff. The facility tried to coach with DM B but her attitude made her difficult to work with and receive feedback, ultimately leading to her termination. Record review of the facility's grievance and complaint log for August showed that on 8/20/25, there were 13 grievances directed towards the dietary department. Record review of the grievances for September 2025 documented 15 complaints directed towards the dietary department. Record review of the Resident Council Meeting minutes conducted on 9/16/25 at 2:00 p.m. revealed that complaints were made regarding food being served cold, overcooked, and failure by kitchen staff to follow meal preferences. Resident #1 stated that her breakfast was served cold that morning and her waffles were still frozen. Resident #1 stated that she did not want any sausage on her breakfast tray but she still received sausage on her tray every time it was served. She also stated that she received two bowls of oatmeal that morning for breakfast instead of the bowl of dry cereal with milk and cranberry juice she requested. Record review of an in-service dated on 09/15/25 revealed that the ADM educated all nursing staff on mealtimes and stated the goal was to deliver warm food with a great presentation. Record review of an in-service dated 09/29/25 revealed that the ADM educated all nursing staff on resident rights, abuse and neglect, and the policy on meal pass times and temperatures. Record review of DM B's employee file reflected that on 10/06/25, DM B received a 90-day performance review that stated that while coaching and feedback were consistently provided, the outcomes have not met the expectations for a food service manager at [name] company. Her areas of concern included the resident dissatisfaction regarding meal services, defensiveness or blame shifting when receiving feedback, raised tones and dismissive behavior towards staff that resulted in low morale and workplace tensions, and low progress to coaching sessions. She was effectively demoted on 10/06/25 to the position as a cook. DM B refused to sign this document and her employment with the facility and the contracted dietary company was terminated. Record review of a letter written by the ADM to whom it may concern from the contracted dietary company on 10/06/25 read that: Despite repeated attempts to address these issues through one-on-one discussions, progress has been limited. A primary barrier to resolution appears to be [DM B's] overall attitude and approach. She frequently became defensive or agitated when concerns were raised, often providing excuses or shifting blame rather than working towards solutions. Additionally, she had been observed raising her voice at her staff and had demonstrated dismissive or uncooperative behavior when approached by her nursing or administrative team members in collaboration. Given the continued complaints, the influence of grievances, and the lack of meaningful improvement, it appears to be the best interest of the facility to move forward and parting ways with [DM B] at this time.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 6 residents (Resident #43) reviewed for ADLs. The facility failed to ensure Resident #43 was provided personal grooming (long fingernails and dark substance under the fingernails) and oral hygiene (dirty teeth and bad breath) by facility staff. These failures could place residents at risk for not receiving the assistance needed for daily care and services to help prevent infection or injuries. Findings included: Record review of Resident #43 face sheet dated 05/29/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included acute respiratory failure with hypoxia (inadequate gas exchange by the respiratory system), history of klebsiella pneumoniae (a bacterial infection), history of viral pneumonia (lung infection), dysphagia (swallowing disorder) and aphasia (a language disorder) following a stroke; hemiplegia and hemiparesis (paralysis to one side of body affecting the right dominant side) following a stroke; tracheostomy status (a condition of a person who had undergone medical procedure to create an opening in the windpipe to facilitate breathing), gastrostomy status (a condition of a person who had undergone a procedure to make a hole into the stomach through the abdomen to insert a feeding tube) and colostomy status (a condition of a person who had undergone a procedure to make an opening in the large intestine to divert stool). Record review of Resident #43's quarterly MDS (a tool for resident assessment and care screening) dated 05/07/25 indicated a BIMS score of 12 out of 15 indicating moderately impaired cognition. Resident #43 had impairment to both upper and lower extremities. Resident #43 required substantial assistance with oral hygiene: the helper did more than half of the effort. Resident #43 was dependent on staff for personal hygiene and required substantial assistance with mobility. Record review of Resident #43's undated care plan included: Focus - Resident #43 had a tracheostomy and a high risk for infection and aspiration. Interventions included provide good oral care daily and as needed. Focus - Resident #43 requires tube feeding and nothing by mouth, r/t dysphagia. Interventions did not include to provide oral care. Focus - Resident #43 had left sided weakness r/t stroke. Interventions included, to assist with ADLs and mobility as needed. Focus - Resident #43 exhibited ADL self-care performance deficit and required assistant due to limited mobility. Interventions included, provide maximum assistance of 1 to 2 staff for all ADLs; provide assistance with eating, dressing, bathing, toileting and grooming as needed. In an observation on 5/28/25 at 7:25 AM, Resident #43 was lying in bed with the head of bed elevated. A flexible respiratory tubing was connected to his tracheostomy. The tubing was connected to a compressor delivering humidified air. He had long jagged fingernails on his left hand with brownish-black matter under each fingernail. In an observation and interview on 5/29/25 at 6:57 AM, Resident #43 was awake, alert and tracking surveyor with his eyes. The RT uncovered the resident's right hand. Resident #43 was able to open his fist when instructed. The fingernails on the right hand were approximately 0.5 cm long, square shaped with sharp corners. The fingernails on the left hand were approximately 0.5cm long, jagged, sharp corners and had dark matter under each fingernail. Resident #43 had dry lips; his teeth were filmy with white substance between the teeth. He was able to cough and clear white frothy sputum from his tracheostomy. His breath had an odor. The resident was asked if he had fingernails cleaned and trimmed recently or had oral care recently. Resident #43 stared at the Surveyor, did not respond nor nod or shake his head. The RT stated he would sometimes not respond to strangers. The RT stated that she did not provide oral care and that the nursing staff were responsible to provide oral care. In interview and observation on 5/29/25 at 7:08 AM, CNA-A stated she had not worked with Resident #43 very often and that she had not seen him yet as she was tending to other residents at the time. CNA-A walked into Resident #43's room to check on him. CNA-A stated that his fingernails on the right hand, could use some cleaning and that keeping them long would risk cutting himself and causing infection. CNA-A stated that the fingernails on his right hand needed to be trimmed as well. CNA-A stated for his dry lips she would use a wet washcloth and wet his mouth. CNA-A stated she was not sure if the black matter under his fingernails was his baseline. In an interview on 5/29/25 at 7:16 AM, LVN-B stated Resident #43 needed nailcare and that the fingernails on the left hand should be clean and trimmed as they could cause infection. LVN-B stated the nursing staff was responsible to provide nailcare as needed. LVN-B stated the nurses were responsible for oral care. LVN-B stated having dry lips could irritate Resident #43 and if his mouth is not clean then germs can grow in his mouth. LVN-B stated as a nurse it was his responsibility to ensure nailcare and mouth care was completed. LVN-B stated he would take care of this right away. In an interview on 5/29/25 at 7:27 AM, CNA-C stated nailcare was done as needed and every Sunday for all residents. CNA-C stated she completed head to toe check on all her residents every 2 hours. CNA-C was not assigned to Resident #43. CNA-C stated residents can get sick from having long and dirty fingernails because food and germs can get under the nails as residents will often put their hands into their mouths. CNA-C stated long, and dirty fingernails could dig into the skin causing cuts and infection. CNA-C stated mouth care is provided every morning and that the risks to the resident would be red gums, odors, bacteria, and problems with eating. In an interview on 5/29/25 at 7:36 AM, LVN-D stated nailcare can be done by the CNAs unless the resident was diabetic, then the nurses will do the nailcare. LVN-D stated if she saw long and dirty nails the risks would be infection. LVN-D stated oral care would be provided by nurses and CNAs. LVN-D stated signs and symptoms of infection could be a white tongue and odors. LVN-D stated if a resident had filmy teeth they may not want to eat, they may have mouth pain, it could lead to weight loss and dry, cracked lips could be a sign of dehydration. In an interview on 5/29/25 at 7:46 AM, the DON stated the nursing staff did nailcare every Sunday and as needed. The DON stated mouth care should be done daily, every shift and as needed. The DON stated the respiratory therapist, nurses and CNAs could do mouth care. The DON stated having long and dirty fingernails could affect Resident #43's personal hygiene. The DON stated Resident #43 does use his left hand often and would handle newspaper with ink. The DON stated moving forward she would conduct staff inservices regarding oral care and nail care. In an interview on 5/29/25 at 8:28 AM, LVN-E stated he audited resident nails weekly and documented on the Nail Care Log sheet. He confirmed that on 5/26/25 he checked Resident #43's nails and documented on the Nail Care Log sheet. LVN-E stated Resident #43's fingernails did look a little sharp. LVN-E stated Resident #43 refused nail trim on 5/26/25 and that he cleaned under the fingernails. LVN-E stated Resident #43 would scratch and get dead skin under the nails. LVN-E stated Resident #43 developed dirty nails fast and he had seen Resident #43 grab the newspaper at times. LVN-E stated he expected nailcare to be provided every Sunday and as needed per facility policy and procedure. LVN-E stated he expected clean nail beds and trimmed as comfortable as possible. LVN-E stated he could not say exactly why Resident #43 had dark matter under the fingernails. In an interview on 5/29/25 at 2:40 PM, the DON stated CNA-F worked with Resident #43 on 5/28/25, when asked who provided nail care on 5/28/25 at 12:51 PM. In an interview on 5/29/25 at 2:45 PM, LVN-B stated he would communicate completion of nailcare and mouth care for Resident #43 by passing the information to the oncoming nurse during shift report. LVN-B stated he would not document the completed task in the chart because he considered it standard nursing care. In an interview on 5/29/25 at 2:50 PM, LVN-D stated if nailcare or mouth care was done, she would document a progress note in the resident's chart and include details because it would be an assessment. LVN-D stated if not documented then it was not done and that it was the facility policy and procedure to do so. In a telephone interview on 5/29/25 at 3:05 PM, CNA-F confirmed she worked with Resident #43 on 5/28/25 and that she provided nailcare by washing his arms, hands and removing dirt from his fingers. CNA-F stated Resident #43 would always get black ink on his fingers because he handles black ink on newspaper. Record review of Resident #43's Plan of Care Response History for Nail Care dated 5/29/25, indicated on 5/28/25 at 12:51 PM, Resident #43 received nail care. Further review did not indicate who the staff member was that provided the care. Record review of the facility's Nail Care Log dated 5/5/25, 5/12/25, 5/19/25, 5/26/25, 400 Hall, indicated Resident #43 had his nails cut on each of those days. Further review indicated the following instruction: Progress note stating completed; if resident refused MD/RP notified and progress note stating this was completed. The log sheet did not include who provided the nail care. Record review of Resident #43's progress notes dated 5/29/25 with the effective date range of 04/29/25 to 5/30/25 revealed no progress note regarding Resident #43's refusal of nail trimming on 5/26/25 as reported by LVN-E. Record review the facility policy and procedure for Care of Fingernails/Toenails, revised April 2007, read in part: .the purpose of this procedure are to clean the nail bed, to keep mails trimmed, and to prevent infection .General Guidelines 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed .4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .10. Gently remove the dirt from around and under each nail with an orange stick .13. Trim fingernails in an oval shape .14. Smooth the nails with a nail file or emery board .The following information should be recorded in the resident's medical record .1 .date and time .2. the name and title of the individual who administered the nail care. 3. The condition of the resident's nails and nail bed .6. If the resident refused the treatment, the reason(s) why and the interventions taken . Record review of the facility policy and procedure for Mouth Care, revised April 2007, read in part: The purpose of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth .the following information should be recorded in the resident's medical record: 1. The date and time the mouth care was provided .who provided mouth care. All assessment data obtained concerning the resident's mouth .Reporting 1. Notify the supervisor if the resident refuses the mouth care . Record review of the facility's undated admission Packet read in part: Acknowledgement and Consent of Treatment .I hereby acknowledge and consent for the facility .to provide the necessary care and treatment while the patient resides in the facility .

Based on interview and record review, the facility failed to ensure 1 resident (CR#1) of 8 residents reviewed for medication administration were free of significant medication errors. -CR#1 was transferred to the hospital due to concerns of hyperglycemia (high blood sugar), and when he arrived at the hospital his blood sugar (the amount of glucose in the blood) was over 600, when the normal range should be 70-130. There was an omission of insulin injections to treat diabetes from 08/20/2024-08/24/2024, and the first dosage was given on 08/25/2024 the same day CR#1 discharged to the hospital. CR #1 was hospitalized from 08/25/24 - 08/29/24 with Diabetic Ketoacidosis (DKA a potentially life-threatening complication of diabetes that occurs when the body doesn't have enough insulin) and was admitted to the Intensive Care Unit (ICU). The noncompliance was identified as Past Non-Compliant. The IJ (Immediate Jeopardy) began on 08/20/2024 and ended on 08/30/2024. The facility corrected the noncompliance prior to entrance. The failure placed the residents receiving insulin to treat diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired) at higher risk for hospitalization to treat hyperglycemia and DKA. Findings included: Record review of CR#1 preadmission assessment dated [DATE] reflected an active diagnosis of type 2 diabetes mellitus. Record review of the Facesheet for CR#1 dated 08/20/2024 revealed he was an [AGE] years old male that admitted to the facility on [DATE], with a primary diagnosis of Metabolic Encephalopathy (a brain disorder due to an underlying condition caused by a chemical imbalance in the blood), and secondary diagnosis of type 2 diabetes mellitus. CR#1 discharged to a local hospital on 08/25/2024, due to evaluated blood sugar. Record review of CR#1's Interim Plan of care dated 08/20/2024 revealed a focus of Diabetic Alert, with a goal to manage symptoms, and intervention to monitor s/s of hypo/hyperglycemia. Record review of CR#1's MDS assessment dated [DATE] revealed in section C a BIMS score of 09 indicating he was moderately impaired cognitively. He was assessed to have diabetes mellitus in Section I and receiving insulin injections in section N. Record review of SBAR dated 08/25/2024 at 7:01am and completed by LVN A revealed CR#1 had a change in condition in which b/s (blood sugar) came back high with blood glucose(also known as blood sugar) reading at 600, physician was notified with orders for insulin with sliding scale at 12 units and recheck in 1 hour. Record review of CR#1's discharge hospital records dated 09/04/2024 reflected that on 08/20/2024, CR#1 discharged from a local hospital with glucose level reading of 103 with a reference range of 70-110 mg/dl. Record review of CR#1's discharge hospital record medication list dated 08/20/2024 reflected orders for Basaglar KwikPen U-100 Insulin 100 Unit/ML (3mL), 16 unit(s) Sub-Q Twice Daily Generic drug: Insulin Glargine. The orders reflected NovoLOG FlexPen U-100 Insulin 100 Unit/ML (3mL) 3-8 unit(s) Sub-Q as directed generic drug: insulin Aspart U-100. Record review of progress note dated 08/25/2024 at 8:05am and complete by LVN A reflected MD return call order received for NovoLOG FlexPen Subcutaneous solution Pen-Injector 100 unit/ML (Insulin Aspart). Inject sliding scale. Recheck FBS in 1 hour and repeat SSI. Recheck in 1 hours if FSBS remains>400 notify MD. Record review of progress note dated 08/25/2024 at 10:05am and complete by LVN A read in part, B/c [sic] continue to remain high MD notified order to continue with current sliding scale orders. 15 units given. Resident remains Alert and follow simple commands. Record review of progress note dated 08/25/2024 at 10:05am and complete by LVN A read in part, B/c [sic] continue to remain high MD notified order to continue with current sliding scale orders. 15 units given. Resident remains Alert and follow simple commands. Record review of progress note dated 08/25/2024 at 11:02am and complete by LVN A read in part, B/c [sic] continue to remain high MD notified order to continue with current sliding scale orders. 15 units given. Resident remains Alert and follow simple commands. Record review of progress note dated 08/25/2024 at 12:16pm and complete by LVN A reflected in part, Resident b/s continued to remain high vitals WNL see vitals notes. Resident remain alert to his [NAME]-line[sic] and responsive to care. RP at bedside and requested a resident be taken to ER (emergency room ) for evaluation. 911 called and EMS (Emergency Medical Service) arrived all further care handed all care over. Resident ambulated with assistance from EMT (Emergency Medical Technician) from gurney chair to stretcher. MD notified and aware. Record review of the August 2024 Order Summary Report for CR#1 reflected phone orders with a start date of 08/25/2024 for Basaglar KwikPen Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Glargine) Inject 16 unit subcutaneously two times a day related to Type 2 diabetes mellitus. The orders reflected NovoLOG FlexPen Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Aspart), to inject as per sliding scale: If 70-50=0 units; 151-200=2 units; 201-250=4 units; 251-300= 6 units; 301-350 = 8 units; 351-399 = 10 units; 400+ = 12 units and call MD, subcutaneously before meals and at bed time related to type 2 diabetes mellitus. Record review of CR#1's hospital records with admitted [DATE] and discharge date of [DATE] reflected that CR#1 presented to the emergency room from the facility for hyperglycemia with evaluated blood sugar of 600. On admission, blood glucose was greater than 900. CR#1 was admitted to the ICU and treated for diabetic ketoacidosis without coma associated with type 2 diabetes mellitus, and the RP of CR#1 said that the facility had not given any insulin for 4 days. Record review of grievance dated 08/26/2024 reflected it was completed by DON and signed by the DON, SW, and Admin reflected in part, The relative of resident called the facility and stated there was an issue with the residents diabetic medications. Residents medications renewed [sic]; it became evident insulin was omitted at admission. Orders added by MD to admisister[sic] sliding scale as directed. Self-Reported Incident (SRI) completed. Record review of Medication Error Report dated 08/25/2024 that the date of the transcription error was 08/20/2024 involving CR#1 when insulin medication as ordered was not on the MAR and not administered. The outcome to resident was hospitalization . Corrective action taken in-services, one on one, and sliding scale audit of insulin. In an interview on 08/30/2024 at 1:28pm with both Unit Manager C and Admin, who said that CR#1 admitted to the facility on [DATE] and discharged on [DATE]. Both said that on 08/26/2024 a relative of CR#1 alleged that the facility was responsible for CR#1's hospitalization when he did not get prescribed medication. Both said that a clinical audit of the medical record of CR#1 was completed by the DON, ADON, Unit Manager C and Unit Manager D, the audit revealed there was an omission of insulin injections to treat diabetes from 08/20/2024-08/24/2024, and the first dosage was given on 08/25/2024 the same day CR#1 discharged . Both said that a root cause analysis revealed that the admitting nurse, LVN A, enlisted the help of LVN B in clarifying the orders from CR#1's hospital discharge summary medication list at the time of the admission with the primary physician (Medical Director). Both said that LVN B did not enter the orders for insulin into the facilities EMR(electronic medical record) system, and LVN A as the admitting nurse was responsible for ensuring the orders were entered. Both said that both Unit Managers, ADON, DON, and ADMIN failed to review the admission of CR#1 thoroughly, the review would have caught the error, the error should have been corrected immediately, and delay in treatment prevented. Both said that residents with diabetes should have medication and glucose monitoring orders at admission. Both said that going without medication and monitoring for long periods of time could cause abnormal blood sugars, cause a need to be sent to hospital, and prolong/untreated elevated blood sugars could be fatal. Both said that LVN A, LVN B, Unit Manager C, Unit Manager, D, ADON, DON, and Admin received one on one counseling/training and disciplinary action. Both said that there was a QAPI held to review the system and correct failure, and there is a PIP in place. In an effort to complete a phone interview on 08/30/2024 at 3:05pm with LVN A when there was no answer, and a message was left. In a phone interview on 08/30/2024 at 3:44pm with a relative of CR#1, who said that she was a MD. She said that CR#1 went without insulin to treat diabetes or glucose monitoring from 08/20/2024-08/24/2024. She said that CR#1 was transferred to the hospital due to concerns of hyperglycemia, and when he arrived at the hospital his blood sugar was over 600, when the normal range should be 70-130. She said that CR#1 was admitted to ICU and treated for DKA. She said that the facility could have killed CR#1. She said that CR#1 was discharged from the hospital on 08/29/2024, he was transferred to another facility, and he was doing much better. In an effort to complete a phone interview on 09/03/2024 at 12pm with LVN A, there was no answer, and a message was left. In an interview on 09/04/2024 at 9:45am with RN E and RN F at a local hospital, who said that CR#1 presented to theER on [DATE], with a chief complaint of hyperglycemia, and his initial labs for blood glucose were 738. Both said that the normal range should be 70-110. Both said that the level of the blood glucose that CR#1 presented to the ER caused a concern that his diabetes was not controlled, treated, or monitored. Both said that CR#1 was admitted to ICU and treated for DKA. Both said that DKA occurs when the body doesn't have enough insulin, it can be fatal, and can be prevented if diabetes is controlled with medication and monitoring. Both said that when CR#1 discharged from the hospital on 08/20/2024 and transferred to the facility his blood glucose levels were 103. In an interview on 09/04/2024 at 11:15am with Admin and DON, who both said that LVN A self-terminated on 09/03/2024 when he did not report to his scheduled shift, and his last day worked was 09/02/2024. In a phone interview on 09/04/2024 at 12:10pm with LVN A, who said that he quit his job, and he does not want to be a part of the investigation. He said that when he was hired at the facility admissions was an all hands-on deck process, it was not assigned to one nurse, and other nurses helped with the admission of CR#1. He said that there was insulin missed, he gets that, but the unit managers were supposed to review all admissions to make sure they are done correctly. He said that he was not going to provide any more details. Interview on 09/04/2024 at 12:26pm with LVN L who works 6am-6pm shift, RN M at 12:42pm who works 6am-6pm shift, and LVN N who works 6am-6pm shift, who acknowledged that training was received on the topics of the admission process, admission orders, and s/s of hyperglycemia and was knowledgeable on the training topics. In an interview on 09/04/2024 at 1:37pm with Perspective Payment System (PPS) Coordinator, she said that she was an LVN, and she ensures the MDS assessments are completed for short term residents. She said that she was a part of the Interdisciplinary Team (IDT), along with social worker, dietary department, rehab department, activities department, but she is the clinical oversight as the nurse. She said that the IDT meets 48 hours after admission, review the clinical records, and ensure initial treatments are in place and addressed. She said that if there are any errors found they should be addressed and corrected immediately. She said that CR#1 had high blood sugar as he had no orders to treat or monitor his diagnosis of diabetes. She said that during the IDT of CR#,1 she only reviewed the current medications, and as the clinical oversight she should have caught that there were no orders to treat or monitor his diagnosis of diabetes. She said that the risk of not receiving medications to treat diabetes was hyperglycemia, a blood sugar of 600 could cause DKA and coma, and that could be fatal. In an interview on 09/04/2024 at 2:08pm with MDS Coordinator, who said that she was an LVN, and she ensures the MDS assessments are completed for long term residents. She said that she was a part of the Interdisciplinary Team (IDT), along with social worker, dietary department, rehab department, activities department, but she was the clinical oversight as the nurse. She said that the IDT meets 48 hours after admission, review the clinical records, and ensure initial treatments are in place and addressed. She said that if there are any errors found they should be addressed and corrected immediately. She said that CR#1 had high blood sugar because she was not getting insulin, and she was sent out to the hospital. She did not take part in the IDT for CR#1 because he was a short term stay resident. She said that the PPS Coordinator should have caught that CR#1 had an admitting diagnosis of diabetes with no orders in place to treat or monitor during the IDT, but any nurse that reviewed the record or provided care should have caught the error. She said that the risk of not receiving medications to treat diabetes could cause DKA and coma, and that could be fatal. In an interview on 09/04/2024 at 2:21pm with DON, who said that LVN B assisted LVN A with contacting the physician to clarify orders at the time CR#1 was admitted on [DATE]. She said that LVN B did not put the orders into the EMR for CR#1's insulin, and LVN A did not ensure the task was completed as the admitting nurse. She said that the Unit Mangers did not review the admission for accuracy the next day, because it was assumed the ADON completed it when she received the chart. She said that Unit Managers and ADON did not review the admission of CR#1 thoroughly to prevent delays in treatment, an as the oversight she did not ensure the Unit Managers and ADON completed the task. She said that CR#1 had a change in condition on 08/25/2024 due to evaluated blood sugar of 600, and he received the initial dose of insulin the same day. She said that the risk to CR#1 was evaluated blood sugar, hyperglycemia, DKA that could lead to coma, and that could be fatal. She said that there was a QAPI held to review the system and correct failure, and there is a PIP in place. She said that LVN A, LVN B, Unit Manager C, Unit Manager D, ADON, Admin, and DON received disciplinary action and one on one training. She said that LVN A self-terminated. In an interview on 09/04/2024 at 3:01pm with the Medical Director, who said that he was the primary physician of CR#1 who admitted to the facility with a diagnosis of diabetes. He said that when nursing staff contacted him to reconcile medications at admission, he gave a verbal order to continue medications on the medication list from the hospital at discharge until he was able to round. He said that he was contacted with change in condition due to evaluated, was told he had not received insulin since admission, gave orders to treat, blood sugar was coming down, but family request CR#1 be sent to the hospital. He said that he participated in a QAPI and there is a PIP in place to ensure the accuracy of the admission process and that mediations are entered and implemented at the time of admission. He said that the admitting nurse should have ensured the orders were in place, and any nurse that reviewed the chart should have been able to correct the error. He said that that the risk to the resident was DKA that can be fatal. He said that it's his expectation that if he gives a verbal order to continue all discharge orders from the hospital that should be done. In an interview on 09/04/2024 at 3:50pm with LVN B, who said that she assisted LVN A with the admission of CR#1 with medication orders. She said that she called the physician (Medical Director) who gave orders to continue medications from the medication list from the hospital at the time of discharge. She said that CR#1 had a diagnosis of diabetes and orders to continue insulin. She said that she did not enter the orders to the EMR, it was an error, and she just missed it. She said that she was not sure how long CR#1 went without insulin to treat diabetes. She said that the risk of CR#1 not receiving insulin from 08/20/2024-08/20/2024 was death, because hyperglycemia could cause DKA. She said that it was the admitting nurse responsibility to ensure the medications are clarified and entered by checking the tasks completed by other nurse, and the unit managers were supposed to review the next day to ensure no errors were made. She said that she received disciplinary action and one on one counseling and training to address the admission process, admission orders, and s/s of hyperglycemia. In an interview on 09/04/2024 at 4:35pm with Unit Manager D, who said there was a QAPI held to review the system and correct failure, and there was a PIP in place. She said that LVN A, LVN B, Unit Manager C, Unit Manager D, ADON, Admin, and DON received disciplinary action and one on one training. In an interview on 09/04/2024 at 4:54pm with the ADON, who said there was a QAPI held to review the system and correct failure, and there was a PIP in place. She said that LVN A, LVN B, Unit Manager C, Unit Manager D, ADON, Admin, and DON received disciplinary action and one on one training. Interview on 09/04/2024 at 5:12pm with RN K, who said that she received disciplinary action and one on one counseling and training to address the admission process, admission orders, and s/s of hyperglycemia as she assisted LVN A with the admission of CR#1, and she was knowledgeable on the training topics. Interview on 09/04/2024 at 6:09pm with LVN G who works 6pm-6am shift, RN H at 6:22pm who works 6pm-6am shift, and LVN I who works 6pm-6am shift, who acknowledged that training was received on the topics of the admission process, admission orders, and s/s of hyperglycemia and was knowledgeable on the training topics. Interview on 09/05/2024 at 6:30am with LVN J who works 10pm-6am shift, who acknowledged that training was received on the topics of the admission process, admission orders, and s/s of hyperglycemia and were knowledgeable on the training topics. Record review of SSA reporting database TULIP reflected Incident intake# 527741 was received on 08/26/2024 with the PIR submitted on 09/04/2024 with the documents to support the following actions were taken, RP and MD notified, and in-service on topics abuse/neglect, blood sugar and accu checks, signs and symptoms of hyper/hypoglycemia, changes in conditions and review of medications list at admission. Further documents to support that satisfaction surveys were conducted, witness statements completed, audit of past 10 admission completed, implemented an audit tool for future admission checklist, Root Cause Analysis completed, QAPI conducted, PIP completed, and one on one counseling and disciplinary actions with LVN A, LVN B, RN K, Unit Manger C, Unit Manger D, ADON, DON, and Admin completed. Record review of QAPI held on 08/27/2024 reflected that that there was a review the facility's admission review practices related to accuracy with review of orders and entering them with use of an admission checklist and noted there was a need for an immediate change in the process. Administrator and DON initiated an action plan on 08/26/2024, with a compliance goal of 08/28/2024, Root Cause Analysis initiated and attached to the system for sustainability, and once compliance was established the DON/Designee would monitor assessments weekly. Record review of PIP dated 08/27/2024 reflected a concern that a nurse omitted insulin medication admission. Goals were for admission checklists to be completed within 24 hours of admission without any omissions. Interventions were for the Don/Designee to complete reeducation on admission checklist, reviewing medication list upon admission, accuchecks, signs and symptoms of hypo/hyperglycemia, and change in condition. Don/Designee will audit the last ten admissions to ensure there were no omissions. DON/Designee would audit admissions checklist five times a week x 4 weeks and periodically thereafter and would upload in the facilities drive monthly ongoing for administrator to review. Record review of Don/Designee audit dated08/27/2024 of the last ten admissions with no omissions. Record review of Administrator Admission Checklist Audit (5 times a week for four weeks) with a starte date of 08/26/2024-09/04/2024 with no errors identified. Record review of DON/Designee Admission Checklist Audit (5 times a week for four weeks) with a starte date of 08/26/2024-09/04/2024 with no errors identified. Record review of Diabetic Resident Audit dated 08/28/2024 to ensure orders were in place treat and monitor, appropriate diet was in place with a snack, and care plan reflected diagnosis. Record review of Disciplinary Measure dated 08/26/2024 reflected that LVN A, LVN B, and RN K received disciplinary action in the form of a counseling for violation date of 8/20/2024 due to clarification with physician on admission for a discharge hospital medication list for residents with diagnosis of Diabetes Mellitus. Record review of Disciplinary Measure dated 08/26/2024 reflected that Unit Manager C, Unit Manger D, ADON, DON and Admin received disciplinary action in the form of a counseling for violation date of 8/20/2024 due to monitoring admission system to assure nurse managers completed admissions accurately to assure no omissions present. Record review of 1:1 Inservice Record dated 08/26/2024 reflected that LVN A, LVN B, Unit Manger C, Unit Manger D, RN K, and ADON received individual counseling topics of Admission System Process Regarding Medication, discharge hospital medication list and follow up with physician on admission, Nursing care of the Resident with Diabetes Mellitus, and Change in A Residents Condition or Status. Record review of 1:1 Inservice Record dated 08/26/2024 reflected that DON and Admin received individual counseling topics of Admission System Process Regarding Medication, Nursing care of the Resident with Diabetes Mellitus, Change in A Residents Condition or Status, and reviewing new admission and monitoring system. Record review of in-service titled Manager Duty-Day dated 08/26/2024 reflected that Unit Manager C and Und Manger D were in-serviced to completed review of all admission before noon the next day. Record review of in-service titled Diabetes Mellitus and Blood Sugar dated 8/26/2024 completed with nursing staff on the Admission System Process Regarding Medication, reviewing admission medication on admission and going over with the physician, Nursing care of the Resident with Diabetes Mellitus, and Change in A Residents Condition or Status. Record review of in-service titled Diabetes Mellitus dated 8/29/2024 completed with nursing staff on ensuring a blood sugar baseline is established at the time of admission time 7 days for resident with a diagnosis of Diabetes Mellitus. Record review of in-serviced titled Admission Checklist dated 08/27/2024 completed with nursing staff to ensure that all admits/readmits have a completed admission checklist submitted to the office of the ADON upon completion by the end of the shift. Record review of in-service titled Abuse and Neglect dated 8/26/2024 completed with nursing staff identifying who to report allegations to, types of abuse and neglect, and reporting timeframes. Record review of facility policy, Administering Medications with revised date December 2012 read in part, . Medications shall be administered in a safe and timely manner, and as prescribed . 3. Medications must be administered in accordance with the orders, including any required time frame . Record review of facility policy, Medication and Treatment Orders with revised date July 2016 read in part, . Orders for medications and treatments will be consistent with principles of safe and effective order writing . 1. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order . Record review of facility policy, Nursing Care of the Resident with Diabetes Mellitus with revised date April 2009 read in part, .The purposes of this guideline are: 2. To help the resident control his/her diabetes with diet, exercise, and insulin (as ordered); 3. Prevent recurrent hyperglycemia/hypoglycemia; .The following complications are associated with diabetes: 1. hypoglycemia (blood sugar above target levels) .2. Diabetic Ketoacidosis (DKA) or hyperosmolar (nonketotic). (Note: Diabetic Ketoacidosis is a life-threatening emergency that needs immediate medical attention): .Glucose Monitoring 1. The management of individuals with diabetes mellitus should follow relevant protocols and guidelines. 2. the physician will order the frequency of glucose monitoring .4. Finger Sticks(capillary blood samples)measure current blood glucose levels .b. Normal ranges are approximately 90-130mg/dl before meals and <180 mg/dl after meals.Medication Management .3. Medication management of type II diabetes may include oral hypoglycemic agents with or without insulin .7. Assist the resident with his or specific medication regimen, as ordered and as needed . The noncompliance was identified as Past Non-Compliant. The IJ (Immediate Jeopardy) began on 08/20/2024 and ended on 08/30/2024. The facility corrected the noncompliance prior to entrance. On 09/04/23 at 5:37pm, the facility administrator was notified of past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the administrator via email.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that: -Food items not labeled and not dated. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease. Findings include: Observation of the facility's kitchen and interview on 01/24/23 between 8:30 am and 8:40 am with the Food Service Manager revealed the following: A container of canned Pineapple dated 1/18/23 No used by date A container of grits no label no used by date A container of scrambled eggs dated 1/13/23 No used by date A Carton of Cream Cheese expiry date 1/11/23 1 Bag of Shredded Carrots expiry date 12/28/22 1 case of Corn Flakes expiry date 12/16/20 The above food should have been labeled and dated so that the staff will know when the used-by date of the food and should have been discarded after the used by date. Interview with the Food Service Manager on 01/24/23 at 9:00 AM he stated that he is responsible for training staff on labeling and storage requirements ensuring dietary requirements are met. Record review of facility's Nutrition Services Policies and Procedures dated 9/2017 read in part .Refrigerated Storage Guidelines: Leftovers must be labeled and dated with the date they are prepared and the use by date.

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for one (Hall 200 nurse medication cart) of four nurse medication carts for drug storage, as evidenced by: -Nurse medication cart on Hall 200 had medication on top of cart and was unattended This deficient practice could place 27 residents who reside on Hall 200 at risk for harm and place the facility at risk for possible drug diversion. The findings include: Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for one of four nurse medication carts (Hall 200 nurse medication cart) reviewed for drug storage, as evidenced by: -Nurse medication cart on Hall 200 had medication on top of cart and was unattended This deficient practice could place residents who reside on Hall 200 at risk for harm and place the facility at risk for a possible drug diversion. The findings include: Observed on 1/27/2023 at 9:07 am on top of medication cart in 200 Hall a bag of liquid medicine labeled Piperacillin Sodium-Tazobactam Sodium (PIP/Tazo) 3.375/NS in 100 ml Normal Saline (NS)(solution to supply water and salt (sodium chloride) to the body) unattended until 9:11 am (PIP/Tazo is a medication given for infection (An infection is the invasion of tissues by pathogens (is any organism or agent that can produce disease), their growth, and the reaction of host tissues to the infectious agent and the toxins they produce)). LVN A approached the medication cart. Interviewed LVN A on 1/27/2023 at 9:11 am she stated she is not supposed to leave medication on top of the cart unattended, as it can be dangerous to other residents and compromise patient privacy. She stated she went to retrieve intravenous (IV), (medicine that goes into the veins) flushes (syringes filled with normal saline (solution to supply water and salt (sodium chloride) to the body) for the intravenous (IV) medication to be administered into the residents' vein. Interviewed the IP on 1/27/2023 at 11:17 am he said medications should be locked in medication cart, not on top of medication cart unattended, because the medication could be picked up, taken by another resident, resident could have adverse signs and symptom (get sick) if take wrong medication. He reported the medication left unattended , is against the facility policy and procedure and also is against the nursing standard of care. Interviewed the DON on 1/27/2023 at 11:22 am regarding medication and orientation process. She reported all medications should be locked in the medication cart, not on top of medication cart unattended, because the medication could be picked up, taken by another resident, a resident could have adverse signs and symptom (get sick) if take wrong medication. She reported leaving medication unattended is against the facility policy and procedure and also is against the nursing standard of care. Record review of the facility policy titled Storage of Medications (Revised April 2007) read in part: Policy Statement The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or cars used to transport such items shall not be left unattended if or otherwise potentially available to others.

Based observation, interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable disease for 2 of 4 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]), in that: - CNA B and Nursing Aide Student did not don all required PPE prior to entering 2 of 4 rooms under isolation precautions. This failure placed residents at risk for acquiring infection of communicable disease. Findings included: Record review of Resident #2's face sheet revealed a [AGE] year-old male admitted into the facility on [DATE] and was diagnosed with COVID-19, muscle weakness and [CONDITION(S)]. Record review of the facility's COVID testing log revealed Resident #2 tested positive for COVID-19 on 11/14/2022. Observations of hall 300 on 11/22/2022 beginning at 12:20PM, revealed room [ROOM NUMBER] was under isolation precautions with sign posted requiring eye-protection, N95 mask, gloves and gown for entry into the room. CNA B was observed retrieving Resident #2's meal tray and coming out of his room wearing personal glasses, no gown, gloves or eye protection, and with his N95 mask lowered beneath his nose. He placed Resident #2's used meal tray on the donning station prior to placing it on the cart. There were no face shields stored at the donning station in front of the room. Interview on 11/22/2022 at 12:20PM, CNA B reported that he did not don any PPE to retrieve Resident #2's meal tray since the resident was sitting near the door ready to hand off his tray to him. When asked if he was supposed to wear any PPE, he stated he usually wears a gown, gloves, a mask, but not a face shield since he already wore glasses. He stated he did not don PPE because he did not think it was necessary with Resident #2 sitting nearby the door at the time he picked up his tray. He stated he received a training at a different facility that said it was okay for him to use his personal glasses as eye protection and said he was not aware his mask was lowered when coming out of the room and it was likely lowered because he forgot to pull the mask back up after talking to the resident. Interview on 11/22/2022 at 12:35PM, the ADON acknowledged there were no face shields on the donning stations for 1 of 2 COVID-19 positive rooms after surveyor pointed it out. She stated the Central Supply Manager is was in charge of restocking and replenishing PPE supplies. Interview on 11/22/2022 at 1:02PM, the Central Supply Manager stated she has been trained on which PPE was necessary for droplet precautions and to prevent the spread of infection. She said the face shields were not in the donning station because she had not gotten around to checking the halls again since earlier in the day. She said there was not a specific number of times she makes rounds during her shift but she generally goes up and down the halls to see if anything is needed. Record review of Resident #3's face sheet revealed a [AGE] year-old male admitted into the facility on [DATE] and was diagnosed with COVID-19. Record review of the factility's COVID testing log revealed Resident #3 tested positive for COVID-19 on 11/16/2022. Observations of all 400 on 11/22/2022 beginning at 1:05PM, revealed room [ROOM NUMBER] was under isolation precautions with sign posted requiring eye-protection, N95 mask, gloves and gown for entry into the room. Nurse Aide Student was observed donning on gown, gloves and N95 mask, but no face shield, entered Resident #3's room to pick up their meal tray, placed it on the clean donning station outside the room, doffed PPE then put the meal tray on the cart. In an interview on 11/22/2022 at 1:08PM, Nurse Aide Student stated it was her first day of training in the facility. She said she received isolation precaution training from her program, and said she forgot to put it on prior to entering the room. She stated saw and understood the isolation precaution sign posted on the door required eye protection prior to enter the room. Interview on 11/22/2022 at 1:15PM, the IP stated that he did not realize they were putting the trays on top of the donning stations and the expectation would be to bring the cart to the room to load trays directly on the cart. He said he has not trained any staff to specifically put the trays on the cart including the nursing students. He also stated he had seen CNA B make the same mistake of not putting on all the necessary PPE prior to entering rooms with isolation precautions earlier today and had to correct him on the spot. Despite CNA B already receiving training on infection control, he will need to train him again. Interview on 11/23/2022 at 12:10PM, the DON stated staff should put on their full PPE prior to entering the room and CNA B was one of those who needed to be reeducated multiple times despite having received infection control training before. She said she and the IP have never considered the infection control concerns during the process of taking trays out of rooms under isolation precautions. Record review of the facility's policy on infection control, not dated, revealed when working with suspected or confirmed [CONDITION(S)]-CoV-2 Residents, a gown, gloves, eye protection and N-95 respirator or higher are to be worn. Record review of CDC's policy on droplet precautions, dated 09/23/2022, revealed, .[health care personnel] who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).

Based on observation, interview, and record review the facility failed to offer 1 of 3 residents (#58) a therapeutic diet as ordered by the health care provider, reviewed for nutrition and hydration status, in that: Facility staff did not follow resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures could affect residents and placed them at risk for not receiving proper nutrition. As evidence by: Record review of Resident #58's face sheet revealed a [AGE] year-old female who was originally admitted on [DATE] and readmitted on [DATE]. She had the following diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #58's Quarterly MDS dated [DATE] revealed she had a BIMS of 6 out of 15 indicating severe cognitive impairment. Her MDS indicated no swallowing disorder problems and no mechanically altered diets. Record review of Resident #58's order summery summary report with active orders as of 11/02/2021 with a dietary order of Mechanical Soft- Dysphagia Advanced texture, regular consistency, No straws/upright for all meals. Start date 8/11/2021. Record review of Resident #58's care plan revised date of 4/09/2021 revealed Resident has nutritional problem or potential nutritional problem of weight fluctuations due to varied intake. Regular diet, no straws. Intervention dated 11/16/2020 provide and serve diet as ordered. Record Review of Resident #58's ST- Therapist Progress and Discharge Summary dated 9/20/2021 read in part Patient has met all goals and is safely consuming least restrictive diet of mechanical soft textures and thin liquids by cup sips. Patient demonstrates insight into need for use of safe swallow strategies and is aware to cue staff as needed to assist with proper positing with all meals. Patient states preference to remain on mechanical soft diet. Patient/caregiver training: patient/staff education for proper positing for all meals, patient education for safe swallow strategies including no use of straws. Observation of Resident #58 on 11/02/2021 at 10:33 am revealed resident in bed with head of bed elevated TV tray had leftover breakfast on tray with a glass of orange juice with straw inside the cup and her water cup with a straw inside the cup. There was a sign behind resident above her bed that red read head of bed elevated no straws from the speech therapist. ser Interview with CNA A on 11/02/2021 at 10:33 AM reveled Resident #58 uses straws on occasion but due to chocking possibility no straws but hasn't seen resident choke. Observation of Resident #58 on 11/02/2021 1:10 PM, resident sitting in bed with head of bed elevated. Lunch tray in front of her. She had a glass with red liquid in it she was drinking it through a straw . Interview with Speech Therapist on 11/02/2021 at 1:17 PM Resident is an aspiration risk and is not supposed to use straws. She stated that was This is why she put up the sign to communicate across all shifts to not use straws. She stated Resident #58 doesn't always aspirate but is at risk for it and that's why she isn't to use straws. She has had to pull the straws from the resident before. Interview with the DON on 11/02/2021 at 1:30 pm revealed the importance of following the recommendation of the speech therapist is for the safety of the patient to ensure patients get appropriate diet as needed and/or care. Resident #58 isn't to use straws because she probably would aspirate. She probably doesn't have the strength to swallow. Most likely the kitchen does not give the resident a straw, but resident is with it enough and asks for one.

Based on observation, interview and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections were maintained for 3 of 4 wings (wing #1, #2 and #3) and 16 of 16 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) reviewed for infection control. The facility did not cohort residents based on their COVID-19 status (COVID-19 positive, COVID-19 negative and unknown) on wing #1, #2, and #3. The facility exposed 8 residents to COVID - 19 (Resident #1, #2, #3, #4, #5, #6, #7, and #8) whom tested negative by keeping them in the room with their roommates (Resident #9, #10, #11, #12, #13, #14, #15, and #16) whom tested positive for COVID - 19 for up to 2 days before surveyor intervention. The facility did not implement plan to designate staff to work with each cohort based on residents COVID-19 status on wing #1 and wing #2. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 12/31/20. While the IJ was removed on 1/2/2021 the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service trainings and evaluate the effectiveness of the corrective systems. These failures placed residents at risk for exposure to COVID-19, health complications, and death. Findings included: Record review of the facility's resident roster dated 12/30/20 and COVID test results from 12/15/20 - 12/24/20 revealed there was 8 rooms (108, 110, 202, 203, 208, 211, 217, and 303) with COVID positive and COVID negative residents in the same room. Resident #1 and Resident #9 Record review of resident roster dated 12/30/20 revealed Resident #1 and Resident #9 resided in room [ROOM NUMBER]. Interview on 12/30/20 at 1:00PM, the IP said Resident #1 had previously tested positive for COVID back in October and was considered recovered since 10/23/20. Record review of facility COVID testing results from 12/15/20 - 12/24/20 revealed Resident #1 was tested for COVID - 19 and tested negative. Further review of the facility test results revealed her roommate Resident #9 received positive COVID results on 12/23/20. Observation on 12/30/20 at 8:10 AM revealed Resident #1 and Resident #9 were in room [ROOM NUMBER] together with sign on door labeling room hot zone. Record review of Resident #9's nurses notes dated 12/23/20 at 5:36 PM revealed the resident had tested positive for COVID and was being moved to an isolation hall. Record review of Resident #9's nurses notes dated 12/28/20 at 6:03 PM revealed the resident was moved back to her room (room [ROOM NUMBER]) on 100 hall to continue her isolation/quarantine. Resident #2 and Resident #10 Record review of resident roster dated 12/30/20 revealed Resident #2 and Resident #10 resided in room [ROOM NUMBER]. Record review of facility COVID testing results from 12/15/20 - 12/24/20 revealed Resident #2 was tested for COVID - 19 and tested negative. Further review of the facility test results revealed his roommate Resident #10 received positive COVID results on 12/28/20. Observation on 12/30/20 at 8:13 AM revealed Resident #2 and Resident #10 were in room [ROOM NUMBER] together with sign on door labeling room hot zone. Record review of Resident #10's nurses notes dated 12/28/20 at 3:00PM revealed the resident had tested positive for COVID. Resident #3 and Resident #11 Record review of resident roster dated 12/30/20 revealed Resident #3 and Resident #11 resided in room [ROOM NUMBER]. Record review of facility COVID testing results from 12/15/20 - 12/24/20 revealed Resident #3 was tested for COVID - 19 and tested negative. Further review of the facility test results revealed his roommate Resident #11 received positive COVID results on 12/28/20. Observation on 12/30/20 at 8:50 AM revealed Resident #3 and Resident #11 were in room [ROOM NUMBER] together with sign on door labeling room hot zone. Record review of Resident #11's nurses notes dated 12/29/20 at 10:55AM revealed the resident had tested positive for COVID and had a mild non - productive cough, fatigue and loss of appetite. Resident #4 and Resident #12 Record review of resident roster dated 12/30/20 revealed Resident #4 and Resident #12 resided in room [ROOM NUMBER]. Record review of facility COVID testing results from 12/15/20 - 12/24/20 revealed Resident #4 was tested for COVID - 19 and tested negative. Further review of the facility test results revealed her roommate Resident #12 received positive COVID results on 12/28/20. Observation on 12/30/20 at 8:51 AM revealed Resident #4 and Resident #12 were in room [ROOM NUMBER] together with sign on door labeling room hot zone. Record review of Resident #12's nurses' notes dated 12/28/20 at 1:01 PM revealed she had tested positive for COVID and she was having some drowsiness, shortness of breath and loss of appetite. Resident #5 and Resident #13 Record review of resident roster dated 12/30/20 revealed Resident #5 and Resident #13 resided in room [ROOM NUMBER]. Record review of facility COVID testing results from 12/15/20 - 12/24/20 revealed Resident #5 was tested for COVID - 19 and tested negative. Further review of the facility test results revealed her roommate Resident #13 received positive COVID results on 12/28/20. Observation on 12/30/20 at 8:52 AM revealed Resident #5 and Resident #13 were in room [ROOM NUMBER] together with sign on door labeling room hot zone. Record review of Resident #13's nurses notes dated 12/28/20 at 12:55 PM revealed she had tested positive for COVID and she was having some drowsiness and shortness of breath. Resident #6 and Resident #14 Record review of resident roster dated 12/30/20 revealed Resident #6 and Resident #14 resided in Rroom [ROOM NUMBER]. Record review of facility COVID testing results from 12/15/20 - 12/24/20 revealed Resident #6 was tested for COVID - 19 and tested negative. Further review of the facility test results revealed her roommate Resident #14 received positive COVID results on 12/28/20. Observation on 12/30/20 at 8:53AM revealed Resident #6 and Resident #14 were in room [ROOM NUMBER] together with sign on door labeling room hot zone. Record review of Resident #14's nurses notes dated 12/28/20 at 2:23 PM revealed she had tested positive for COVID. Resident #7 and Resident #15 Record review of resident roster dated 12/30/20 revealed Resident #7 and Resident #15 resided in room [ROOM NUMBER]. Record review of facility COVID testing results from 12/15/20 - 12/24/20 revealed Resident #7 was tested for COVID - 19 and tested negative. Further review of the facility test results revealed her roommate Resident #15 received positive COVID results on 12/23/20. Observation on 12/30/20 at 8:54AM revealed Resident #4 and Resident #12 were in room [ROOM NUMBER] together with sign on door labeling room hot zone. Record review of Resident #15's nurses' notes dated 12/23/20 at 10:56 AM revealed she had tested positive for COVID and was being moved to isolation hall for quarantine. Record review of Resident #15's nurses notes dated 12/28/20 at 5:56PM revealed she was being moved back to her room on 200 hall and was going to continue her quarantine there. Resident #8 and Resident #16 Record review of resident roster dated 12/30/20 revealed Resident #8 and Resident #16 resided in room [ROOM NUMBER] together. Record review of facility COVID testing results from 12/15/20 - 12/24/20 revealed Resident #8 was tested for COVID - 19 and tested negative. Further review of the facility test results revealed her roommate Resident #16 received positive COVID results on 12/28/20. Observation on 12/30/20 at 9:36AM revealed Resident #8 and Resident #16 were in Rroom [ROOM NUMBER] together with sign on door labeling room hot zone. Record review of Resident #16's nurses notes dated 12/28/20 at 12:57 PM revealed she had tested positive for COVID. Interview on 12/30/20 at 1:00PM, the IP confirmed Residents #1, #2, #3, #4, #5, #6, #7, and #8 had tested negative for COVID - 19 as of results received on 12/28/20 and their roommates #8, #9, #10, #11, #12, #13, #14, #15, and #16 had tested positive for COVID - 19 between 12/23/20 - 12/28/20. She said the decision was made to keep them in the room together because previously when they had situations where one roommate tested positive and on roommate tested negative, they would separate them, and the negative roommate would end up testing positive the next time they were tested . She said to cut down on the movement of residents around the building which she felt could be furthering the spread of COVID around the facility, they felt it was best to let the negative resident remain in the room with the positive resident. The IP said Resident #1, #2, #3, #4, #5, #6, #7, and #8 (negative residents) were retested for COVID on 12/30/20, results were still pending. Record review of facility COVID - 19 test results collected on 12/30/20 and resulted 12/31/20 revealed Resident #5 and Resident #8 (previously negative) had tested positive. Further review of the results revealed Resident #1, #2, #3, #4, #6, and #7 tested negative. Record review of resident COVID - 19 test results revealed: On testing collected 12/15/20, resulted 12/16/20, there was one positive resident. (start of breakout) On testing collected 12/18/20, resulted 12/21/20, there was 10 additional positive residents. On testing collected 12/20/20, resulted 12/20/20, there was one additional positive resident. On testing collected 12/21/20, resulted 12/21/20, there was one additional positive resident. On testing collected 12/22/20, resulted 12/22/20, there was one additional positive resident. On testing collected 12/22/20, resulted 12/23/20, there was 10 additional positive residents. On testing collected 12/24/20, resulted 12/28/20, there was 16 additional positive residents. Further review of the COVID test results from 12/15/20 - 12/24/20 revealed the facility had 40 residents test positive for COVID - 19. Interview on 12/30/20 at 7:50 AM, the Unit Manager was asked where the COVID - 19 unit was in the facility and she replied it was on the 300 wing but their facility was having an outbreak so there was COVID positive residents on all wings of the facility except for 400 wing which was there warm unit (where residents with unknown COVID status reside). She said the rooms were labeled with signs to identify if it was a hot or cold room. Hot rooms were COVID positive residents and cold rooms were COVID negative residents. Observation on 12/30/20 at 8:00 AM, 100 wing had staff members on the hall picking up breakfast trays out of resident rooms. Resident doors were closed on the wing with paper signs on the door labeling the room hot or cold. Further observation revealed there were hot and cold rooms mixed throughout the wing. Further observation revealed room [ROOM NUMBER], 115, and 116 were cold rooms and rooms 101, 103, 104, 105, 106, 107, 108, 109, 110, 112, and 117 were hot rooms. Observation on 12/30/20 at 8:10AM, LVN A went into room [ROOM NUMBER] which was labeled a hot room. She already had goggles and an N-95 face mask on, she donned a gown before entering. LVN A went into the room and closed the door behind her. At 8:14AM, approximately 4 minutes later LVN A was observed leaving out of room [ROOM NUMBER] with goggles and an N-95 face mask on. Observation on 12/30/20 at 8:19 AM, the call light went on outside of room [ROOM NUMBER] which was labeled a cold room. LVN A was observed to knock on the door and enter room [ROOM NUMBER] with the same goggles and N-95 facemask on, no additional PPE was donned before entering. The LVN went into the room and closed the door behind her. The LVN left out of the room shortly after entering, she was rubbing her hands together with hand sanitizer upon her exit from the room. LVN A proceeded to walk to the nurse's station in the middle of the facility. Interview on 12/30/20 at 8:35 AM, the Administrator said the facility COVID-19 outbreak started a few weeks ago and stated the DON was currently out due to testing positive for COVID-19 on 12/24/20. The Administrator said the facility Infection Preventionist (IP) was assisting with the COVID outbreak in the DON's absence. The Administrator said the back end of the 300 wing (310 -317) was the original COVID unit and they also had to use part of 400 wing as the COVID outbreak continued to spread. The administrator said all residents and staff were being tested twice a week and they received additional positive results on 12/28/20. She said at that time (12/28/20) the 300 hall and 400 hall COVID unit was full. The administrator said the IP called the Health Department and spoke with the epidemiologist regarding what to do because they did not have any more rooms on their COVID unit. The administrator said she would let the IP explain the epidemiologist recommendations. Interview on 12/30/20 at 8:45 AM, the IP said up until 12/28/20 the facility had two COVID units, part of 300 wing (310 - 317) and part of 400 wing. She said both areas were full when they received several more positive results on 12/28/20. She said she spoke with the epidemiologist about the situation and he said they could isolate the residents in their rooms where they resided if their unit was full and have designated staff to work with the positive residents. The IP said she also told the epidemiologist that on their previous testing if one roommate tested negative and one tested positive, the negative roommate was testing positive on their next round of testing. She said the epidemiologist said it was okay for them to leave negative roommates in the room with the positive roommate and treat both residents as if they were positive since the trend was they were both going to eventually test positive per previous testing patterns. In a telephone interview on 12/30/20 at 11:58 AM, the health department epidemiologist said he had been in contact with the facility's DON and IP concerning their COVID breakout. He said he last spoke with the IP on 12/28/20 and said she reported the facility COVID unit was full. He said he told the IP if the facility had no more room on the COVID unit they could isolate the additional COVID positive residents in their rooms and to designate staff to work with those residents. The epidemiologist said he never told the facility it was okay to keep COVID positive and COVID negative residents in the same room. The epidemiologist said that was wrong and the negative roommates should have been immediately separated from positive and put on their warm unit if they had one. The Epidemiologist said the staff could have used their nursing judgement to know that keeping negative and positive residents in a room together was inappropriate. Observation on 12/30/20 at 8:50 AM, the rooms on 200 wing had either hot or cold signs on the door throughout the hall. All the doors were closed on the hallway. There were 6 rooms with hot signs on the doors which were Room's 202, 203, 205, 208, 211, and 217. There were 8 rooms with cold signs on the doors which were Rooms 204, 207, 209, 210, 212, 213, 214, and 215. Interview on 12/30/20 at 8:55 AM, MA A said there were COVID - 19 positive and negative residents in rooms together on the 200 hall. She said all the residents were tested in the facility and there were situations where one roommate tested negative and the other roommate tested positive. She said in that case the negative roommate was not moved out of the room or separated from the positive resident and the two residents remained in the room with each other. MA A said both residents are to be treated as if they were positive. MA A said she knew there was some roommates like that on the 200 hall but was not sure who they were. Observation on 12/30/20 at 9:15 AM, MA A entered room [ROOM NUMBER] (hot room) and closed door behind her. MA A was observed placing a gown and gloves on before entering room [ROOM NUMBER] with a medication cup. MA A had a N-95 face mask on and a face shield on as well. Observation on 12/30/20 at 9:20AM, MA A was observed leaving out of room [ROOM NUMBER] (hot room) closing the door behind her and rubbing hands together with hand sanitizer. Her gown and gloves were already doffed, and her face shield and N-95 mask remained on. MA A then went directly across the hall to room [ROOM NUMBER] (cold room) where CNA A was still inside and closed the door behind her. MA A did not don PPE before entering room [ROOM NUMBER]. Observation on 12/30/20 at 9:28 AM, 400 wing was labeled with a sign at the start of the wing that noted warm zone. There was a plastic barrier up attached to ceiling and walls. There was a zipper in the middle of the plastic that was zipped open and each side was pulled to the side exposing the hallway. Further observation revealed there were three rooms in use on the hallway. There was a total of 14 rooms available on the 400 wing (warm unit) with only 3 rooms occupied. Interview on 12/30/20 at 9:29 AM, the IP said the 400 wing was their warm zone. She said the only residents on the unit were new admit or readmit residents from the hospital. She said the back area of the 400 wing, was briefly used as a COVID unit but when they got more positive results on 12/28/20 they transitioned the residents on the 400 wing COVID unit, back to their original rooms and isolated them there per the recommendation from the epidemiologist. Observation on 12/30/20 at 9:36 AM, the 300 wing had rooms labeled hot and cold throughout the hallway. There were 5 rooms labeled as hot or isolation rooms, Room's 302, 303, 310, 312, and 315 and 12 rooms labeled as cold, Room's 301, 304, 305, 306, 307, 308, 309, 311, 313, 314, 316 and 317. Further observation of the hallway revealed Rooms 310 - 317 (mentioned above by IP as their COVID unit) consisted of a mixuture of hot and cold rooms. rooms [ROOM NUMBER] did not have a sign on door labeling whether the room was hot or cold. There was a sign on the door that said to knock before entering and there were isolation carts outside of their doorway. On top of the isolation carts were two cards sitting on top of the cart, one noted droplet precautions and the other noted contact isolation. Interview on 12/30/20 at 11:00 AM, the IP said rooms [ROOM NUMBER] were hot rooms and the residents in the rooms were COVID-19 positive. Interview on 12/30/20 at 9:34 AM, the Corporate Nurse said the facility was having a large active COVID outbreak. She said the facility had exhausted their COVID units and had to isolate residents in their rooms which was on all wings of the facility. She said the facility was in communication with an epidemiologist who said what they were doing was okay. She said the facility did have designated staff to work with only COVID positive residents. She said she would provide surveyor with schedule for the day that identified what staff should be working with hot rooms and what staff should be working with cold rooms. She said staff were only supposed to work with their designated zone rooms. Record review of the facility Daily Assignment Sheet (provided by the Corporate Nurse) was dated 12/30/20 for the 6am - 2pm shift revealed LVN A was assigned to hot rooms on 100 hall (who was previously observed going into hot and cold room on 100 wing). Further review of the assignment sheet revealed MA A was assigned to work only cold rooms on 200 wing (who was previously observed going into hot and cold room on 200 wing). CNA A was assigned to only work cold rooms on 200 wing (who was observed standing in the doorway of a hot room requesting help from MA #1). Further review of the assignment sheet indicated there were 6 staff members designated to work in hot rooms, the 6 staff included 2 nurses, 1 MA, and 3 CNA's: One nurse was assigned to the hot 100 wing, COVID-19 positive residents. One nurse was assigned to the hot 300 wing, COVID-19 positive residents. There was no nurse assignment for the 200 wing COVID-19 positive residents. One CMA was assigned hot 100 hall COVID-19 positive residents. There was no MA assignment for the 200 and 300 wing COVID-19 positive residents. One CNA was assigned to the left side of 100 hall, COVID-19 positive residents. (left side) One CNA was assigned to the right side of 100 hall, COVID-19 positive residents. (right side) One CNA was assigned to the 300 hall (hot) COVID-19 positive residents There was no CNA assignment for 200 hall COVID-19 positive residents. Interview on 12/30/20 at 12:30 PM, the IP said staff are supposed to be designated to hot or cold rooms but sometimes they get confused. She said the facility had some staff members not show up for work so there was some confusion with the schedule but there were assignments for all staff to work certain zones that covered the whole building. She said some staff may want to help out because the designated staff for that room/zone may be busy or not around, so they would go into a hot or cold room to help out when it was not their assigned zone. She said she noticed staff were going into the wrong rooms earlier and had already addressed it and clarified everyone's room/zone assignments. Interview on 12/30/20 at 1:43 PM, MA A said it was her first day back to work and she had not observed the facility in its current setup with hot and cold rooms throughout the building before, so she was unaware she had an assigned zone (hot or cold rooms). The CMA said she was just told maybe an hour ago she was only supposed to be passing medications to cold rooms and not going into hot rooms. MA A said when she came into work at 6 a.m. she was just told to work on 200 hall and was not told to only work with cold residents. She said she had passed medications to hot and cold rooms all morning and afternoon before she was notified of changes an hour ago. Interview on 12/30/20 at 1:49 PM, CNA A said she was assigned to work cold rooms today and said she had only gone into one hot room this morning because the resident needed assistance with eating and the assigned staff for that room was not available. The CNA further said she was informed yesterday (12/29/20) of the staff only working certain rooms (hot or cold). She said she was not told at the start of her shift yesterday to work certain designated rooms, so she was working both hot and cold rooms for a few hours before she was informed she should only be working cold rooms. Interview on 12/30/20 at 5:00 PM, the Administrator said the most positive residents the facility had at one time since the start of the breakout was 41. She said there was one resident who was transferred to the hospital and tested positive and returned to the facility on [DATE] which made the total 41. She said the current number of positive residents in the facility was 31 as some of the residents who tested positive when the outbreak started had recovered. The Administrator said there was no longer a COVID unit on the 400 wing and they had moved the COVID positive residents from that unit back to their original rooms on 12/28/2020 and it was decided to isolate any further positive residents in their current rooms after 12/28/20. The Administrator was told about the conversation the surveyor had with epidemiologist and how he stated, I did not tell them it was okay to keep COVID positive and negative residents in the same room and said what they were doing was incorrect. The Administrator said she would notify the IP, so they could clarify what should be done. Record review of the facility undated Coronavirus - (COVID - 19) - Interim Policy for Suspected or Confirmed Coronavirus (COVID - 19) policy revealed in part, . The facility will design a plan related to physical plant and resident placement to residents who have confirmed COVID - 29, residents quarantined and for residents who are COVID - 19 negative . If the resident is known to have COVID move resident to the COVID + unit (hot zone) . place on both contact and droplet precautions . Further review of the policy revealed in part, . in the event of a facility outbreak, institute outbreak management protocols: Define authority (IP, DON, Administrator, Medical Director, etc.) . place residents in private rooms with its own bathroom when possible, on standard, contact, droplet (airborne if available) precautions, Cohort resident identified with same symptoms/COVID - 19 confirmation if necessary, implement consistent assignment of employees . If non - isolation unit personnel are required to enter isolation unit, they must leave facility, shower, don clean clothing and clean/disinfected shoes prior to returning to the facility. Further review of the policy revealed staffing protocol, the facility will cohort residents based on their COVID - 19 status (positive, negative, or unknown) and will designate staff for each cohort. Sharing staff between cohorts is not recommended and should be avoided it at all possible. If the facility must share staff in order to maintain adequate staffing it should consider the following guidance: When necessary, share staff between unknown COVID - 19 (warm zone) and COVID - 19 positive (hot zone) areas. The administrator and IP was notified on 12/31/20 at 1:00 PM that an Immediate Jeopardy situation was identified due to the above failures. The administrator was provided the Immediate Jeopardy template on 12/31/20 at 1:00 PM. The facility's Plan of Removal was accepted on 1/1/21 at 1:42 PM and included: PLAN OF REMOVAL Date: 12/31/2020 Immediate action: 1. Facility immediately relocated all residents identified as PUIs having positive roommates on 12/30/2020 as following: PUI Resident from room [ROOM NUMBER] was relocated to room [ROOM NUMBER]A. PUI Resident in room [ROOM NUMBER] was relocated to room to 314A. PUI Resident 202 was relocated to room [ROOM NUMBER] B. PUI Resident room [ROOM NUMBER] to room [ROOM NUMBER]A. PUI Resident 208 relocated to room to 212A. PUI Resident 211 to room [ROOM NUMBER]A. PUI Resident 217 to room [ROOM NUMBER]B. PUI Resident 303 to room [ROOM NUMBER]B. There are no COVID-19 residents cohorted with PUI's or negative residents. 2. The COVID + units are 100 hall and 400 hall, and both have designated staff assigned to provide care to the COVID19 positive residents. All residents on these halls are currently COVID-19 positive. Residents who are COVID positive will be monitored and will follow CDC guidelines for the discontinuation of Transmission Based Precautions. o Patients with mild to moderate illness who are not severely immunocompromised: o At least 10 days have passed since symptoms first appeared and o At least 24 hours have passed since last fever without the use of fever-reducing medications and o Symptoms (e.g., cough, shortness of breath) have improved Note: For patients who are not severely immunocompromised and who were asymptomatic throughout their infection, Transmission-Based Precautions may be discontinued when at least 10 days have passed since the date of their first positive [MEDICAL CONDITION] diagnostic test. o Patients with severe to critical illness or who are severely immunocompromised: o At least 20 days have passed since symptoms first appeared and o At least 24 hours have passed since last fever without the use of fever-reducing medications and o Symptoms (e.g., cough, shortness of breath) have improved Note: For severely immunocompromised patients who were asymptomatic throughout their infection, Transmission-Based Precautions may be discontinued when at least 20 days have passed since the date of their first positive [MEDICAL CONDITION] diagnostic test. Once the resident meets the criteria for the discontinuation of Transmission-Based Precautions they will be moved off the COVID + unit. 3. Facility will continue to complete outbreak testing per County Positivity requirements until the facility goes 14 days without any new resident or employee testing positive. The facility will isolate residents based on the COVID test results received through required testing. Resident cohorting will be as follows: COVID-19 positive residents with COVID-19 positive residents, unless the resident requires a private room due to infection with another infectious agent, such as [MEDICAL CONDITION]; PUI's will be cohorted with PUI's and negative residents with other negative residents. 4. In-services were initiated on 12/29/2020 by IP with staff on Hot Zone, Warm Zone, and Cold Zones, PPE Doffing/Donning, Transmission Based Precautions for Covid-19 positive cases, Signs/Symptoms of Covid-19, Sanitation of Equipment, Handwashing, and Designated Staff. Facility assigned specific staff to work with only Covid-19 positive residents. All residents who are COVID-19 positive are only housed on 100 hall or 400 hall. Designated Covid positive staff on halls 100 and 400 have a separate entrance to each of the designated COVID-19 positive units (100 and 400 halls) so they do not enter the general area of the facility and they only work with the COVID-19 positive residents. There is designated staff on each hallway to care for the COVID-19 positive residents. 5. Facility has a census of 75 residents as of 12/31/2020 and all residents are separated based on their current covid-19 test results received as of 12/30/2020. Positive residents are housed on separate hallways away from other residents who are under investigation or who are negative. Residents have been moved and are housed as follows: 100 hall and 400 hall only has COVID-19 positive residents. 200 hall houses negative and/or recovered residents. 300 halls houses residents who are under investigation for COVID-19 and recovered residents. There is a barrier between the residents on 300 hall that are under investigation and those that are recovered. 6. All residents are monitored three times daily for signs and symptoms for Covid-19. 7. On 12/31/2020 1:1 in-services initiated with facility staff on Infection Control Practices, Handwashing, PPE Donning/Doffing, Cold, Warm, Hot Zones, Sanitation of equipment, staff assignment based on Covid-19 status. Staff will not be allowed to work until in-servicing is completed. 8. On 12/31/20, the Administrator, DON and facility Infection Preventionist were in-serviced on how to cohort residents with COVID-19, residents who are under investigation, and residents who are negative. The in-service was completed by the Regional Infection Preventionist. 9. Newly hired staff will be in-serviced on Infection Control Practices, Handwashing, PPE Donning/Doffing, Cold, Warm, Hot Zones, sanitation of equipment and staff assignment based on Covid-19 status. Newly hired staff will not be allowed to work until this in-servicing is completed Quality Assurance A Quality Assurance and Performance Improvement review of the plan of removal was completed on 12/31/2020 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring of Plan of Removal Monitoring of the facility plan began on 1/1/2021 by reviewing completed in - services, documentation of room changes, the staffing plan for the next month to have designated staff for each zone and development of warm, cold, and hot zones in the facility. Record review of in-services completed on 12/31/20 revealed topics of infection control to include discussion over handwashing, donning and doffing PPE, cold vs. warm vs. hot zones, staff zone assignments, mask wearing, face shield vs. goggles that was completed with nursing staff. Record review of one on one in-service records dated 12/31/20 revealed the DON, IP, and Administrator were in-serviced over cohorting residents/patients in the facility based on their COVID - 19 status that indicated they voiced understanding after 1 on 1 in-service. <b (TRUNCATED)

Based on observation, interview and record review, the facility failed to review and revise the comprehensive person-centered care plan for 1 of 8 residents (Resident #1) reviewed for care plan timing and revision in that: Resident #1's care plan was not updated and revised to reflect her current eating. This failure affected 1 resident and placed her at risk of inappropriate care and decline in health. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE]. She had [DIAGNOSES REDACTED]. lacrimal gland; constipation, unspecified; [MEDICAL CONDITION], unspecified; unspecified [MEDICAL CONDITION] not due to substance or known physiological condition; major [MEDICAL CONDITION], recurrent, unspecified; anxiety disorder, unspecified; [MEDICAL CONDITION], and [MEDICAL CONDITION]. Record review of Resident #1's annual MDS (Minimum Data Set) dated 8/5/19 revealed a BIMS (Brief Interview Mental Status) score of 9 out of 15 which indicated her cognition was moderately impaired. Resident #1 utilized a wheel chair. Her functional status revealed she required extensive assistance with two-person physical assist in bed mobility and transfer. She required extensive assistance with one-person physical assist in dressing, eating, toileting, and personal hygiene. She required total dependence in bathing. Record review of Resident #1's comprehensive care plan dated 8/29/17 and last revised on 9/20/17 revealed her activities of daily living related to eating read, The resident requires tray set up and supervision assistance to eat. Interview with CNA A on 8/30/19 at 1:50pm revealed Resident #1 was blind and hard of hearing. She said that Resident #1 required two-person assist when transferring to the bed and to the wheel chair. She said resident also needs physical assistance eating during meals. She said she had noticed a decline in Resident #1 since her last fall. Interview with MDS Nurse on 8/30/19 at 2:15pm revealed care plans with supervision assistance can mean staff was helping resident eat, is close by, or watching the resident close by. When MDS reads extensive assistance and one-person physical assist it meant the resident required one staff member with physically assisting the resident eat. Interview with LVN A on 8/30/19 at 4:22pm revealed Resident #1 was mobile, walked around the facility, and ate by herself with no assistance prior to her fall on 7/24/19. Since resident's most recent return from the hospital, she needs more assistance. Staff take the resident to the dining room and assist in feeding her. Interview with DON on 8/30/19 at 4:44pm revealed extensive assistance with one-person assist under eating on the MDS means resident requires someone to physically assist in feeding them. Observation of Resident #1 on 8/30/19 at 5:30pm revealed Resident eating in dining room with one staff assisting in feeding her. She had her eyes closed and had minimal interaction with staff or other residents. Record review of the facility's Care Plans, Comprehensive Person-Centered policy, revised (MONTH) (YEAR), revealed: 13. Assessments of residents are ongoing and care plans are revised as information about the residents and residents' condition change.

Based on observation, interview and record review, the facility failed to store drugs and biologicals used in the facility were secured and stored properly for one of eight medication carts (400 Hall Medication Aide Cart) reviewed for drug storage. -The facility failed to ensure 400 Hall Medication Aide Cart was secured when left unattended on 01/03/19. This failure could place 24 residents who resided on the 400 hall and received medications from the 400-hall medication aide cart at risk for harm and placed the facility at risk for possible drug diversion. The findings include: Intake # 7, 5, 1 Observation on 1/3/19 at 8:20AM revealed, MA (Medication Aide) A was standing at the 400 hall MA medication cart in front of room [ROOM NUMBER]. MA A gathered the medications and walked into room [ROOM NUMBER]. The medication cart was left unlocked. During this observation one room down the hall on the opposite side in front of room [ROOM NUMBER] was RN A looking in her computer with her back to the MA medication cart. RN A did not turn and look toward the MA cart during this observation. No residents were in the immediate area of the medication cart, one resident was at the end of the hall self propelling in a wheelchair. At 8:22AM MA A returned to the medication cart. In an interview on 1/3/19 at 8:22AM with MA A, she stated the medication carts were to be locked when left unattended and she realized she did not lock it the minute she got in the room. During this interview she was asked why she did not return to the cart when she realized she left it unlocked she stated she did not know all she knew was she messed up. Observation on 1/3/19 at 9:00AM during an inventory of the 400 Hall MA medication cart with MA B revealed: -Drawer #1: - Over the counter medications; Multivitamins, Fish oil, Folic acid, Vitamin C, Tylenol ASA Stool Softener Calcium Vitamin D Vitamin B Cranberry Supplement TUMS Iron -Drawer #2: -Resident individual bubble pack medications; Locked narcotic box with medications for 13 residents -Drawer #3 -Resident individual bubble packs; -Drawer #4 - Resident individual bubble packs; -Right side - Drawer #1- eye drops; Drawer #2 -[MEDICATION NAME] [MEDICATION NAME] and Liquids Nasal Sprays; Drawer #3- [MEDICATION NAME] [MEDICATION NAME] and Liquids Drawer #4- supplies In an interview on 1/3/19 at 10:50AM with the DON, she stated all medications carts were to be locked when they were left unattended because anyone can walk up and take something. Record review of the facility policy titled Security of Medication Cart 2001 MED-PASS, Inc. (Revision dated (MONTH) 2007) The medication cart shall be secured during medication passes .1. The nurse must secure the medication cart during medication pass to prevent unauthorized entry . 4. Medication carts must be securely locked at all times when out of the nurse's view .

Based on interview and record review, the facility failed to consult with the physician regarding a change in condition for 1 of 5 residents (CR#1) reviewed for change of condition. The facility failed to immediately notify CR#1's physician when eye drops were needed for the resident's red and swollen dry eyes This failure affected one former resident by placing him at risk for not receiving appropriate care and interventions. Intake # 7 Findings included: Record review of the clinical record for CR#1 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. CR#1 was discharged home with home health on 12/4/18. Record review of CR#1's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed in part: -Hearing and vision are adequate and uses corrective lenses; -Speech clarity was clear; -Makes self understood and understand others; -The resident's Brief Interview for Mental Status (BIMS) was scored 15 out of 15 to indicate cognition was intact; -Resident required extensive assistance of two staff members with bed mobility, transfers, locomotion on and off unit, dressing, toilet use and personal hygiene; -Resident had functional limitation in range of motion to his bilateral lower extremities; -Resident was occasionally incontinent of urine and frequently incontinent of bowel; Record review of CR#1's telephone orders dated 11/14/2018 revealed Natural tears 2 drops in each eye twice a day x 7 days; indications dry eyes; Record review of CR#1's telephone orders dated 11/15/18 revealed DC Natural Tears start artificial tears ii gtts to both eyes through 11/22/18. Record review of CR#1's care plan date initiated on 11/16/18 revealed in part; -Focus: CR#1 has an ADL self care performance deficit related to limited mobility; -Goal: Will maintain current level of function in bed mobility, transfer, eating, dressing, toilet use and personal hygiene; -Interventions: Observe/report to physician PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Record review of CR#1's progress notes dated 12/3/18 did not reveal documentation regarding asssessment of CR #1's swollen eyes or notification to the physician. Record review of CR#1's Nurses Progress Notes documented by LVN A dated 12/04/18 at 0055 (12:55am) revealed Health Status Note Text: Upon obtaining report pm nurse advised me that the patient's eyes are swollen, and he is requesting eye drops. Pt was assessed, and left eye is noted to be swollen shut. Texted the Dr. awaiting a call back. Record review of Progress Notes for CR#1 dated 12/4/18 at 10:00AM revealed lubricating eye drops use 1-2 drops to each eye up to 4 times a day for dry eyes. Bottle of eye drops sent with the resident to discharge home with family member. Record review of CR#1's Nurse's Progress Notes documented by RN B dated 12/4/2018 at 11:07 AM revealed Discharge Summary Note Text: The resident has been discharged from the facility with his son. Record review of the Complainant's letter with the intake revealed in part .Well sir both my eyes are starting to swell shut and hurt badly. Well sir my left eye was starting to swell shut. Interviews with CR#1 were attempted but unable to make contact. In an interview on 1/4/19 at 9:21AM with LVN B and Unit Manager, they stated the resident's symptoms started around midnight the day of discharge. She stated she saw him the morning of his discharge and he did not have any swelling or drainage, but he did have slight redness. LVN B stated she followed up with the doctor who told her to give CR#1 a bottle of lubricating eye drops and send them home with the resident. Which she stated she did. LVN B stated she did not write the order for the lubricating eye drops on an order for [REDACTED]. In a telephone interview on 1/4/19 at 9:50AM with LVN C, she stated she worked a double shift on 12/3/18, the 6am-2pm and 2pm to 10pm shifts. LVN C stated she discovered his swollen red eyes while making rounds at the end of her shift with the oncoming night shift nurse. She stated, she did not call the physician or document it because she asked the night shift nurse to take care of it. In a telephone interview on 1/4/19 at 10:20 AM with RN B, she stated she was the nurse who discharged the resident and when she was getting him ready for discharge he asked her what we were going to do about his red, swollen, dry eyes and eye drops he was supposed to start last night. RN B stated we got him drops and sent them home with him. RN B Stated she did not not see swollen eyes but they were slightly red. In a telephone interview on 1/4/19 at 10:55AM with LVN A, she stated she saw CR#1's eyes and they were red and his left eye was swollen shut. The right eye was not. She stated she told the resident she would contact his doctor. LVN A stated she called the call center first and there was no answer, so she sent a text to the doctor. She stated this was standard practice for this doctor. When asked if she made any other attempts to contact the physician before the end of her shift she stated no. She stated she did notify the oncoming day shift. When asked if she and LVN C discovered the resident's red and swollen eyes at the same time during the walking rounds at shift change she stated no they did do walking rounds but were unable to view the resident's eyes from the door where they were. She was notified in report and observed his eye while rounding on the resident after midnight during her resident rounds. In an interview on 1/4/19 at 11:50AM the DON stated when there is a change of condition in a resident of course if it is life threatening don't wait call 911 first. Other less life-threatening changes call the physician if you do not hear back place another call, notify me so I can attempt to reach them. If you still do not hear we call the medical director. Should keep trying every hour until you get some response. You should document each time you call. This process also applies to texting and even in the middle of the night. Some doctors prefer we contact them by text. When the next shift comes on you give the information in report and they are expected to follow up. I should be made aware of any issues.A resident's eye being swollen shut requires physicians immediate attention, so the drops would have been started. There should have been more than one attempt made and the oncoming shift should have been trying to reach the physician prior to the resident asking at the time of discharge . On the day of discharge, we did start his drops and sent them home with him. I believe the time frame was a corporate thing for some medications since the resident did not come in on the medication from the hospital and he did not have a [DIAGNOSES REDACTED]. Record review of the facility's policy and procedure dated 2001 MED-PASS, Inc. Revision dated (MONTH) 2007 titled Change in a Resident's Condition read in part; Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition. Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse will notify the resident's attending physician or on call physician when there has been: e. A need to alter the resident's medical treatment significantly .

Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medications errors for one of eight residents (Resident #360) reviewed for medications, in that; MA-G failed to verify Resident #360's medications prior to entering the Resident's room. [MEDICATION NAME] 500 mg would not have been administered had the Surveyor not stopped and had her recheck the order This failure could have affected one resident and could place the other eleven residents who receive [MEDICATION NAME] at risk for adverse consequences. Findings included: Record review of the facility face sheet revealed Resident #360 was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident #360's Order Summary Report (Physician Orders) revealed the resident was to receive the following medication at 9:00 am on 7/26/18: 1. [MEDICATION NAME] 40 mg - 1 tablet once daily for hypertension 2. Pantoprazole 40 mg - 1 tablet once daily for GERD 3. Potassium Chloride ER 20MeQ - 1 tablet once daily for [DIAGNOSES REDACTED] 4. [MEDICATION NAME] 500 mg - 1 tablet two times daily for Type 2 Diabetes Mellitus 5. Carvediol 25 mg - 1 tablet two times daily for hypertension 6. [MEDICATION NAME] 4 mg - 1 tablet two times daily for [MEDICAL CONDITION] 7. [MEDICATION NAME] 80 mg - 1 tablet once daily for heart failure 8. [MEDICATION NAME] Patch 0.2 mg/24 hr - Apply 1 patch one time daily every 7 days for hypertension Observation on 7/26/18 at 9:15 am, revealed MA-G administering medication for Resident # 360; MA-G removed all blister packs required from the Medication Cart. The Surveyor instructed MA-G to hand the surveyor the blister pack of medication AFTER the tablet or capsule was placed in the dispensing cup. As she placed a tablet in the dispensing cup she then handed the card to the Surveyor for recording. Once she completed placing the medication in the dispensing cup she began to enter the residents room. She was stopped by the Surveyor and was asked for a count of tablets in the dispensing cup. She stated there were six tablets in the cup and with the patch the total count was seven. The surveyor then informed MA-G that the Surveyor count was seven tablets and one patch totaling eight, and instructed MA-G to determine which medication was missing. After going over each blister pack MA-G determined the missing tablet was [MEDICATION NAME] 500 mg. At that time MA-G then administered the required medication for Resident # 360. According to Drugs.com, [MEDICATION NAME] is an oral diabetes medicine that helps control blood sugar levels. [MEDICATION NAME] is used together with diet and exercise to improve blood sugar control in adults with Type II Diabetes Mellitus. [MEDICATION NAME] is sometimes used together with insulin and other medications. Record Review of Resident # 360's Blood Sugar level the morning of 7/27/18 revealed Blood Sugar level of 255 resulting in 6 units of Humalog Insulin 100 units/ml. In an Interview with MA-G at 9:30 am on 7/26/18, she said she thought she had included the [MEDICATION NAME] and was confused when the surveyor asked for the blister pack for recording. She said she was going too fast and thought she had placed the right number of medication in the cup. In an Interview with the DON on 7/27/18 at 8:00 am she said that MA-G did inform her of the error and told the DON she was nervous with two surveyors watching her. A copy of the facility Policy and Procedures on Medication Administration was requested and not received by exit According to the facility provided form 672 census is 102

Based on observation, interview and record review, the facility failed to ensure that drugs and biological's used in the facility were stored in locked compartments for 1 of 4 medication carts reviewed for drug storage. RN B failed to ensure Resident #58's medications were secured in the locked medication cart and that the cart was within sight when she entered the resident's room to administer medication. This deficient practice affected 1 resident and placed an additional 25 residents on Hall 200 at risk for drug diversion, misuse of medication, accidental ingestion. Findings include: Record Review of Resident # 58's Face Sheet dated 07/27/18 revealed Resident #58 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record Review of the Admission MDS assessment dated [DATE] revealed Resident #58's cognition was severely impaired, with a BIMS score of 0. Record Review of Resident # 58's physician orders and MAR indicated [REDACTED]. During an observation on 07/26/18 at 11:15 am, by two Surveyors, RN B, removed Resident #58's [MEDICATION NAME] Acid Solution from the Hall 200 nurse medication cart. RN-B then poured 15 ml of [MEDICATION NAME] Acid Solution and placed the medications on top of the cart. RN-B then went into Resident #58's room allowing the medication cart to remain in the hallway, outside of the nurse's line of sight. There was a resident sitting in a wheelchair watching. RN-B then proceeded to administer Resident #58's physician ordered [MEDICATION NAME] Acid Solution via [DEVICE]. After she was finished administering the medications, she asked surveyor how she did. Surveyor told her to look at her cart. She looked at the cart and said oh no, I left the [MEDICATION NAME] Acid out. In an interview with RN-B at 11:45 am on 7/26/18, she stated she knew policy required her to make sure there were nothing left on top of the medication cart and the cart was to be locked whenever the cart was to be left attended. She stated she was nervous since this was the first time she was observed by the State. In an interview with the DON at 8:15 am on 7/27/18. She stated she has already worked one on one with RN-B and went over all proper procedures with medication storage. She state RN-B told her she was nervous and forgot all about the medication bottle she left out. She stated she knew better but was nervous. Record Review of the facility policy and procedure for Storage of Medication (Revised (MONTH) 2007) revealed the following under Policy Interpretation and Implementation reads as follows: 7. Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biological's shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. According to the facility provided Form 672, census was 102

Based on observation, interview and record review the facility failed to ensure personal privacy during personal care for 1 of 1 residents (#28) observed for [MEDICAL CONDITION] care in that: -The RT failed to provide privacy for Resident #28 during [MEDICAL CONDITION] care. This deficient practice affected 1 (Resident #28) who received [MEDICAL CONDITION] care in the facility and could result in loss of dignity and low self esteem. The findings were: Record review of Resident #28 face sheet revealed that she was a [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #28's Quarterly MDS assessment dated [DATE] revealed that she had severely impaired decision making. She was non-verbal. Resident #28 required extensive assistance of one to two person support for activities of daily living. She required [MEDICAL CONDITION] care. Record review of Resident #28's care plan last revised 6/23/2018 revealed in part; Focus: Resident #28 had communication problem related to [MEDICAL CONDITION], receptive [MEDICAL CONDITION]. She has a [MEDICAL CONDITION]. -Interventions: [MEDICAL CONDITION] care as ordered. Record review of Resident #28's consolidated MD orders dated (MONTH) (YEAR) revealed orders in part; -[MEDICAL CONDITION] care every day. Observation on 07/25/18 at 09:59 AM the RT washed his hand and done gloves. He explained to Resident #28 that he was going to do [MEDICAL CONDITION] care and proceeded with the procedure. Resident #28's curtains were wide open. Roommate (Resident #20) was present. In an interview on 07/25/18 at 10:19 AM with the RT, he stated that he did not close the curtains because he was trying to keep an eye on Resident #20 while doing the [MEDICAL CONDITION] care. He then said that Resident #20 was coughing and scratching (No coughing heard from the Resident#20 noted during the procedure) and that he needed to be observing her during the procedure. The RT then said I usually do it that way. Should I had pulled the curtain? Yes, but I was keeping an eye on Resident #20. They are my babies. In an interview on 7/27/2018 at 2:25 PM with the DON, she stated that staff was supposed to provide privacy to the residents during care including [MEDICAL CONDITION] care. DON further said that the RT had been trained on protecting the residents' privacy during care. 1. Record review of https://www.medicinenet.com/[MEDICAL CONDITION]/article.htm revealed in part; A [MEDICAL CONDITION] is a procedure used to create an opening in the neck to bypass an obstructed airway to more easily deliver oxygen to the lungs. [MEDICAL CONDITION] (trach) care is done to keep [MEDICAL CONDITION] clean. This helps prevent a clogged tube and decreases your risk for infection.[MEDICAL CONDITION] includes suctioning and cleaning parts of the tube and your skin. Record review of the facility's policy and procedure revised (MONTH) (YEAR) with title Confidentiality of Information and Personal Privacy revealed in part; Policy Statement: Our facility will protect and safeguard resident confidentiality and personal privacy . CMS 672 revealed one resident receiving [MEDICAL CONDITION] care.

Based on observation, interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported to the State Survey Agency, for one Resident (Resident #90) of 30 residents reviewed for abuse/neglect. -The facility did not report an incident of possible neglect to the state agency within 24 hours for Resident #90 This failure affected one resident (Resident #90) and could place the other 101 residents at risk of abuse/neglect. The findings were: Record review of the facility policy and procedure revised (MONTH) 2010 titled, Abuse investigations revealed in part; .All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 6.- The individual in charge of the abuse investigation will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the review process . Record review of the facility policy and procedure revised (MONTH) 2007 titled, Abuse and Neglect - Clinical protocol revealed in part; Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness Further record review of the policies revealed no information regarding notification of allegations of abuse or neglect to State Office. Record review of Resident #90 face sheet revealed a [AGE] years old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #90's Admission Minimum Data Set (MDS) assessment, dated 07/02/18, revealed that Resident #90 had a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible of 15 indicating was cognitively intact. She required extensive assistance by two staff for bed mobility, transfers, locomotion on unit, dressing, toilet use, and personal hygiene. She was frequently incontinent of bowel and bladder. Record review of Resident #90's care plan initiated 7/3/2018 revealed in part; -Focus: Resident #90 has risk for bladder incontinence related to impaired mobility. -Interventions: Incontinent: Check the resident during rounds and as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. In an interview on 07/24/18 at 01:46 PM with Resident #90, she stated that there was a night shift Nurse Aide that would tell her that she had to hold her urine for longer period of time so the Nurse Aide would not have to run the halls back and forth too often. Resident #90 then said I am unsure of her name. She is an African American Nurse Aide with short hair and has happened several times during the night time. The most recent was last night. It was bad enough getting used to the briefs but for the Nurse Aide to tell me that, it made me feel worse. Sometimes it would take 2 to 3 hours for her to come back and do incontinent care on me. The urine would burn my skin and I had history of urinary tract infections. Further interview at that time, Resident #90 stated that she had not reported the incident to anyone because she was trying to fix the problem herself and that she had told the Nurse Aide that it was her job to help her with incontinent care. Surveyor reported all above information to Administrator and Corporate Nurse on 07/24/18 at 02:45 PM. Record review of Resident #90's nurses note dated 7/24/2018 18:54 and signed by LVN A revealed in part Health Status Note Text: Resident stated that a staff member on night shift made her hold her urine. Resident stated she had not said anything prior to today. Resident described the staff member, and the DON began an investigation. Staff member was identified and removed from the schedule. This information was relayed to the resident and she was content with this information . In an interview on 07/26/18 at 09:00 AM with the Administrator and the DON, the Administrator said that the CNA involved in the allegation (CNA A) was suspended. The Administrator further said that Resident #90 did not tell him the facts as surveyor reported to him on 7/24/2018. He then said that when CNA A was interviewed, CNA A denied having any problems with Resident #90. Administrator then said that Resident #90 told him that the CNA was trying to get her up for the bathroom every 2 hours at night and that Resident #90 did not want to be checked every 2 hours. Administrator continued saying that the issue was that CNA A was trying to get Resident #90 up at night and that Resident #90 did not want to get up at night and then said It was most like a Customer Service issue. Administrator further said that the facility did not report the incident to the State Office because it was more of a Customer Service issue. DON then said at that time that the facility had already changed the care plan of Resident #90 saying that Resident #90 did not want to get up at night. DON further said that CNA A told her that Resident #90 would fuss anytime that CNA A would come and checked on her during the night time to make sure she wasn't wet and that CNA A had reported the issue to a Nurse but DON did not remember who was the nurse or when was reported. In an interview on 07/26/18 at 09:50 AM with the Administrator, he said that CNA A was suspended due to the investigation. In an interview on 7/26/18 at 02:38 PM with LVN A, she stated that she was told to go talk to Resident #90, so she did. LVN A stated Resident # 90 told her that an aide on the night shift told her she couldn't change her brief or help her. She further said that she told Resident #90 that the issue would be addressed and that she took it straight to the DON. In an interview on 7/27/2018 at 12:40 PM with Resident #90, she stated that on the day she spoke with surveyors regarding the problem with the night shift Aide (7/24/2018) the Administrator went to see her in the Therapy room and told her that he was sorry that something like that had to happened to her. That he was going to take care of the problem. Resident #90 then said He came back to my room yesterday morning and told me that he had already taken care of the problem but did not say how. When asked if the Administrator or the DON had asked her details of what had happened, Resident #90 said No, the Administrator did not ask me anything. The DON hasn't come to talk to me yet. The night shift Aide shouldn't treat residents that way. Residents shouldn't been told to wait that long for incontinent care or to hold their urine that long. In an interview with the Administrator on 7/27/2018 at 2:50 PM, he stated that the facility did not report the incident to the State Office based on the information that Resident #90 gave him and CNA A. Administrator then said Resident #90 said that the Aide was rude and that Resident #90 did not want to be checked when she was sleeping, so I told her that we were going to change her care plan. I talked to Resident #90 in her room and in the Therapy room. I asked her details of what had happened. The information that Resident #90 gave me did not indicate any abuse or neglect. In a phone interview on 7/27/2018 at 3:16 p.m. with CNA A, she stated that she was called and told that she did not change a brief on time and that the facility had to put her off the schedule. CNA A then said that she remembered one incident involving Resident #90, did not remember when and then said I was in a room with a resident, then Resident #90 put her call light and said that she needed incontinent care, but I had been in her room [ROOM NUMBER] minutes ago, so I went back and finished the resident that I was working with, but I had other 4 residents to finish my round, so I went and finished my round before I went back to Resident #90. I went back with her until I was done because I had just been in her room. CNA A did not remember how long it took for her to go back and assist Resident #90 with incontinent care. Record review of DADS Provider Letter 14-13 dated 8/19/17 states in part: Facilities are required to ensure that all alleged violations involving mistreatment, neglect or abuse, including suspicious injuries of unknown source and misappropriation of resident property, are reported immediately to DADS. CMS 672 indicated a census of 102.

Based on interview and record review the facility failed to complete an initial comprehensive assessment within 14 calendar days after admission of the resident's functional capacity for 1 (Resident #1) of 5 residents reviewed for MDS accuracy and completeness, as evidenced by, - Resident #1 admitted to the facility on [DATE] and an Admission assessment was started on 7/13/18 and was not completed. This deficient practice affected 1 resident and placed an additional 101 residents at risk of not receiving a completed initial assessment which could result in not receiving necessary care and services based on their individually assessed needs. Findings include: Record review of Resident # 1's face sheet revealed she admitted on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident # 1's MDS Admission assessment revealed it was started on 7/13/18 and was not completed. The assessment Status read In Progress. The sections of the MDS were not completed. Further review of Resident # 1's records revealed she originally admitted to the facility on [DATE] and discharged on [DATE] with return not anticipated. In an interview with LVN B on 07/27/18 at 12:53 PM she stated she was responsible for completing the admission MDS assessment for Resident # 1. She stated Resident # 1's MDS Admission Assessment was started on 7/13/18, and should have been completed by 7/19/18. She stated she was off work from 7/13-7/23/18 and she returned to work on 7/23/18 and the Annual Survey started the next day. LVN B stated she was trying to catch up the best she can. In an interview with the DON on 7/26/18 at 2:21 PM she stated the other MDS nurse should've covered completing Resident # 1's admission MDS. She stated the two MDS nurse's usually cover for each other and the Corporate MDS nurse also usually assists with the MDS's when one of them is out. She stated the admission assessment should have been completed. Record review of the facility's policy titled Resident Assessment Instrument, dated 2001, revised (MONTH) 2009, revealed it read, A comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission . The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity .Information derived from the comprehensive assessment enables the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. According to the facility's CMS Form 672 the census was 102.

Based on observation, interview and record review, the facility failed to develop and implement a Baseline Care Plan for each resident that includes needed to provide effective and person-centered care of the resident that met professional standards of quality care for one Resident of six residents (CR #1) reviewed for Baseline Care Plans. -The facility failed to have a Baseline Care Plan that effectively gave instructions for management of CR#1's [MEDICAL CONDITION] and recurrent [MEDICAL CONDITION] diagnosis. This failure affected one former resident (CR #1) and could affect the other 15 residents residing at the facility who were identified with [MEDICAL CONDITION] by placing them at risk of not having their care needs met. The findings were: Intake # TX 732/ 4 Record review of CR #1's medical records revealed she was admitted to the facility on [DATE] and re-admitted on [DATE]. CR #1 was discharged to the hospital on [DATE]. Her [DIAGNOSES REDACTED]. She was an [AGE] year old female. Record review of CR #1's Admission MDS assessment dated [DATE], revealed CR #1 had a BIMS score of 7 out of 15, indicating moderate cognitive impairment. She required extensive assistance for all of her activities of daily living. CR #1 was frequently incontinent of bowel and bladder. Her active [DIAGNOSES REDACTED]. Record review of CR #1's electronic interim care plan dated 5/7/2018 revealed in part; -[MEDICAL CONDITION] alert: Concern was not identified or checked on the Interim Plan of care. Record review of CR #1's hospital discharge medication report dated 5/2/2018 revealed in part; -[MEDICATION NAME] sprinkle (trade name: [MEDICATION NAME] sprinkle) 250 mg oral twice daily. (medication is used to treat [MEDICAL CONDITION] disorders). Record review of CR#1's facility consolidated physician's orders revealed in part; -[MEDICATION NAME] Sodium Tablet Delayed Release 250 MG Give 1 tablet by mouth two times a day related to [MEDICAL CONDITION] and recurrent [MEDICAL CONDITION]. Start Date- 05/08/2018 Record review of CR #1's laboratory report dated 5/8/2018 revealed in part; -[MEDICATION NAME] Results <10 ug/mL Reference Range (50 - 100 ug/mL) Record review of https://labtestsonline.org/tests/[MEDICATION NAME]-acid revealed in part; .The [MEDICATION NAME] ([MEDICATION NAME]) Acid test measures the level of [MEDICATION NAME] Acid in a person's blood. The [MEDICATION NAME] acid level in the blood must be maintained within a narrow therapeutic range. This test measures the level of [MEDICATION NAME] acid in the blood. [MEDICATION NAME] acid is a drug that is used primarily to control certain [MEDICAL CONDITION] by lessening their severity and frequency. [MEDICAL CONDITION] disorders affect the brain's ability to transmit electrical impulses and to regulate nerve activity . Record review of CR #1's MAR for (MONTH) (YEAR) revealed that CR #1 received [MEDICATION NAME] Sodium Tablet Delayed Release 250 MG two times a day from (MONTH) 8, (YEAR) to (MONTH) 29, (YEAR). Record review of CR #1's electronic Progress Notes/Nurses notes revealed in part; -5/30/2018 at 7:17 a.m. CR #1 with low blood pressure. Appears weak and she is very restless. 911 notified, admitted to a local hospital -6/5/2018 at 11:29 p.m. CR #1 arrived with [DIAGNOSES REDACTED]. MD notified of CR #1 arrival Record review of CR #1's hand written document with title Admission Worksheet completed by LVN A revealed in part; .6/5/2018 MD notified of CR #1 arrival and medication reconciliation. Don't start [MEDICAL CONDITION] medication until he (MD) comes and assess CR #1 . Further record review of the CR #1's Progress Notes/Nurses notes revealed that information was not written on the resident electronic Progress Notes/Nurses. Record review of CR #1's Care Plan for admitted [DATE] revealed no care plan to address CR #1's [DIAGNOSES REDACTED].#1 was not going to be on [MEDICATION NAME] Sodium Tablet Delayed Release 250 MG Give 1 tablet by mouth two times a day related to [MEDICAL CONDITION] and recurrent [MEDICAL CONDITION] until MD visit with precautions or monitoring interventions. Record review of CR #1's electronic interim care plan dated 6/5/2018 revealed in part; -[MEDICAL CONDITION] alert: Concern was not identified or checked on the Interim Plan of care. Record review of facility's Care Plan Conference Summary dated 6/6/2018 revealed that CR #1 had a meeting with the IDT. Further record review revealed under section Plan of Care: Nursing Continue plan of care. No information found on document related [DIAGNOSES REDACTED].#1 was not going to be on [MEDICATION NAME] Sodium Tablet Delayed Release 250 MG Give 1 tablet by mouth two times a day related to [MEDICAL CONDITION] and recurrent [MEDICAL CONDITION] until MD visit. Record review of CR #1's hand written MD progress notes dated 6/12/2018 and 6/13/2018 revealed no information related to [DIAGNOSES REDACTED].#1 was not on any medication to treat her condition. Section was checked to continue Plan of Care, Continue Present Medications and Continued Rehab. Record review of CR #1's electronic MD progress notes dated 6/12/2018 at 12:41 p.m. written by MD #1 revealed in part; -Subjective: Feels nauseous. Therapy reports she is doing better. -Objective: Physical Exam: Alert, abdomen soft non-tender. Rehab: debility, urinary tract infection, dementia, functional [MEDICAL CONDITION]. PT/OT/ST for bed mobility training, transfer training, gait training, balance and endurance training, strengthening and ROM improvement, ADL training, cognitive training. Pain: No complaint. Nausea: [MEDICATION NAME] as needed. Further record review revealed no information related to [DIAGNOSES REDACTED].#1 was not on any [MEDICAL CONDITION] medications . Record review of CR #1's Progress Notes/Nurses notes dated 6/12/2018 and 6/13/2018 revealed no information that nursing inquired MD regarding CR #1 [DIAGNOSES REDACTED].#1 was not on any [MEDICAL CONDITION] medications. Record review of CR #1's electronic MD progress notes dated 6/26/2018 at 3:35 p.m. written by MD #1 revealed in part; -Subjective: Resting comfortable. No nausea complaint. -Objective: Physical Exam: Alert, abdomen soft non-tender. Rehab: debility, urinary tract infection, dementia, functional [MEDICAL CONDITION]. PT/OT/ST for bed mobility training, transfer training, gait training, balance and endurance training, strengthening and ROM improvement, ADL training, cognitive training. Pain: No complaint. Nausea: [MEDICATION NAME] as needed. Further record review revealed no information related to [DIAGNOSES REDACTED].#1 was not on any [MEDICAL CONDITION] medications Record review of CR #1's Progress Notes/Nurses notes dated 6/26/2018 revealed no information that nursing inquired MD regarding CR #1 [DIAGNOSES REDACTED].#1 was not on any [MEDICAL CONDITION] medications. Record review of CR #1's Progress Notes/Nurses notes dated 6/27/2018 at 5:07 a.m. revealed in part; .CNA notified nurse at 4:20 a.m. that CR #1 not acting like herself. CNA log rolled CR #1 where she started having a [MEDICAL CONDITION]. Facial twitching and full body jerking noted. 911 called at 4:37 a.m. [MEDICAL CONDITION] continued as CR #1 was leaving the building . In a phone interview on 6/30/2018 at 3:07 p.m. CR #1's RP, she stated that CR #1 was admitted to a local hospital on [DATE] due to [MEDICAL CONDITION] about an hour. CR #1's RP further said that CR #1's [MEDICATION NAME] level on the ER was less than 3 and that the normal levels were between 50 and 100. CR #1's RP then said that she called the NF to asked if CR #1 had received [MEDICATION NAME] for [MEDICAL CONDITION] disorder and that the nursing had given her conflicting information. Observation and interview on 6/30/2018 at 6:45 p.m. revealed that CR #1 was in a local hospital. CR #1 said that she was feeling much better. In an interview on 6/30/2018 at 7:05 p.m. with the hospital RN, she stated that CR #1 was currently on [MEDICATION NAME] (anticonvulsant) 500 mg twice a day and [MEDICATION NAME] (anticonvulsant ) 500 mg twice a day. In an interview on 7/11/2018 at 1:42 p.m. with RN A, she stated that CR #1 went out to the hospital once due to low blood pressure and that the next time, CR #1 was sent to the hospital because of [MEDICAL CONDITION]. RN A said that she remembered that CR #1 was taking [MEDICAL CONDITION] medications before she went to the hospital with low blood pressures but that later the [MEDICAL CONDITION] medications was discontinued in the hospital. RN A then said Unit Manager for the evening shift got the order to discontinue the [MEDICAL CONDITION] medication. In an interview on 7/11/2018 at 2:38 p.m. with LVN A, she stated that she was the nurse that admitted CR #1 on 6/5/2018 and then said I called MD #2 to verify CR #1's orders. MD #2 told me not to start any medication for [MEDICAL CONDITION] until he comes and see CR #1. When asked how she communicated that information to the other nursing members and where in CR #1's medical file was written that information and if CR #1's care plan was updated with that information and if CR #1's RP was notified. LVN A responded I just told the staff, I did not write it on CR #1's nurses notes or care planned the information. I did not write it on the 24 hour report either. When asked how pertinent information about resident's care is communicated with other staff members for appropriate follow up, LVN A stated I have no answer. CR #1 was on [MEDICAL CONDITION] medication. I did not follow up with the MD and I don't know if any other staff members talked to the MD. I am assuming that the nurses working with CR #1 followed up. I was not her regular nurse. There is not specific nurses working on specific halls. They rotate us all over. Further interview at that time, LVN A then said I should had written the information that the MD told me on the progress/nurses notes and the 24 hour book. I did not write it anywhere else, only on the Admission Worksheet, that form is what we complete during admission report. In an interview on 7/11/2018 at 2:59 p.m. with Unit Manager, she stated that nurses were in charge of verifying orders with the MD during admissions and that she only helped the nurses if they needed help. Unit Manager said that she did not remember CR #1 when she was readmitted the second time to the facility. Unit Manager then said that she was not aware that the MD said to stop [MEDICATION NAME] Sodium Tablet Delayed Release 250 MG Give 1 tablet by mouth two times a day related to [MEDICAL CONDITION] and recurrent [MEDICAL CONDITION] medication until his next visit and she did not know to follow up with any information regarding CR #1. Unit Manager further said Any pertinent information regarding MD communication needs to be written on the progress/nurses notes and on the 24 hour book for follow up. We use the 24 hour book during shift report. I do not remember seeing any information regarding CR #1 on the 24 hour book and I did not talk to any MD regarding CR #1's medications. In an interview on 7/11/2018 at 3:22 p.m. with the ADON, she stated that nursing management reviewed the new admissions and re-admissions on the daily meetings. She further said that CR #1 went back to the hospital once and then returned with no orders for [MEDICAL CONDITION] medication. ADON then said that she was not aware that CR #1's MD had given instructions to hold the [MEDICAL CONDITION] medication until his next visit and that she did not know to follow up with the MD about CR #1's [MEDICAL CONDITION] medications. When asked about the facility's protocol for residents with [DIAGNOSES REDACTED]. We check the 24 hour book during clinical meetings in the morning. We monitor the residents with [MEDICAL CONDITION] diagnosis, make sure bed is in low position because of the high fall risk, we place a fall mat. During admission, the admission nurse would complete the section on the interim care plan for residents with [MEDICAL CONDITION]. Then the DON and the PPS nurse will monitor that care plans are updated. Further observation, interview and record review on 7/11/2018 at 3:44 p.m. with the ADON, ADON verified that CR #1's comprehensive care plan or interim care plans did not have any information regarding CR #1's [MEDICAL CONDITION] [DIAGNOSES REDACTED]. In an interview with the DON on 7/11/2018 at 4:25 p.m. she stated that during daily clinical meetings, the nursing department ensures that all documentation is initiated during the admission or re-admission process. DON then said that CR #1's [MEDICATION NAME] (anticonvulsant) levels were low upon admission on (MONTH) (YEAR) and that the facility initiated the medication. DON further said CR #1 went to hospital then when she returned, CR #1 was no longer on the [MEDICAL CONDITION] medication. The MD said No, I will come and see the resident. When asked if anyone in the nursing department or herself talked to the MD on 6/12/2018 or 6/13/2018 during the MD visits and inquired about CR #1's order of [MEDICATION NAME] Sodium (anticonvulsant), the DON said No, I did not talk to the MD and don't know if anyone follow up. Further interview with the DON on 7/11/2018 at 4:32 p.m. the DON stated we implemented the [MEDICAL CONDITION] medication when CR #1 was first admitted to the facility, then CR #1 went back to the hospital and the medication was discontinued. The MD is responsible to assess the patients. When asked what was the facility's Plan of Care for CR #1 that was readmitted to the facility without [MEDICATION NAME] Sodium (anticonvulsant) medication orders, what were the interventions to manage and monitor CR #1's [DIAGNOSES REDACTED]. When CR #1 went out and came in. We let the MD know and the MD made the decision. That's what we do with residents with [MEDICAL CONDITION]. The MDS nurse is responsible to complete the care plan. When asked if CR #1 had any care plan to address CR #1's [DIAGNOSES REDACTED].#1 was not going to be on any anticonvulsant medications until MD visit with precautions or monitoring interventions, the DON responded I see that there is an opportunity to improve. I can see. In an interview on 7/11/2018 at 5:05 p.m. with the PPS nurse, she stated that she was responsible to initiate and update the care plans. PPS nurse further said that she was not aware of any information regarding CR #1's [MEDICAL CONDITION] and recurrent [MEDICAL CONDITION] [DIAGNOSES REDACTED]. PPS nurse then said that when residents have [DIAGNOSES REDACTED]. When told that CR #1 was treated on her first admission of (MONTH) (YEAR) with [MEDICATION NAME] Sodium (anticonvulsant) medication, the PPS nurse then said I probably did not care planned that one. In a phone interview on 7/12/2018 at 9:46 a.m. with MD #1, he stated that he was a Physical medicine and Rehab MD, and that he was a consultant for the facility that only overlooked the therapy department. MD further said that he did not manage any medications on the facility including [MEDICAL CONDITION] medications. MD #1 said that he saw CR #1 for therapy purposes only. In a phone interview on 7/12/2018 at 9:51 with MD #2, he told surveyor that he was driving and that after he arrived to his office he was going to review CR #1's information and he was going to call the surveyor back. Record review of MD #2 returned message to surveyor on 7/12/2018 at 1:21 p.m. that read I will be at the NF tomorrow, will review and get back to you. MD #2 never called the surveyor back. Record review of the facility policy and procedure revised (MONTH) 2010 with title Care Plans - Comprehensive revealed in part; .Policy statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing needs is developed for each resident. Purpose of the Care Plan: a. Incorporate identified problem areas, b. Incorporate risk factors associated with identified problems, e. Reflect treatment goals, timetables and objectives in measurable outcomes, i. Reflect currently recognized standards of practice for problems and conditions List provided by facility revealed 15 residents identified with [MEDICAL CONDITION] diagnosis.

Based on interview and record review, the facility failed to incorporate the recommendations from the PASRR level II determination for 1 of 6 residents (Resident #2) reviewed for PASRR. -The facility failed to provide and arrange for Specialized Therapy, Service Coordination and Independent Living Skills Training as discussed in the Interdisciplinary Team meeting on 4/23/18 for Resident #2. -The facility failed to enter information in the portal in the required timeframe for Resident #2. This failure affected one Resident (Resident #2) and had the potential to affect any of the other four PASRR positive residents with a documented mental illness, intellectual and/or developmental disability by placing them at risk for not receiving needed services. Findings include: Intake TX 360/ 5 Record review of Resident #2's Face Sheet documented a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. on feet, unspecified lack of coordination, dysphagia, unspecified, overactive bladder, unspecified combined systolic (congestive) and diastolic (congestive) heart failure,[MEDICAL CONDITION], unspecified organism, [MEDICAL CONDITION], unspecified, anxiety disorder, unspecified, essential (primary) hypertension, [MEDICAL CONDITIONS] of native coronary artery without [MEDICAL CONDITION] pectoris, [MEDICAL CONDITION], unspecified, constipation, unspecified, shortness of breath, heartburn and gastrostomy status. Record review of Resident #2's Admission MDS assessment dated [DATE], revealed Resident #2 had severe cognitive impairment and had a BIMS score of 5 out of the 15 possible. She required extensive to total assistance for all of her activities of daily living. Resident #2 was always incontinent of bowel and bladder and had a feeding tube. Preadmission Screening and Resident Review (PASRR) information was not answered on assessment. Record review of Resident #2's PASRR Specialized Services (PSS) form, dated 4/23/18, revealed in part; -A1300 Type of SPT Meeting: Initial -A1400 Date of SPT Meeting: 4/23/2018 -A1500 Individual PASRR Condition: The Individual is PASRR positive for IDD only. -A1700. List of Nursing Facility Specialized Services. Check only the services the Individual or their Legally Authorized Representative agreed to: F. Specialized Occupational Therapy, G. Specialized Physical Therapy, H. Specialized Speech Therapy. -A1800 List of LA/LMHA Specialized Services: A. Service Coordination and F. Independent Living Skills Training. -A2000. Does the individual wish to transition into the community? Yes. Record review of Resident #2's Care Plan initiated 6/19/18, revealed in part; -Focus: Resident #2 PASRR assessment has identified needs for specialized services due to MI; ID. Specialized services will be provided to maintain the highest level of function. -Interventions: Follow up with local authorities recommendations as indicated. In an interview on 7/11/2018 at 1:08 p.m. with PPS Nurse, she stated that on 4/23/2018 there was an IDT meeting with the LA (Local Authority) regarding Resident #2's care. PPS Nurse then said that the plan was for Resident #2 to return to her personal care home and that the plan was for Resident #2 to receive Specialized PT, Specialized OT and Specialized ST. The PPS Nurse further said Resident #2 has been receiving skilled therapy services since she was admitted to the facility. When asked if Resident #2 had received any Specialized PT, Specialized OT and Specialized ST, The PPS Nurse said that she did not know if there was any difference between Skilled services and Specialized services. Further interview on 7/11/2018 at 1:17 p.m. with PPS Nurse, she stated that the LA (Local Authority) called the facility once to request the facility to update the LTC Online Portal regarding Resident #2's IDT meeting and that the facility updated the LTC Online Portal immediately. PPS Nurse did not remember the date the facility was called. PPS Nurse then said that she was responsible of updating the LTC Online Portal and that she was not aware that she needed to update the LTC Online Portal after the IDT meeting. PPS Nurse continued saying that the facility had scheduled another IDT meeting for Resident #2 today because Resident #2 did not go to the personal care home and that the facility delayed having the meeting again because the LA (Local Authority) did not give clear directions on what to do after Resident #2 decided to stay in the facility. In an interview on 7/11/2018 at 1:52 p.m. with LA (Local Authority) Supervisor, she stated that they were present at Resident #2's IDT meeting on 4/23/2018 and that the facility did not enter the information from the IDT meeting into the Medicaid Healthcare Partnership (TMHP) or Simple LTC online portal as required. LA (Local Authority) Supervisor then said we had to call the facility multiple times and was not done until finally they entered the information about 3 weeks ago. I even called the DON on 5/18/2018 at 1:15 p.m. and asked her to enter the information of Resident #2's IDT meeting to the LTC Online Portal and the DON told me that the facility was going to do it on that day and it was not done. It did not happen. The reason we had the IDT meeting again today for Resident #2 was because the facility never provided the Specialized services that were agreed upon in the IDT meeting on 4/23/2018. That's why we are here again, to add the services to Resident #2's care plan. Resident #2 never received the Specialized services that we agreed on 4/23/2018. Facility would never do the IDT meetings within 14 days as required. Resident #2 was admitted to the facility on [DATE] and we received an alert from the facility about Resident #2 on 4/12/2018. Resident #2's PASRR evaluation was not done until 4/18/2018 because we did not get the alert until 4/12/2018. Meeting was on 4/23/2018, which was not within the 14 days required. The facility failed to update the Medicaid portal with the IDT meeting information within the required time. The PASRR unit told us we were not in compliance because the facility did not update the LTC Online Portal and the Specialized services had not been provided to Resident #2. Resident #2 agreed today in the meeting to have Specialized PT and Specialized OT. In an interview on 7/11/2018 at 3:11 p.m. with the Rehabilitation Director, she stated that Resident #2 has been receiving Skilled therapy services from admitted until 5/15/2018, but that Resident #2 has not received any Specialized or habilitative (maintenance-based) therapy so far. Rehabilitation Director then said we just had the meeting today with the LA (Local Authority) and they got Resident #2 approved for Specialized PT and Specialized OT, Resident #2 will receive habilitative (maintenance-based) therapy. We have 20 days to start the Specialized therapy from today's date. In an interview on 7/11/2018 at 4:09 p.m. with the DON, she stated that new admission files are reviewed the next day of admission during the morning meetings including PASRR assessments. DON further said that the Administrator, DON and Corporation were responsible to monitor PASRR assessments and to make sure the services were provided for qualified residents. DON then said that Resident #2 had been receiving the Specialized Rehabilitation services and that today's IDT meeting with Resident #2 was to re-assess the services provided at the facility. When asked if she knew the difference between Specialized rehabilitation and Skilled rehabilitation, the DON said that it was the same thing. DON then said that the LA (Local Authority) has never communicated with her regarding updating the online portal for Resident #2. Record review of the facility policy of procedure dated (MONTH) 2014 with title PASRR Clinical Policy revealed in part; .Purpose: The PASRR evaluation is designed to confirm the suspicion of MI, ID, or DD/RC and ensure the individual is placed in the most integrated residential setting receiving the specialized services needed to improve and maintain the individual's level of functioning . Nursing responsibilities 8.- The MDS/PPS Nurse will schedule the IDT within 14 days of admission. 11.- The MDS/PPS Nurse will coordinate and deliver specialized services the facility is responsible for providing. 13.- The MDS/PPS Nurse/ DON and or/ designee will initiate delivery of specialized services within 30 days of the date added to plan The DON indicated there were five PASRR positive residents.

Based on observation, interview, and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 2 residents (Resident #63) reviewed for quality of care. The facility failed to anchor or secure Resident #63 indwelling catheter tubing in place with a secure device to prevent pulling. Resident #63 had a blood tinged discharge from his penis and feelings of pain during incontinent care. This failure affected 1 of 2 residents with indwelling catheters and placed an additional 1 resident with indwelling catheters at risk for urinary tract infection, pain/discomfort and urinary trauma. The findings include: Record review of Resident #63 face sheet dated 7/27/17 revealed he was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. Observation of incontinent care for Resident #63 on 7/26/2017 at 10:30 p.m. performed by CNA S who was assisted by CNA D revealed the following: CNA S positioned Resident # 63 to his back with the assistance of CNA D. CNA S pull the foreskin back on Resident #63 penis to clean that area. Resident #63 facial grimaced and stated Go easy on it that hurts. CNA S continued to clean the indwelling catheter from the tip of the penis to the Y of the tubing and on the wipe from cleaning tubing at the tip of the penis and insertion site there was a small amount of bloody drainage. Resident #63 shoulders flinched with facial grimacing while CNA C cleaned the catheter at tip of penis and Resident #63 said Ouch. CNA S continued to wipe upward on Resident #63 shaft of his penis, while the resident continued to facial grimace. During incontinent care CNA S and CNA D rolled the resident to his left side and then to his right side to apply his incontinent brief. During this time the indwelling catheter tubing moved frequently as the resident was turned, and Resident #63 stated that hurts. CNA S again cleaned the indwelling catheter in a downward motion which moved the catheter tubing again and the resident shoulders flinched, face showed grimacing, and Resident #63 said Be careful that hurts. CNA S stated to Resident #63 It's hurting because it's pulling and CNA S and CNA D continued to pull-up Resident # 63 pants with the indwelling catheter running inside the left pant leg and Resident # 63 stated Why does it hurt so? CNA D replied to Resident #63 Probably because it's pulling Resident #63 then said IT sure does hurt, WOW! while facial grimacing. CNA S and CNA D did not secure or anchor the tubing after providing care. In an interview on 7/26/17 at 11:00 a.m. with RN G who is assigned to Resident #63 revealed she was not aware that Resident #63 had blood coming from the tip of his penis. RN G stated that Resident #63 had the indwelling catheter inserted yesterday. RN G stated that she was not aware that Resident #63 did not have a leg strap/anchoring device on to secure his indwelling catheter. RN G said licensed nurses are responsible for checking and maintaining the anchoring device and CNAs will usually let them know one is not in place, but no one had notified her about Resident #63. RN G stated that Resident's with indwelling catheters should have a anchoring device to prevent bleeding, trauma, pain, discomfort or pulling out. Record review of Resident #63's current Care Plan revealed initiated date of 7/25/17. The care plan did not include care or reflect the use of an anchoring device to prevent urethral pain/discomfort, trauma or dislodgement. Revised care plan handed to surveyor on 7/27/17 revealed updated 7/26/17. Under the section Interventions .in part .Place Stat Loc(anchoring device) to reduce movement of foley. Resident removing stat loc. Record review of Resident #63's Nursing Progress Notes dated 7/22/27 revealed Foley catheter was re-inserted had a residual of 850 ml clear urine Record Review of Resident # 63 monthly Physician order [REDACTED]. In an interview on 7/27/17 at 2:00 PM with DON revealed Resident #63 should have had a securing device on to secure the catheter. DON revealed it was the nurses' responsibility to ensure the indwelling catheter straps were in place, and she expected the nurse to make rounds observe each shift and document that the catheter strap was in place. The CNAs were to report to the nurses if the catheter strap was not in place, wet, dirty, or damaged. According to the Center for Disease Control (CDC) guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009 information retrieved 7/28/17 from http://www.cdc.gov/hicpac/cauti/001_cauti.html, proper techniques for urinary catheter maintenance states Properly secure indwelling urinary catheters after insertion to prevent movement and urethral traction. Record review of the Texas Curriculum for Nurse Aids in Long-Term Care Facilities 2016 Fifth Edition revealed: Pages 197 thru 199 entitled Procedural Guideline #35-Indwelling Urinary Catheter Care: A. Purpose: 1. To maintain the indwelling urinary drainage system. 2. To help avoid urinary tract infections. B. Guidelines for Maintaining the Urinary Drainage System 2. Check that the catheter remains secured with tape or leg strap following facility policy, to reduce friction and movement at the insertion site. CMS form 672 reflected two residents who had indwelling catheters.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #63) reviewed for indwelling catheters. The facility failed to anchor or secure Resident #63 indwelling catheter tubing in place with a secure device to prevent pulling. Resident #63 had a blood tinged discharge from his penis and feelings of pain during incontinent care. This failure affected 1 of 2 residents with indwelling catheters and placed an additional 1 resident with indwelling catheters at risk for urinary tract infection, pain/discomfort and urinary trauma. The findings include: Record review of Resident #63 face sheet dated 7/27/17 revealed he was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. Observation of incontinent care for Resident #63 on 7/26/2017 at 10:30 p.m. performed by CNA S who was assisted by CNA D revealed the following: CNA S positioned Resident # 63 to his back with the assistance of CNA D. CNA S pull the foreskin back on Resident #63 penis to clean that area. Resident #63 facial grimaced and stated Go easy on it that hurts. CNA S continued to clean the indwelling catheter from the tip of the penis to the Y of the tubing and on the wipe from cleaning tubing at the tip of the penis and insertion site there was a small amount of bloody drainage. Resident #63 shoulders flinched with facial grimacing while CNA C cleaned the catheter at tip of penis and Resident #63 said Ouch. CNA S continued to wipe upward on Resident #63 shaft of his penis, while the resident continued to facial grimace. During incontinent care CNA S and CNA D rolled the resident to his left side and then to his right side to apply his incontinent brief. During this time the indwelling catheter tubing moved frequently as the resident was turned, and Resident #63 stated that hurts. CNA S again cleaned the indwelling catheter in a downward motion which moved the catheter tubing again and the resident shoulders flinched, face showed grimacing, and Resident #63 said Be careful that hurts. CNA S stated to Resident #63 It's hurting because it's pulling and CNA S and CNA D continued to pull-up Resident # 63 pants with the indwelling catheter running inside the left pant leg and Resident # 63 stated Why does it hurt so? CNA D replied to Resident #63 Probably because it's pulling Resident #63 then said IT sure does hurt, WOW! while facial grimacing. CNA S and CNA D did not secure or anchor the tubing after providing care. In an interview on 7/26/17 at 11:00 a.m. with RN G who is assigned to Resident #63 revealed she was not aware that Resident #63 had blood coming from the tip of his penis. RN G stated that Resident #63 had the indwelling catheter inserted yesterday. RN G stated that she was not aware that Resident #63 did not have a leg strap/anchoring device on to secure his indwelling catheter. RN G said licensed nurses are responsible for checking and maintaining the anchoring device and CNAs will usually let them know one is not in place, but no one had notified her about Resident #63. RN G stated that Resident's with indwelling catheters should have a anchoring device to prevent bleeding, trauma, pain, discomfort or pulling out. Record review of Resident #63's current Care Plan revealed initiated date of 7/25/17. The care plan did not include care or reflect the use of an anchoring device to prevent urethral pain/discomfort, trauma or dislodgement. Revised care plan handed to surveyor on 7/27/17 revealed updated 7/26/17. Under the section Interventions .in part .Place Stat Loc(anchoring device) to reduce movement of foley. Resident removing stat loc. Record review of Resident #63's Nursing Progress Notes dated 7/22/27 revealed Foley catheter was re-inserted had a residual of 850 ml clear urine Record Review of Resident # 63 monthly Physician order [REDACTED]. In an interview on 7/27/17 at 2:00 PM with DON revealed Resident #63 should have had a securing device on to secure the catheter. DON revealed it was the nurses' responsibility to ensure the indwelling catheter straps were in place, and she expected the nurse to make rounds observe each shift and document that the catheter strap was in place. The CNAs were to report to the nurses if the catheter strap was not in place, wet, dirty, or damaged. According to the Center for Disease Control (CDC) guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009 information retrieved 7/28/17 from http://www.cdc.gov/hicpac/cauti/001_cauti.html, proper techniques for urinary catheter maintenance states Properly secure indwelling urinary catheters after insertion to prevent movement and urethral traction. Record review of the Texas Curriculum for Nurse Aids in Long-Term Care Facilities 2016 Fifth Edition revealed: Pages 197 thru 199 entitled Procedural Guideline #35-Indwelling Urinary Catheter Care: A. Purpose: 1. To maintain the indwelling urinary drainage system. 2. To help avoid urinary tract infections. B. Guidelines for Maintaining the Urinary Drainage System 2. Check that the catheter remains secured with tape or leg strap following facility policy, to reduce friction and movement at the insertion site. CMS form 672 reflected two residents who had indwelling catheters.

Based on interview and record review the facility failed to ensure that one of six residents (CR#2) reviewed for care provided, were provided care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care, as evidenced by: --The facility failed to Care plan interventions to treat and/or monitor CR #2's after being admitted to the facility following heart valve surgery (Aortic valve replacement). CR #2 developed [MEDICAL CONDITION], low oxygen saturation and nausea within a week of his admission and his care plan was not updated. Care plan did not have information related to his laboratory findings of critical low potassium levels on 3/10/2016. --The facility failed to follow-up on CR#2's admission laboratory orders. Laboratory orders were not carried out until 7 days after being ordered by the MD with results of critical low potassium levels. The facility failed to follow-up on a second laboratory order for CR#2 to follow-up on his critical potassium levels. -- The facility failed to provide timely assessments, closely monitor and provide adequate treatment and interventions for CR #2 when his oxygen saturation was below 90%. The facility did not update the MD regarding his breathing status and his need for continuous oxygen therapy. CR#2 was brought to the ER by his family member and he was diagnosed with [REDACTED]. These failures affected one former resident (CR#2) who had delayed medical treatment and could place the 8 residents who required respiratory treatment at risk of not receiving adequate assessments, medical care, pain and decline in their physical, mental and psychosocial health and self esteem. Findings included: Intake # 5 Record review of the facility face sheet revealed CR #2 was a [AGE] year old male admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #2 was admitted to a local hospital on [DATE] with [DIAGNOSES REDACTED]. Record review of hospital's extended care facility form dated 3/2/2016 at 6:00 p.m. revealed that CR#2 had an Aortic valve replacement (open heart surgery used to treat problems with the heart's aortic valve) on 2/26/2016 and his discharged [DIAGNOSES REDACTED]. Record review of CR #2's Interim Plan of Care dated 3/02/2016 revealed no information related to his post surgical status. Record review of the comprehensive care plan initiated 3/3/2016 revealed that #2 had recent open heart surgery. Care plan did not have interventions in place related to post surgical precautions to treat and monitor CR#2. In continued record review revealed no information related to his laboratory findings of critical low potassium levels on 3/10/2016, developing of [MEDICAL CONDITION], low oxygen saturation and need for continuous oxygen and nausea. Record review of the MDS dated [DATE] revealed CR #2 required limited assistance for bed mobility, locomotion, personal hygiene and bathing and extensive assistance for dressing and toilet use. Record review of CR #2's telephone orders in part dated: - 3/2/2016: complete metabolic panel and complete blood count tomorrow. *complete metabolic panel (blood test that measures the sugar level, electrolyte and fluid balance, kidney function and liver function). *complete blood count (measures the concentration of white blood cells, red blood cells and platelets in the blood). - 3/9/2016: [MEDICATION NAME] (anti-nausea) 4 mg every 8 hours as needed. - 3/11/2016: basic metabolic panel (provides key information regarding fluid and electrolytes status) on 3/13/2016 in a.m. Ted hose to bilateral lower extremities one time a day related to embolism and [MEDICAL CONDITION] of unspecified vein. Further record review revealed no orders for oxygen therapy. Record review of CR#2's electronic clinical notes revealed in part: -03/10/2016 at 7:46 a.m. Respiratory treatment assessment: CR #2's oxygen saturations are running low and nurse has been notified. Oxygen saturation during pre-administration of hand held nebulizer was 86% and oxygen saturation during his post administration of hand held nebulizer was 89%. Further record review of electronic clinical notes revealed no information of MD notification. -03/10/2016 at 5:44 p.m. Skilled nurses notes: continues with oxygen via nasal cannula. Summary: oxygen continuous at 2 liters per minute via nasal cannula. -03/11/2016 at 7:49 a.m. Respiratory treatment assessment: CR#2 is now on 2 liters of oxygen via nasal cannula for low saturations of oxygen. CR#2 now with oxygen saturations of 95% at 2 liters of oxygen. Record review of CR#2's laboratory report that was collected on 3/10/2016 at 4:27 p.m. and released on 3/10/2016 at 9:58 p.m. revealed a Potassium level of 2.9 (critical low, expected range 3.5 - 5.3). Further record review of CR#2's electronic clinical notes in part: -Late entry 03/11/2016 at 5:00a.m. received a verbal critical laboratory value for CR#2 for potassium of 2.9 mEq/L (expected range 3.5 - 5.3) at 3:45 a.m. Vital signs stable. Awaiting return call from MD on call . -SBAR 03/11/2016 at 11:28 a.m. .Describe the problem/symptom: Potassium 2.9 mEq/L (expected range 3.5 - 5.3). Oxygen saturation 94% with oxygen via nasal cannula. Progress notes: NP with new orders to give Potassium 60meq one time dose now and tomorrow, tomorrow start Potassium 20 meq every day and basic metabolic panel on Sunday 3/13/2016 . -03/11/2016 at 5:18 p.m. Skilled nurses notes: oxygen at 2 liters via nasal cannula continuous. Oxygen saturation 93%. No [MEDICAL CONDITION]. -Late entry 03/13/2016 at 3:15 a.m. Vital signs: blood pressure 128/69, heart rate 76, temperature 97.6, respirations 18, oxygen saturation 95%. -Late entry 03/13/2016 at 12:15 p.m. .CR#2 stated is going out on pass with his family member and will be back in a couple of hours . -Late entry 03/13/2016 at 2:15 p.m. .Received a phone call from CR #2's family member at 4:00 p.m. she stated that CR#2 was sent to a local hospital . Record review of CR#2's Medication Administration Record [REDACTED]. Record review of CR#2's hospital History and Physical dated 3/13/2016 at 5:47 p.m. revealed in part: XXX[AGE] year old male with recent surgery of Aortic Valve replacement, came in from the rehab feeling dyspnea (difficulty breathing) and leg [MEDICAL CONDITION] bilateral 3+. Per patient, leg swelling getting worse. Dizzy, pale and not feeling good. Laboratory report in part: Potassium level low at 3.2. Impression and Plan: [DIAGNOSES REDACTED] (low Potassium levels), [MEDICAL CONDITION] and acute [MEDICAL CONDITION] . CR#2 was discharged from the hospital on [DATE]. In an interview on 3/23/2016 at 2:10 p.m. with Unit Manager, LVN A, he stated that CR#2 was admitted to the facility for therapy and that he had bypass heart surgery before being admitted to the facility. He further stated that CR#2 had post surgical precautions due to his heart surgery and that CR#2 had to hold a pillow to his heart when getting up from bed so he would not put force on his chest. He continued saying that he was not doing the care for the residents and that MDS nurse was in charge of doing all care plans. When asked about the laboratory order for CR#2 ordered on [DATE], he stated that he did not know what happened and that he was going to check on the computer. In an interview on 3/23/2016 at 2:32 p.m. with ADON B, she stated that CR#2 only had laboratory reports dated 3/10/2016 and that she did not know why the laboratory work was done until 3/10/2016 and not on 3/3/2016 as ordered by the MD. When asked if CR#2 had any laboratory work done on 3/13/2016 in a.m. as ordered, ADON B stated I don't see any other laboratory reports for CR#2, but I need to check the laboratory requisitions. Further interview with Unit Manager, LVN A, he stated that he did not remember if CR#2 had any changes in condition before he was discharged from the facility and that he did not remember hearing or being told that CR#2 ever had low oxygen saturations and said changes in respiratory status is a change in condition and the MD needs to be notified immediately. He continued saying that residents needed orders for oxygen and further said I do not see any orders for oxygen for CR#2. The MD needed to be notified and obtain orders. In an interview on 3/23/2016 at 3:10 p.m. with RN C, she stated that CR#2 had problems with his oxygen saturations during the night shift and that she received report that the MD was notified. She further stated that she did not call the MD because when she came on duty CR#2 was already on oxygen and that she remembered that after that time, CR#2 required continuous oxygen but that she did not check if there was an order for [REDACTED]. In an interview on 3/23/2016 at 3:24 p.m. with the DON, she stated that the facility has been having issues with the laboratory and that they had a couple of issues where laboratory work was not done timely including CR#2 and that CR#2 did not get to have his blood drawn on 3/13/2016 in a.m. because the laboratory did not come until 3:00 p.m. DON further said that at that time CR#2 had already left the facility with his family member. DON continued saying that the facility did not need to have written orders for oxygen therapy because those were standing orders. DON then said that CR#2 should had a care plan for his low oxygen saturations and development of [MEDICAL CONDITION] and continued saying Information about his low oxygen saturations was addressed but I don't remember hearing about the swelling to his legs. The PPS (Prospective Payment System) nurse is in charge of updating the care plans because we discussed changes in condition during our morning meetings and she is supposed to update the care plans. In an interview on 3/23/2016 at 3:40 p.m. with LVN D, she stated that she was the PPS nurse and said that she did not remember hearing any discussion of CR#2 having any changes in condition with his oxygen saturations, nausea or [MEDICAL CONDITION] during the morning meetings. She further said that an SBAR was completed on CR#2 due to his low potassium levels but she said she did not find an SBAR for the changes in oxygen saturation, [MEDICAL CONDITION] or the nausea. In a second interview on 3/23/2016 at 4:00 p.m. with ADON B, she stated that the MD should be notified if the oxygen saturations are below 90% in the residents and that the facility had a protocol for oxygen therapy but when oxygen saturations are below 90% it was beyond the facility's protocol and that the MD needed to be contacted for further instructions. In an interview on 3/24/2016 at 9:35 a.m. with CR#2's family member, she stated that on 3/13/2016 when she went to visit CR#2 at the facility, she found him white as a ghost and that CR#2 was complaining of inability to breath. She further said that she took CR#2 to a local clinic at that moment because he did not look good and couldn't breath and that the clinic called an ambulance immediately and that CR#2 was admitted on that day to the hospital and was diagnosed with [REDACTED].#2 stayed at the hospital for 8 days. In an interview on 3/24/2016 at 4:18 p.m. with NP E, she stated that she was notified only once about CR#2 running low oxygen saturations but that she did not hear more about it from the facility. She further said that CR#2 had admission orders [REDACTED]. She further said that she ordered to repeat the laboratory work because CR#2's potassium was critically low and that she did not heard anything more about the laboratory order results. NP E said that she heard that CR#2 went out on pass and did not return to the facility. Record review of the facility's policy and procedure Change in a Resident's Condition or Status revised April 2007 read in part: Our facility shall promptly notify the resident, his or her Attending Physician of changes in the resident's medical/mental condition and/or status . Record review of the facility's policy and procedure Oxygen Administration revised March 2004 revealed in part: The purpose of this procedure is to provide guidelines for safe oxygen administration. 1.- Verify that there is a physician's order for this procedure . Record review of the facility's policy and procedure Care Plans - Comprehensive revised April 2010 revealed in part: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 5.- The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans: A. When there has been a significant change in the resident's condition Record review of the facility's policy and procedure Laboratory and diagnostic test results - Clinical protocol revised April 2007 revealed in part: The physician will identify and order diagnostic and laboratory testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests The CMS 672 dated 3/23/16 indicated 8 residents required respiratory treatment.

Based on interview and record review, the facility failed to provide services in accordance with the written Plan of Care for 1 of five residents reviewed for plan of care. (CR #2) -The facility failed to follow on CR#2's admission laboratory orders. Laboratory orders were not carried out until 7 days after being ordered by the MD with results of critical low potassium levels. -The facility failed to follow on a second laboratory orders for CR#2 to followed up on his critical potassium levels. This failure affected one former resident (CR#2) and placed the 84 residents residing at the facility at risk for not receiving the care and services according to their plan of care that will place them at risk of a decline in overall status. Findings include: Intake # 5 Record review of the facility face sheet revealed CR #2 was a [AGE] year old male admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #2 was admitted to a local hospital on [DATE] with [DIAGNOSES REDACTED]. Record review of hospital's extended care facility form dated 3/2/2016 at 6:00 p.m. revealed that CR#2 had an Aortic valve replacement (open heart surgery used to treat problems with the heart's aortic valve) on 2/26/2016 and his discharged [DIAGNOSES REDACTED]. Record review of CR #2's Interim Plan of Care dated 3/02/2016 revealed no information related to his post surgical status. Record review of the comprehensive care plan initiated 3/3/2016 revealed that #2 had recent open heart surgery. Care plan did not have interventions in place related to post surgical precautions to treat and monitor CR#2. In continued record review revealed no information related to his laboratory findings of critical low potassium levels on 3/10/2016, developing of [MEDICAL CONDITION], low oxygen saturation and need for continuous oxygen and nausea. Record review of the MDS dated [DATE] revealed CR #2 required limited assistance for bed mobility, locomotion, personal hygiene and bathing and extensive assistance for dressing and toilet use. Record review of CR #2's telephone orders in part dated: - 3/2/2016: complete metabolic panel and complete blood count tomorrow. *complete metabolic panel (blood test that measures the sugar level, electrolyte and fluid balance, kidney function and liver function). *complete blood count (measures the concentration of white blood cells, red blood cells and platelets in the blood). - 3/9/2016: [MEDICATION NAME] (anti-nausea) 4 mg every 8 hours as needed. - 3/11/2016: basic metabolic panel (provides key information regarding fluid and electrolytes status) on 3/13/2016 in a.m. Ted hose to bilateral lower extremities one time a day related to embolism and [MEDICAL CONDITION] of unspecified vein. Further record review revealed no orders for oxygen therapy. Record review of CR#2's electronic clinical notes revealed in part: -03/10/2016 at 7:46 a.m. Respiratory treatment assessment: CR #2's oxygen saturations are running low and nurse has been notified. Oxygen saturation during pre-administration of hand held nebulizer was 86% and oxygen saturation during his post administration of hand held nebulizer was 89%. Further record review of electronic clinical notes revealed no information of MD notification. -03/10/2016 at 5:44 p.m. Skilled nurses notes: continues with oxygen via nasal cannula. Summary: oxygen continuous at 2 liters per minute via nasal cannula. -03/11/2016 at 7:49 a.m. Respiratory treatment assessment: CR#2 is now on 2 liters of oxygen via nasal cannula for low saturations of oxygen. CR#2 now with oxygen saturations of 95% at 2 liters of oxygen. Record review of CR#2's laboratory report that was collected on 3/10/2016 at 4:27 p.m. and released on 3/10/2016 at 9:58 p.m. revealed a Potassium level of 2.9 (critical low, expected range 3.5 - 5.3). Further record review of CR#2's electronic clinical notes in part: -Late entry 03/11/2016 at 5:00a.m. received a verbal critical laboratory value for CR#2 for potassium of 2.9 mEq/L (expected range 3.5 - 5.3) at 3:45 a.m. Vital signs stable. Awaiting return call from MD on call . -SBAR 03/11/2016 at 11:28 a.m. .Describe the problem/symptom: Potassium 2.9 mEq/L (expected range 3.5 - 5.3). Oxygen saturation 94% with oxygen via nasal cannula. Progress notes: NP with new orders to give Potassium 60meq one time dose now and tomorrow, tomorrow start Potassium 20 meq every day and basic metabolic panel on Sunday 3/13/2016 . -03/11/2016 at 5:18 p.m. Skilled nurses notes: oxygen at 2 liters via nasal cannula continuous. Oxygen saturation 93%. No [MEDICAL CONDITION]. -Late entry 03/13/2016 at 3:15 a.m. Vital signs: blood pressure 128/69, heart rate 76, temperature 97.6, respirations 18, oxygen saturation 95%. -Late entry 03/13/2016 at 12:15 p.m. .CR#2 stated is going out on pass with his family member and will be back in a couple of hours . -Late entry 03/13/2016 at 2:15 p.m. .Received a phone call from CR #2's family member at 4:00 p.m. she stated that CR#2 was sent to a local hospital . Record review of CR#2's Medication Administration Record [REDACTED]. Record review of CR#2's hospital History and Physical dated 3/13/2016 at 5:47 p.m. revealed in part: XXX[AGE] year old male with recent surgery of Aortic Valve replacement, came in from the rehab feeling dyspnea (difficulty breathing) and leg [MEDICAL CONDITION] bilateral 3+. Per patient, leg swelling getting worse. Dizzy, pale and not feeling good. Laboratory report in part: Potassium level low at 3.2. Impression and Plan: [DIAGNOSES REDACTED] (low Potassium levels), [MEDICAL CONDITION] and acute [MEDICAL CONDITION] . CR#2 was discharged from the hospital on [DATE]. In an interview on 3/23/2016 at 2:10 p.m. with Unit Manager, LVN A, he stated that CR#2 was admitted to the facility for therapy and that he had bypass heart surgery before being admitted to the facility. He further stated that CR#2 had post surgical precautions due to his heart surgery and that CR#2 had to hold a pillow to his heart when getting up from bed so he would not put force on his chest. He continued saying that he was not doing the care for the residents and that MDS nurse was in charge of doing all care plans. When asked about the laboratory order for CR#2 ordered on [DATE], he stated that he did not know what happened and that he was going to check on the computer. In an interview on 3/23/2016 at 2:32 p.m. with ADON B, she stated that CR#2 only had laboratory reports dated 3/10/2016 and that she did not know why the laboratory work was done until 3/10/2016 and not on 3/3/2016 as ordered by the MD. When asked if CR#2 had any laboratory work done on 3/13/2016 in a.m. as ordered, ADON B stated I don't see any other laboratory reports for CR#2, but I need to check the laboratory requisitions. Further interview with Unit Manager, LVN A, he stated that he did not remember if CR#2 had any changes in condition before he was discharged from the facility and that he did not remember hearing or being told that CR#2 ever had low oxygen saturations and said changes in respiratory status is a change in condition and the MD needs to be notified immediately. He continued saying that residents needed orders for oxygen and further said I do not see any orders for oxygen for CR#2. The MD needed to be notified and obtain orders. In an interview on 3/23/2016 at 3:10 p.m. with RN C, she stated that CR#2 had problems with his oxygen saturations during the night shift and that she received report that the MD was notified. She further stated that she did not call the MD because when she came on duty CR#2 was already on oxygen and that she remembered that after that time, CR#2 required continuous oxygen but that she did not check if there was an order for [REDACTED]. In an interview on 3/23/2016 at 3:24 p.m. with the DON, she stated that the facility has been having issues with the laboratory and that they had a couple of issues where laboratory work was not done timely including CR#2 and that CR#2 did not get to have his blood drawn on 3/13/2016 in a.m. because the laboratory did not come until 3:00 p.m. DON further said that at that time CR#2 had already left the facility with his family member. DON continued saying that the facility did not need to have written orders for oxygen therapy because those were standing orders. DON then said that CR#2 should had a care plan for his low oxygen saturations and development of [MEDICAL CONDITION] and continued saying Information about his low oxygen saturations was addressed but I don't remember hearing about the swelling to his legs. The PPS (Prospective Payment System) nurse is in charge of updating the care plans because we discussed changes in condition during our morning meetings and she is supposed to update the care plans. In an interview on 3/23/2016 at 3:40 p.m. with LVN D, she stated that she was the PPS nurse and said that she did not remember hearing any discussion of CR#2 having any changes in condition with his oxygen saturations, nausea or [MEDICAL CONDITION] during the morning meetings. She further said that an SBAR was completed on CR#2 due to his low potassium levels but she said she did not find an SBAR for the changes in oxygen saturation, [MEDICAL CONDITION] or the nausea. In a second interview on 3/23/2016 at 4:00 p.m. with ADON B, she stated that the MD should be notified if the oxygen saturations are below 90% in the residents and that the facility had a protocol for oxygen therapy but when oxygen saturations are below 90% it was beyond the facility's protocol and that the MD needed to be contacted for further instructions. In an interview on 3/24/2016 at 9:35 a.m. with CR#2's family member, she stated that on 3/13/2016 when she went to visit CR#2 at the facility, she found him white as a ghost and that CR#2 was complaining of inability to breath. She further said that she took CR#2 to a local clinic at that moment because he did not look good and couldn't breath and that the clinic called an ambulance immediately and that CR#2 was admitted on that day to the hospital and was diagnosed with [REDACTED].#2 stayed at the hospital for 8 days. In an interview on 3/24/2016 at 4:18 p.m. with NP E, she stated that she was notified only once about CR#2 running low oxygen saturations but that she did not hear more about it from the facility. She further said that CR#2 had admission orders [REDACTED]. She further said that she ordered to repeat the laboratory work because CR#2's potassium was critically low and that she did not heard anything more about the laboratory order results. NP E said that she heard that CR#2 went out on pass and did not return to the facility. Record review of the facility's policy and procedure Change in a Resident's Condition or Status revised April 2007 read in part: Our facility shall promptly notify the resident, his or her Attending Physician of changes in the resident's medical/mental condition and/or status . Record review of the facility's policy and procedure Oxygen Administration revised March 2004 revealed in part: The purpose of this procedure is to provide guidelines for safe oxygen administration. 1.- Verify that there is a physician's order for this procedure . Record review of the facility's policy and procedure Laboratory and diagnostic test results - Clinical protocol revised April 2007 revealed in part: The physician will identify and order diagnostic and laboratory testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests The CMS 672 dated 3/23/16 indicated a census of 84 residents.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 20 residents (Resident # 91) reviewed for pain management, as evidenced by: The facility failed to provide comprehensive pain assessments and adequate pain relief for Resident # 91 for 6 days after being admitted to the facility, 10/16/15 - 10/21/15. This failure affected 1 resident and placed an additional 35 residents on the pain management program at risk of not reaching their highest practicable physical, mental, and psychosocial well-being. Findings included: Resident # 91 Record review of Resident # 91's facility medical record revealed she had been admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident 91's unfinished MDS admission assessment revealed that her BIMS score for cognition was 11 out of a possible 15 indicating little cognitive impairment. The MDS assessment was still in it's completion time. During an observation on 10/20/2015 at 9:30 AM of Resident # 91 in her room she was crying and moaning. She was sitting up in a wheelchair, dressed in day clothing. She was observed to be grimacing and rubbing her right leg from the upper knee to below the knee. During an interview on 10/20/2015 at 9:30 AM with Resident # 91 she said she was in A lot of pain. I am in so much pain. I can't get my pain medication I am used to. I have really bad arthritis in my knees. I keep telling the nurses that I am in so much pain. I was out of pain medication for 1 ½ days until Sunday when a doctor came in and gave me something. I couldn't get my [MEDICATION NAME]. Resident # 91 stated her pain was much more than 10 (scored by a pain assessment of 0 being no pain to 10 being the worst pain the person could imagine) it is unbearable. Resident # 91 said that she did not receive her pain medication from Friday (10/16/2015) when she was admitted , until Monday (10/19/2015). She said she had a long history of pain from arthritis and that she had Always taken [MEDICATION NAME] every 4 hours. I even had a [MEDICATION NAME]. The doctor came in Sunday afternoon and prescribed [MEDICATION NAME], but only one every 8 hours. That doesn't work. I am here for therapy for a [MEDICAL CONDITION] and pain, so I can walk again. She said the nurse told her they had talked to the doctor over the phone to get the prescription. During an interview on 10/20/2015 at 9:45 AM with LVN D regarding Resident 91's pain medication, he said that he would check and see what she had for pain. He said that she was a new admit to the facility and he did not know too much about her. He said She asks for pain medication all the time. I put in a call to her doctor about it and I am waiting to hear back. He said that she had [MEDICATION NAME] for pain which the weekend doctor had ordered for her as needed. On 10/21/2015 at 12:30 PM an observation of Resident # 91 revealed she was in her wheelchair in the hallway, trying to wheel herself back to her room. She was observed to be grimacing. During an interview with Resident # 91 at this time she said she had to ask several times to get a pain pill, but she didn't know what it was. She said she still had to ask for a pain pill and was being told she could only have pain medication every 8 hours. She said she kept telling them it didn't last. She was unaware if it was [MEDICATION NAME] or Tylenol # 4 (Tylenol with [MEDICATION NAME]). She said the staff did not tell her what she was taking. She said she was very distressed and frustrated to have to wait so long for some pain relief. During an interview on 10/21/2015 at 4:40 PM with Dr. A related to Resident # 91's pain and management of her pain, he said he did not want to give anyone a lot of pain medication. He said he had not personally seen his patient, but that Dr. B had prescribed [MEDICATION NAME] 50 mg PRN. He said that he had written an order for [REDACTED]. A said he did not want to over-dose anyone. Surveyor explained to Dr. A what Resident # 91 had told her about the resident's long history of having received pain medications every 4 hours. Dr. A then was observed to go to the resident's room. On 10/21/2015 at 4:55 PM, Dr. A came to the conference room where the surveyors were situated and stated that the surveyor had been right. He said that upon observation and talking to Resident # 91 he would write a different script order for her to have pain medication more often. He said I couldn't see the pain she was having over the phone. So when I saw her I have planned on giving her [MEDICATION NAME] every 6 hours and will give her steroid injections that I will bring here because she can't come to my office. Record review of Resident #91's medical record revealed that an Admission Pain Assessment, dated 10/17/2015, documented that Resident # 91 had frequent pain. The verbal pain assessment was blank. The pain assessment was mostly blank not recording where the resident was having pain. The pain frequency had not been addressed. According to this Admission Pain Assessment , section D, Resident 91 told the interviewer that her pain was a 4 indicating that it was Very severe, horrible. In section G, the interviewer documented that Resident 91 had received PRN pain that had been documented as effective. The actual pain medication, the date and time she received the medication was not documented. This Pain Assessment tool did not indicate the identity of the nursing staff who interviewed the resident. Further record review of Resident # 91's medical record revealed progress notes dated 10/16/2015 at 6:32 PM documenting she received [MEDICATION NAME] 50 mg. Give 1 tablet by mouth as needed for Pain - Moderate related to Pain in unspecified joint. An entry in progress notes dated 10/16/2015 at 7:18 PM read in part [MEDICAL CONDITION] noted on bilateral lower extremities, pt c/o leg pain This E-Progress note did not identify the writer. A progress note dated 10/17/2015 at 11:41 PM read in part Resident expressed concerns of which pain medications she would be getting. Dr. (B) was rounding this evening and spoke with resident as well as the resident's son on the telephone. He wrote new orders for PRN pain medications. An entry documented in the progress notes dated 10/17/2015 at 1:15 PM read in part [MEDICATION NAME] 50 mg. Give 1 tablet by mouth as needed for Pain . This E-Progress note did not identify the writer. A progress note dated 10/18/2015, documented by therapy at 11:53 PM, read in part .Wheelchair dependent. DX: Total hip replacement. A progress note dated 10/18/2015 at 12:42 PM read [MEDICATION NAME] 50 mg. Give 1 tablet by mouth as needed for Pain - Moderate, related to Pain in unspecified joint. This E-Progress note did not identify the writer. A physician progress notes [REDACTED]. (A) .This is a female with hx of depression, [MEDICAL CONDITIONS], generalized joint pain who is admitted to (nursing facility) for subacute rehab. Patient does not voice any limiting factors with therapy other than generalized pain Pain: on [MEDICATION NAME] prn. Would consider initiation of [MEDICATION NAME] for [MEDICAL CONDITION] if patient is unable to participate well in therapy. A progress note dated 10/20/2015 at 2:11 PM read [MEDICATION NAME] 50 mg. Give 1 tablet by mouth as needed for Pain - Moderate related to Pain in unspecified joint. A progress note dated 10/20/2015 at 4:06 PM read in part Resident has N.O. order for Tylenol #4 for pain as needed. Administered PRN med for pain. C/O [MEDICATION NAME] 10/325 mg 1 PO Q 8 hours is not often enough. MD will not increase dosage or administration time She also has a current order for [MEDICATION NAME] 50 mg 1 PO Q 4 hours PRN for pain. We will try to manage pain with current PRN and scheduled pain meds. There was no identification of which nursing staff documented this information on the E-progress notes. Record review of Resident # 91's MAR indicated [REDACTED] 10/16/2015: [MEDICATION NAME] 50 mg. given at 5:37 PM and 11:55 PM. Both MAR indicated [REDACTED]. given at 4:00 PM (routine medication) 10/17/2015: [MEDICATION NAME] 50 mg. given at 6:00 AM. Documented in MAR indicated [REDACTED]. 10/18/2015: [MEDICATION NAME] 50 mg. given at 09:10 AM and documented as effective; [MEDICATION NAME] 300 mg ([MEDICAL CONDITION]) given TID; [MEDICATION NAME] 10-325 mg. at 3:00 PM and 11:00 PM. 10/19/2015: [MEDICATION NAME] 300 mg ([MEDICAL CONDITION]) given TID; [MEDICATION NAME] 10-325 mg. at 7:00 AM, 3:00 PM, and 11:00 PM. 10/20/2015: [MEDICATION NAME] 50 mg. given at 11:00 AM and was documented as effective; [MEDICATION NAME] 300 mg. given TID; [MEDICATION NAME] 10-325 mg. at 7:00 AM, and 3:00 PM. Record review of the facility's policy and procedure titled Pain Assessment and Management, dated April 2009,revealed it read in part: General Guidelines .2) Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident 5) Conduct a comprehensive pain assessment upon admission to the facility 6) Assess the resident's pain and consequences of pain at least each shift for acute pain, or significant changes in levels of chronic pain Implementing Pain Management Strategies: 3) Addiction to narcotic [MEDICATION NAME] is not likely if used appropriately for moderate to severe pain 5) b) Administering medications around the clock rather than PRN; c) Combining long-acting medications with PRNs for breakthrough pain .Documentation: 1)Document the resident's reported level of pain .2) Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record. According to the CMS Form 672 provided by the DON there were 36 residents in the facility on a pain management program.

Based on interview and record review, the facility failed to provide services in accordance with the written Plan of Care for 1 of 5 residents (CR #1) reviewed for compliance with physician's orders [REDACTED]. -CR # 1 did not receive the correct IV hydration as ordered by the MD. This failure affected 1 resident and could place an additional 102 residents at risk for not receiving the care and services ordered by the physician and a decline in health status. Complaint # 0 Findings include: Record review of the facility face sheet revealed CR #1 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. CR #1 expired in the facility on [DATE]. Record review of the care plan dated [DATE] for CR #1 revealed in part:- Focus- alteration in nutrition/hydration at risk for aspiration due to CR #1 requires tube feeding related to dysphagia. Goals - CR #1 will maintain adequate nutritional and hydration status as evidenced by no signs and symptoms of dehydration through target date [DATE]. Record review of the facility Nutrition assessment for CR #1 dated [DATE] revealed in part "current tube feeding was not meeting nutritional goals. Risk for dehydration, weight loss and wound decline". Record review of the admission MDS dated [DATE] revealed CR#1 had an intellectual disability, required extensive assistance of two persons for bed mobility, transfers, toilet use and was total dependent on staff for eating. Record review of CR#1's facility laboratory chemistry results, collected and dated [DATE] revealed: Sodium Critical High 157 mmol/L Reference Range (,[DATE]) and BUN High 53 mg/dl Reference Range (,[DATE]). Record review of CR#1's facility laboratory chemistry results, collected and dated [DATE] at 5:25 am revealed: Sodium Critical High 156 mmol/L Reference Range (,[DATE]) and BUN High 65 mg/dl Reference Range (,[DATE]). Further record review revealed nursing facility was made aware by the laboratory of results on [DATE] at 10:06 am and MD was made aware on [DATE] at 12:00 p.m. Record review of CR #1's telephone orders dated [DATE] at 3:00 pm revealed orders: D5W at 70 cc/hour 2 liters. Record review of CR #1's physician progress notes [REDACTED]. Nursing error noted D5NS was hung. Rhonchi (a course rattling respiratory sound) noted - D5W (5% [MEDICATION NAME] in water) just started. Record review of CR #1's progress notes dated [DATE] at 6:12 pm revealed in part: Health status note - received sleeping, oxygen at 3 liters oxygen saturation 92%, blood pressure ,[DATE], pulse 72, respirations 20 and temperature 101.1 axillary. MD here. Further record review revealed health status note in part at 8:24 pm - temperature 101.1 axillary. Tylenol 650 mg via gastrostomy. Continued review revealed health status notes at 11:07 pm read in part: shift change rounds CR #1 found by staff to be in [MEDICAL CONDITION] when nurse entered room, patient did not have a pulse, did not have a blood pressure and respirations were 0. CPR was initiated. After 10 minutes CR #1 was pronounced dead. In an interview on [DATE] at 10:30 am, MD C revealed CR #1 had high Sodium levels due to poor intake of fluids. She stated on [DATE] around 6:00 p.m. she entered the room of CR #1 and he was connected to different IV fluids from what she had ordered. She stated "it was the wrong fluid, it was Sodium, and it would make his Sodium levels go higher". She stated CR #1 had been infused with approximately 200 cc of the wrong IV fluids when she noticed the error. She stated a nurse was inside of the room and immediately removed the wrong IV fluids. In an interview on [DATE] at 11:10 a.m. LVN A stated he was the nurse for CR #1 on [DATE] on the 6 - 2 p.m. shift and he remembered getting some critical lab results for CR #1 during the morning and calling the doctor. He further stated he also remembered the doctor ordered IV fluids. He stated he gave the orders to the DON for follow up and that he did not hang the IV "it was almost time for him to go home, so I gave it to the DON so she could clarify the orders because CR#1 did not have a peripheral line". In continued interview at that time, LVN A stated he did not document on CR #1's chart regarding his critical laboratory levels, assessments or the notification to the doctor. LVN A stated he was supposed to document any laboratory results and any follow up including assessments. He further stated they are supposed to notify the doctor immediately if the laboratory values were critical. In an interview on [DATE] at 1:50 pm, LVN B revealed she was the nurse for CR #1 on [DATE] for ,[DATE] p.m. shift. She stated when she arrived to work on [DATE] at 2:00 p.m., CR #1's IV was already infusing. She stated when she noticed that CR #1 had D5NS infusing, the doctor was already at the facility and was made aware. She stated she did not make the DON aware of the wrong IV fluids infusing to CR #1. In continued interview LVN B stated on [DATE], CR #1 was very lethargic and had fever on her shift. She also stated she signed CR #1's MAR indicated [REDACTED]. She stated she did not start the IV. In an interview on [DATE] at 2:00 p.m. the DON revealed she was not aware that CR#1 had wrong IV fluids infusing on [DATE]. She stated LVN A did not notify her of any orders for CR#1. Record review of the facility Hydration - Clinical Protocol, revised [DATE], read in part: " ...Assessment and recognition: The staff, with the Physician's input, will identify individuals with signs and symptoms (for example, [MEDICAL CONDITION], lethargy, increased thirst, etc.) or laboratory test results (for example, [MEDICAL CONDITION], azotemia, etc.) that might reflect existing fluid and electrolyte imbalance. A. They will report this information promptly to the attending physician. Monitor and follow-up. 2.- The physician will adjust treatments based on specific information (laboratory results, level of consciousness, etc) relevant to that individual. According to the CMS 672 dated [DATE], there were 102 residents in the facility.

Based on interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental or psycho-social well being according to the plan of care and comprehensive assessment for 1 of 5 residents (CR #1)reviewed for care and services, as evidenced by: -CR #1 dietary recommendation written on [DATE] regarding his hydration needs were not addressed; -On [DATE] was given the wrong hydration orders. These deficient practices affected one resident and could place 9 residents with tube feedings at risk of dehydration, skin breakdown, urinary tract infections, kidney failure and death. Intake # 0 Findings include: Closed record review of the facility face sheet revealed CR #1 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. CR #1 expired in the facility on [DATE]. Record review of CR #1 admission physician orders [REDACTED]. Record review of the facility Nutrition assessment for CR #1 dated [DATE] revealed in part "current tube feeding was not meeting nutritional goals. Risk for dehydration, weight loss and wound decline". Review of the Nutrition Progress notes for CR #1 dated [DATE] at 1:29 pm revealed in part: Admission assessment continued: Recommend 1) change formula via PEG to [MEDICATION NAME] 1.5 65 cc/hr continuous 2) Modify water flushes to 100 cc every 6 hours, 30 cc before/after medications, 10 cc between medications. New regimen will supply approximately 1495 cc/ 2243 kcal/1163 cc free water. Record review of the admission MDS dated [DATE] revealed CR#1 had an intellectual disability, required extensive assistance of two persons for bed mobility, transfers, toilet use and was total dependent on staff for eating. CR #1 was identified with a feeding tube. Continued record review revealed CR #1 had received diuretics during the last 7 days or since admission. Record review of the care plan dated [DATE] for CR #1 Revealed in part:- Focus- alteration in nutrition/hydration at risk for aspiration due to CR #1 requires tube feeding related to dysphagia. Goals - CR #1 will maintain adequate nutritional and hydration status as evidenced by no signs and symptoms of dehydration through target date [DATE]. - Interventions - Registered dietician to evaluate quarterly and as needed. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. CR #1 is dependent with tube feeding and water flushes. Further review revealed no information of CR #1 being admitted to the facility on [MEDICATION NAME] therapy. Record review of consolidated physician orders [REDACTED]. Continued reviewed revealed [MEDICATION NAME] was discontinued on [DATE]. Record review of CR#1's facility laboratory chemistry results, collected and dated [DATE] revealed: Sodium Critical High 157 mmol/L Reference Range (,[DATE]) and BUN High 53 mg/dl Reference Range (,[DATE]). Record review of CR#1's facility laboratory chemistry results, collected and dated [DATE] at 5:25 am revealed: Sodium Critical High 156 mmol/L Reference Range (,[DATE]) and BUN High 65 mg/dl Reference Range (,[DATE]). Further review revealed nursing facility was made aware by the laboratory of results on [DATE] at 10:06 am and MD made aware on [DATE] at 12:00 p.m. Record review of CR #1's telephone orders dated [DATE] at 3:00 pm revealed orders: D5W (5% [MEDICATION NAME] in water)at 70 cc/hour 2 liters. Record review of CR #1's the [DATE] MAR indicated [REDACTED] Record review of CR #1's physician progress notes [REDACTED]. Nursing error noted D5NS (5% [MEDICATION NAME] in normal saline) was hung. Rhonchi ( coarse rattling respiratory sounds) noted - D5W just started. Record review of CR #1's progress notes dated [DATE] at 6:12 pm revealed in part: Health status note - received sleeping, oxygen at 3 liters oxygen saturation 92%, blood pressure ,[DATE], pulse 72, respirations 20 and temperature 101.1 axillary. MD here. Record review of the health status note dated [DATE] at 20:24, revealed in part: temperature 101.1 axillary. Tylenol 650 mg via gastrostomy. Continued review revealed health status note at 11:07 pm read in part: shift change rounds CR #1 found by staff to be in [MEDICAL CONDITION] when nurse entered room, patient did not have a pulse, did not have a blood pressure and respirations were 0. CPR was initiated. After 10 minutes CR #1 was pronounced death. In an interview on [DATE] at 3:30 p.m. with nurse consultant D revealed the DON was on vacation and the dietary recommendation folder was in the DON's office for follow up. In an interview on [DATE] at 4:20 p.m. nurse consultant D stated the dietary recommendations for CR #1 dated [DATE] were not followed up. She stated "we are going to check them all to make sure none gets missed or overlooked again". In an interview on [DATE] at 10:30 am, MD C revealed CR #1 had high Sodium levels due to poor intake of fluids. She stated on [DATE] around 6:00 p.m. she entered the room of CR #1 and he was connected to different IV fluids from what she had ordered. She stated "it was the wrong fluid, it was Sodium, and it would make his Sodium levels go higher". She stated CR #1 had been infused with approximately 200 cc of the wrong IV fluids when she noticed the error. She stated a nurse was inside of the room and immediately removed the wrong IV fluids. In an interview on [DATE] at 11:10 a.m. LVN A stated he was the nurse for CR #1 on [DATE] on the 6 - 2 p.m. shift and he remembered getting some critical lab results for CR #1 during the morning and calling the doctor. He further stated he also remembered the doctor ordered IV fluids. He stated he gave the orders to the DON for follow up and that he did not hang the IV "it was almost time for him to go home, so I gave it to the DON so she could clarify the orders because CR#1 did not have a peripheral line". In continued interview at that time, LVN A stated he did not document on CR #1's chart regarding his critical laboratory levels, assessments or the notification to the doctor. LVN A stated he was supposed to document any laboratory results and any follow up including assessments. He further stated they are supposed to notify the doctor immediately if the laboratory values were critical. In an interview on [DATE] at 1:50 pm, LVN B revealed she was the nurse for CR #1 on [DATE] for ,[DATE] p.m. shift. She stated when she arrived to work on [DATE] at 2:00 p.m., CR #1's IV was already infusing. She stated when she noticed that CR #1 had D5NS infusing, the doctor was already at the facility and was made aware. She stated she did not made DON aware of the wrong IV fluids infusing to CR #1. In continued interview LVN B stated on [DATE], CR #1 was very lethargic and had fever on her shift. She stated she signed CR #1's MAR indicated [REDACTED]. She stated she did not hang the IV. In an interview on [DATE] at 2:00 p.m. the DON revealed she was not aware that CR#1 had wrong IV fluids infusing on [DATE]. She stated LVN A did not notify her of any orders for CR#1. Record review of the facility Enteral Nutrition policy and procedure, revised [DATE], read in part: " .... Adequate nutritional support through enteral feeding will be provided to residents as ordered. Policy interpretation and implementation: 1.- A dietitian will assess residents who are receiving enteral feedings, and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. 2.- The dietitian will review admission information with the nursing staff and Physician to determine the initial orders. Record review of the facility Hydration - Clinical Protocol, revised [DATE], read in part: " ...Assessment and recognition: The staff, with the Physician's input, will identify individuals with signs and symptoms (for example, [MEDICAL CONDITION], lethargy, increased thirst, etc.) or laboratory test results (for example, [MEDICAL CONDITION], azotemia, etc.) that might reflect existing fluid and electrolyte imbalance. A. They will report this information promptly to the attending physician. According to the CMS 672 dated [DATE], there were 9 residents on tube feedings.