Every finding on record at Ponce Therapy Care Center and Rehab, The

Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #85) of a total sample of 34 residents, received housekeeping services to maintain a sanitary interior in their room. The findings include: A review of the medical record revealed that Resident #85 was initially admitted to the facility on [DATE], and was readmitted on [DATE]. His diagnoses included the following: Encounter for other orthopedic aftercare, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, unspecified fracture of the lower end of left radius, subsequent encounter for closed fracture with routine healing, and diabetes mellitus with unspecified diabetic retinopathy. A review of the admission minimum data set (MDS) assessment, dated 7/26/23, revealed that a brief interview for mental status (BIMS) was not conducted because the resident was rarely/never understood. The facility staff documented Resident #85's cognitive status as moderately impaired. On 10/23/23 at 10:45 AM, Resident #85's room was observed. The floor adjacent to the resident's bed, an approximate three by three-feet-wide area, was covered with splatters of a red and orange substance on the floor near the upper left hand corner of the resident's bed. Multiple splatters of the red and orange substance were on the baseboard near the upper left side of the resident's bed, and multiple splatters of the red and orange substance were on the upper left side of the resident's bed rail. (Photographic evidence obtained) The resident explained that the splatters were a result of his vomiting the night before. On 10/23/23 at 2:25 PM, a second observation was made of the splatters of red and orange substance on the floor near the upper left hand corner of the resident's bed, multiple splatters of the red and orange substance on the baseboard near the upper left of the resident's bed, and multiple splatters of the red and orange substance on the upper left side of the resident's bed rail. There had been no change since the previous observation on 10/23/23 at 10:45 AM. (Photographic evidence obtained). On 10/24/23 at 10:12 AM, an observation of the resident's room revealed that the areas splattered with the red and orange substance had been partially cleaned. On 10/26/23 at 10:30 AM, Certified Nursing Assistant (CNA) E reported that she was assigned to care for Resident #85. She stated she did not notice the splatters of a red and orange substance on the resident's floor. On 10/26/23 at 11:00 AM, Registered Nurse (RN) F explained that she did not observe the red and orange splatters on the resident's floor. If she were to observe a mess in a resident's room, she would not walk past it, but clean it up. On 10/26/23 at 11:08 AM, Licensed Practical Nurse (LPN) G reported that she did not observe splatters of a red and orange substance while in the resident's room performing bedside blood glucose monitoring. On 10/26/23 at 11:21 AM, Housekeeper I reported that she was assigned to Resident #85's room. She explained that she did not see splatters of the red and orange substance on the floor or bedrail in the resident's room. On 10/26/23 at 11:30 AM, CNA H reported that she was familiar with Resident #85 and said she noticed what appeared to be soup splattered in the resident's room on 10/23/23. She reported it to housekeeping that day. She said the resident did not complain of an upset stomach. The resident often put food on the bedroom floor with the intent to feed his cats and dogs, which were not in the facility. She also explained the resident had soup and a sandwich the night before (10/22/23), and housekeeping thought the spill on the floor was tomato soup. On 10/26/23 at 12:42 PM, the Director of Housekeeping and Laundry was interviewed and reported resident rooms and bathrooms had a regular daily clean, which included wiping down hard surfaces, sweeping and mopping to disinfect the floor. Bathroom supplies, such as hand soap and paper towels were replenished. Rooms were deep cleaned once a month or more frequently if needed. If a CNA or nurse saw a mess in a resident's room, they were expected to contact Housekeeping and request housekeeping services. If Housekeeping Services observed a mess on the floor, they were expected to clean it up. Housekeeping began cleaning resident rooms at 8:00 AM and finished at 3:00 PM. From 3:00 PM to 8:00 PM, someone from Housekeeping was available to do as needed cleaning. A review of the facility's Daily Resident/Patient Room Cleaning process noted required items to conduct cleaning services and a procedure. The room cleaning tasks should be performed in the following order: Straighten up the resident's room, dust all flat surfaces with a cloth and disinfectant, clean the air vent covers, and spot clean all necessary areas; dust mop the floor and sweep all trash and debris to the door and pick it up wit the dustpan . wet mop the room using disinfectant .

Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #52) of four residents reviewed for inability to carry out Activities of Daily Living (ADLs), from a total sample of 34 residents, received proper grooming. The findings include: A review of Resident #52's medical record revealed that he was initially admitted to the facility on [DATE] and was readmitted on [DATE]. His diagnoses included the following: orthopedic aftercare, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, unspecified fracture of the lower end of left radius, subsequent encounter for closed fracture with routine healing, and diabetes mellitus with unspecified diabetic retinopathy. A review of the quarterly minimum data set (MDS) assessment, dated 8/2/23, revealed a brief interview for mental status (BIMS) score of 10 out of 15 possible points, indicating moderate cognitive impairment. On 10/23/23 at 10:45 AM, Resident #52 was observed with facial hair on his chin, cheeks, and upper lip, which measured approximately one and three quarter inches long. The resident explained that the long facial hair bothered him, and he had requested that the staff trim his facial hair several months ago but no one responded. He also stated he disliked the long hair on his upper lip, which came into contact with his mouth while he spoke and ate. On 10/24/23 at 10:24 AM, Resident #52 was observed with five of ten fingernails extending approximately one half inch beyond his fingertips. (Photographic evidence obtained) Many of the long fingernails were jagged. The resident explained that he did not like his fingernails so long, and had asked facility staff multiple times to trim his nails. The resident also said he touched his face often and was fearful he would scratch his eye with such long, jagged nails. On 10/26/23 at 10:30 AM, Certified Nursing Assistant (CNA) E, assigned to provide care to the resident, reported that she was familiar with the resident and his activities of daily living needs. She explained that she did not notice the resident's long facial hair or long fingernails. She said she could not recall the resident asking to have his facial hair or nails trimmed. On 10/26/23 at 11:00 AM, Registered Nurse (RN) F, assigned to Resident #52's hallway, reported that she was familiar with the resident and his activities of daily living needs. She explained that routine care of residents should include daily observations of resident appearance and grooming needs. When a resident's nails were excessively long and had grown past the top of the fingers, they should be trimmed because long nails could potentially cause a resident to scratch themself. The process to trim nails was to clean the nail, soak the nail and either file down or clip the nail tip to shorten the length. She stated that when a resident's facial hair was long, or grew over the lip, the facial hair should be trimmed. She explained that shaving facial hair should be part of the daily routine while providing residents with activities of daily living care. On 10/26/23 at 11:08 AM, Licensed Practical Nurse (LPN) G reported that she was assigned to care for Resident #52. She explained that when she encountered the resident, the resident did not request her to shorten his nails or facial hair. LPN G expressed that she performed blood glucose monitoring for the resident and did not notice the length of his nails while checking his blood glucose level. She explained that she used to work as a certified nursing assistant and was well familiar with providing activities of daily living and grooming care. On 10/26/23 at 11:25 AM, LPN D reported that she worked at the facility on an as needed basis and provided the names of staff assigned to care for the resident. On 10/26/23 at 11:30 AM, CNA H explained that she was assigned to provide care to Resident #52 during the day shift and was familiar with the care the resident required. She expressed that she did not notice the resident had excessively long fingernails. She reported that the resident did not request that his nails or facial hair be trimmed. If she noticed the resident's nails or facial hair was long, she would have trimmed the facial hair and nails. A review of the resident's medical record revealed no documented evidence that the resident refused care or assistance in activities of daily living. A review of the facility's Standards and Guidelines: Activity Care and Assistance Manual - Nursing (Implemented on 01/15/21 and Reviewed/Revised on 1/15/21), documented Personal Hygiene: How resident maintains personal hygiene, including combing hair, brushing teeth, shaving . .

Based on observations, staff, resident and family interviews, record review, and facility policy review, the facility failed to ensure that one (Resident #36) of two residents reviewed for skin conditions, from a total of 34 residents sampled, received wound treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The findings include: On 10/23/23 at 12:30 pm, Resident #36 was observed sitting up in a wheelchair in his room, next to his bed, dressed in day clothes. Both of his lower extremities were observed with a dressing on each leg. The dressings were dated as follows: 10/18/23 on the right lower leg, and 10/22/23 on the left lower leg. Observation of the left lower leg dressing revealed reddened skin with a small black area at the furthest end visible outside of the dressing area. The dressing had a small amount of drainage visible on the top and bottom of the dressing. The dressing on the right lower leg was dated 10/18 and had a second (undated) dressing on top of it with one spot of drainage noted on the right side of the second dressing. The resident was asked how often his leg dressings were changed, and he replied that he wasn't sure. On 10/24/23 at 3:15 pm, Resident #36 was observed lying in bed. His wife was visiting at bedside. She was asked if she knew how often wound care was provided to the resident's legs. She stated, I think it's every other day. Dressings were still dated 10/18/23 on the right lower leg and 10/22/23 on the left lower leg. The left lower leg dressing observation revealed reddened skin with a black area at furthest end visible outside of the dressing area. The dressing had drainage visible on the top and bottom of the dressing. The dressing on the right lower leg, dated 10/18, was observed with a second (undated) dressing on top of it with one spot of drainage noted on the right side of second dressing. (Photographic evidence obtained) On 10/24/23 at 3:25 pm, Licensed Practical Nurse (LPN) A/Wound Care Nurse was observed in the 100 hallway at a treatment cart. She was asked if she was the wound care nurse. She stated yes. She was asked if she had any other wound treatments or assessments on this hallway to complete. She stated just one at the end of the hallway. She and the wound care physician were observed entering the room at the end of the hallway. They were not observed entering Resident #36's room. On 10/25/23 at 6:55 am, Resident #36 was observed lying in bed. He was asked if his leg dressings had been changed. He stated I don't think so. Look and see. Observation of both lower extremities revealed a dressing on the right lower leg dated 10/18, and a left lower leg dressing dated 10/22. The left lower leg dressing observation revealed reddened skin with a black area at the furthest end visible outside of the dressing area. The dressing had drainage visible on the top and bottom of the dressing. The right lower leg dressing had a second (undated) dressing on top of the dressing dated 10/18, with one spot of drainage noted on the right side of second dressing. (Photographic evidence obtained) A review of Resident #36's medical record revealed a physician's order dated 10/9/2023, which read: Cleanse denuded area on right lower extremity with normal saline, pay dry. Apply Xeroform, cover with border gauze every day shift, every 3 days for wound care. The medical record review did not reveal a wound care order for the resident's left lower extremity. Further review of the record revealed an electronic treatment administration record (eTAR), which showed that the treatment for the right lower leg had been signed off by nursing as though care had been provided as ordered on October 10, 13, 19, and 22 (2023). A review of the person-centered care plan for Resident #36 revealed: Focus (7/10/23) The resident has potential/actual impairment to skin integrity related to history cellulitis. Goal: The resident will be free from injury through the review date. The resident will maintain or develop clean and intact skin by the review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Monitor/document location, size, and treatment of skin injury. Record abnormalities. In an interview with LPN A/Wound Care Nurse on 10/26/23 at 10:50 am, she was asked about Resident #36's lower extremity wounds. She stated, Yes, he bumped his right lower leg. It was about a month ago. His wife came and told me, and I observed a skin tear and the area was denuded. His left lower leg, when I went in to see him yesterday I saw someone had placed a dressing, but no one had told me about it, so I wasn't aware. It looks like a skin tear area. He has a history of Peripheral Vascular Disease (PVD) and edema, and he does get skin tears easily. He also has a history of vascular wounds, but those are all completely healed at this time. She was asked what the treatments for each lower leg wound were. She stated, Both wounds are cleansed with normal saline and Xeroform is applied and then covered with a border gauze. She was asked how often the dressings were changed. She stated, Every three days. She was asked who changed the dressings. She stated, I do if it falls on a weekday. If it falls on the weekend, the floor nurse assigned to the resident changes the dressings. She was asked why the dressing for the right lower extremity hadn't been changed from 10/18/23 until 10/25/23. She stated, I don't know. I think it was due to be changed on the weekend. The nurse must not have changed it. I changed it yesterday. She was asked if she knew why the treatment was signed off as having been completed on 10/22/23. She stated, No, I don't know why it was signed off if it wasn't completed. She was asked to confirm that the dressing on the resident's right lower extremity had not been changed as ordered for seven days. She stated, That's correct. She was asked to clarify whether the left lower extremity had any wound care due when she discovered the dressing on that area yesterday. She stated, No, he didn't have any wound care due for his left lower leg. I found the dressing dated 10/22 yesterday and no one had told me anything about it. I called the doctor and got an order. A review of the facility's policy titled Wound Care (revised 1/15/21) revealed: Standard: It will be the standard of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds, and the treatment of skin impairment. Guidelines: 6. Wound care procedures and treatments should be performed according to physicians' orders. .

Based on observations, interviews and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for one (Resident #1) of 34 residents sampled. Resident #1's room was observed over a period of three days with several razors left lying on the resident's sink. This practice could result in injury to this resident or any other resident who entered this room and had access to the razors. The findings include: On 10/23/23 at 11:11 am, three disposable razors were observed in the bathroom belonging to Resident #1. The razors were positioned behind the water faucet on the sink. Two of the razors were covered by a clear plastic cap. The third was uncovered and appeared to have been used. (Photographic evidence obtained) A second observation of the razors was made on 10/24/23 at 3:46 pm. The razors remained in the same location in the resident's bathroom positioned behind the water faucet. A third observation of the razors was made on 10/25/23 at 10:17 am. The razors remained in the same location. The resident was present in the room outside of the bathroom. He was asked about the use of the razors. He stated the aides used the razors to shave him when he got his showers. He did not know who provided the razors or how long they had been there. A review of the medical record revealed that Resident #1 was admitted to the facility on [DATE]. His diagnoses included cerebral palsy, chronic obstructive pulmonary disease (COPD), hypertension, anxiety disorder, and major depressive disorder. A review of the quarterly minimum data set (MDS) assessment, dated 8/25/23, revealed that Resident #1 had a brief interview for mental status (BIMS) score of 14 out of 15 possible points, indicating intact cognition. He required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. He required supervision with locomotion on and off the unit and for eating. During an interview conducted on 10/25/2023 at 10:22 am with Licensed Practical Nurse (LPN) D, she stated sharps were not permitted in resident rooms. She stated they were stored in the nurses' bin. It was the responsibility of all staff to monitor the residents' rooms. She stated they did rounds daily and checked the residents' rooms. On 10/25/2023 at 10:39 am, a tour was conducted of Resident #1's room with LPN D. Three disposable razors remained positioned behind the water faucet on the sink in the resident's bathroom. Upon observing the razors, LPN D gathered all of the razors in her hand. She removed them from the resident's bathroom and exited the resident's room. She confirmed that the razors should not have been left in the resident's bathroom. During an interview conducted on 10/25/23 at 3:25 pm with the Assistant Director of Nursing (ADON), she stated there was a list of items not permitted in resident rooms. She stated the residents had to sign it and it was uploaded in the electronic medical system. She stated residents were discouraged from bringing the disposable razors, adding that they were provided by the facility. She stated the were kept in a box in the shower room, not in the residents' rooms. She stated the facility staff conducted rounds to check resident rooms for prohibited items i.e., razors. She stated the Guardian Angels and Department Heads went around and checked the resident rooms and their belongings, adding that they had to ask the residents first, but they check for anything that they might sneak in. She stated the rounds were conducted Monday through Friday during the morning shift, however, if they were unable to do it before the clinical meeting, they did it after the meeting. She stated a second round was performed during the afternoon. This was done because some of the residents' families would sneak things in. She stated the razors found in the bathroom of Resident #1 were brought in by a family member the previous day. She was advised that the razors had been present in the resident's bathroom for three days. She stated she had not been made aware of that information. She confirmed that the razors should not have remained in the resident's bathroom. A review of the facility's Items Not Allowed in the Residents' Rooms list revealed the following: Under Federal Law, these items are prohibited in residents' rooms and may present a hazard to the health of the residents. Included in the list of items not allowed were knives and shart objects. These items are prohibited in residents' rooms for the safety of your loved ones and our other residents. If management finds these items in a resident's room, they will be removed. You may retrieve these items when you discharge. .

Based on observations, staff, resident and family interviews, medical record review, and facility policy review, the facility failed to ensure that one (Resident #36) of two residents reviewed who required respiratory care, from a total of 34 residents sampled, was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan. The findings include: On 10/23/23 at 12:30 pm, Resident #36 was observed sitting up in a wheelchair in his room, next to his bed, dressed in day clothes. He was receiving oxygen via a nasal cannula. The oxygen concentrator was set at 1 liter per minute (LPM). The resident requested to go back to bed. Two certified nursing assistants (CNAs) assisted the resident back to bed via a mechanical lift. One CNA was observed removing the resident's nasal cannula in order to complete the transfer. When she was finished, she asked the resident if he would like to have his oxygen back on. She stated, Do you want your oxygen back on? It's as needed, so it's up to you. The resident stated yes. The concentrator was set at 1 LPM after the CNA left the room. On 10/24/23 at 10:45 am, Resident #36 was observed lying in bed, awake. His nasal cannula was in place on his face. The oxygen concentrator was set at 1 LPM. (Photographic evidence obtained) On 10/24/23 at 3:15 pm, Resident #36 was observed lying in bed. His spouse was visiting. His oxygen flow rate was set at 1 LPM on the concentrator. (Photographic evidence obtained) His spouse was asked if she knew at what rate the resident's oxygen should be set. She stated, The last I knew, it was 2 LPM. I'm not sure. On 10/25/23 at 6:55 am, Resident #36 was observed lying in bed, awake. His oxygen cannula was observed on his bedside table. (Photographic evidence obtained) The oxygen concentrator was set at 1 LPM. (Photographic evidence obtained) He was asked why his nasal cannula was not on his face. He stated, I don't know, it's around here somewhere. On 10/25/23 at 10:25 am, Resident #36 was observed lying in bed, awake and watching TV. His oxygen concentrator was set at 4 LPM. The nasal cannula was in the resident's bed. On 10/25/23 at 10:27 am, Licensed Practical Nurse (LPN) B was asked if he was caring for Resident #36 today. He stated yes. He was asked what the resident's oxygen flow rate should be set at. He stated, I was told at report that it's 3 LPM. I haven't checked it yet today. He was asked what time he started his shift today. He stated 7:00 am. He was asked to observe the resident's oxygen flow rate. Upon entering the resident's room, he stated, It's up above 4 LPM. He was asked if the order was for continuous oxygen or oxygen as needed. He stated, I'm not sure. I need to go check the order. He returned and stated, I just checked. His order is continuous. He was asked if he had observed this morning that the resident was not using his oxygen. He stated, No, I'm just getting to this room. On 10/25/23 at 1:30 pm, Certified Nursing Assistant (CNA) C was asked if she was caring for Resident #36 today. She stated, No, but I have cared for him on other days and I do assist his assigned aide with him. She was asked what her role as a CNA was regarding his oxygen. She stated, Well the nurse monitors it. If I see he doesn't have it on, I'll let the nurse know. I will let the nurse know if anyone has their oxygen off, but as the CNA, I don't put it back on. She was asked if she was aware of what setting the residents' oxygen should be set on. She stated, No, not generally. I usually know my own residents' settings just from caring for them and knowing them, but I don't know the settings for all the residents on the floor. On 10/25/23 at 1:35 pm, Resident #36 was observed lying in bed with the head of the bed elevated and eating lunch. His wife was sitting next to him. He was observed not wearing his oxygen. He was asked why his oxygen was off. He stated, I take it off when I'm eating. His wife stated he did remove it while he was eating. He was asked if he was able to put it back on when he was finished eating. He stated, Sometimes I can. He was asked if staff assisted him with putting it back on. He stated, Sometimes they do, sometimes they don't. A review of Resident #36's medical record, revealed a physician's order dated 7/3/23, which stated: Oxygen at 3 liters/minute via nasal cannula with humidification. Further medical record review revealed a person-centered care plan which revealed: Focus (7/10/2023) The resident has altered respiratory status/difficulty breathing related to chronic obstructive pulmonary disease (COPD). Goals: The resident will have no complications related to shortness of breath through the review date. The resident will have no signs/symptoms of poor oxygen absorption through the review date. Interventions: Oxygen settings: Oxygen per MD orders. A review of the facility's policy titled Respiratory Care and Oxygen Administration (revised 1/15/21) revealed: Standard: It is the standard of this facility to provide guidelines for respiratory care and safe oxygen administration. Guidelines: 1. Verify there is a physician's order for oxygen use. Review the physician's order for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident.

Based on interviews and record review, the facility failed to ensure that a resident who was continent of bladder and bowel on admission received services and assistance to maintain continence unless his or her clinical condition was or became such that continence was not possible to maintain, and that a resident who was incontinent, received appropriate treatment and services to restore continence to the extent possible, for two (Residents #5 and #6) of six residents sampled. Specifically, these residents were placed in briefs and were not offered other means of toileting. Failure to maintain continence or attempt to improve incontinence, when possible, could lead to functional loss and impaired dignity. The findings include: During an interview with Director of Rehabilitation (DOR) B on 6/12/2023 at 4:42 p.m., she stated Occupational Therapy assessed residents upon admission, while the Certified Nursing Assistants (CNAs) assessed the residents' toileting functioning levels. Therapists promoted dignity and the resident trying to use the bathroom. They did not encourage the use of incontinence pads. The goal was to get the residents to use the toilet, however, if it was not safe for the staff, then therapy would encourage a bedside commode or bedpan for the resident's use. Therapy worked with residents to find the most dignified way for them to use the bathroom. On 6/13/2023 at 12:42 p.m., Resident #5 was observed in his room with his personal Case Manager. The resident stated he was aware of his rights in the facility. When asked about toileting, he stated he could go to the bathroom on his own. If he had an accident in his brief, staff would come in and help him get cleaned up. He confirmed that he was wearing a brief at the time of the interview and stated he preferred to use the toilet or the urinal. No urinal was observed in the resident's room or bathroom. He stated he could walk to the bathroom with the use of his walker. A walker was observed within his reach. An interview was also conducted with the resident's Case Manager who was in the resident's room at the time. She stated she had concerns that the facility was causing Resident #5 to become incontinent by forcing him to wear incontinence briefs. She stated upon admission, he was fully continent and his episodes of incontinence had begun to increase. In the past, she had spoken with DOR B regarding Resident #5 having a urinal in his room to promote and maintain urinary continence; however, someone kept removing it. She addressed this again on 6/12/2023 with DOR B who provided the resident with another urinal at that time; however, when the Case Manager arrived on the morning of 6/13/2023, the urinal had been removed from the resident's room again. A record review revealed that Resident #5 was admitted into the facility on [DATE]. His diagnoses included unspecified fracture of left femur - subsequent encounter for closed fracture with routine healing; unspecified dementia; atrial fibrillation; fecal impaction and peripheral vascular disease. A review of the Admission Minimum Data Set (MDS) assessment, dated 4/15/2023, revealed that Resident #5's Brief Interview for Mental Status (BIMS) score was 15/15, indicating intact cognition. He was totally dependent on staff for transfers and locomotion on and off the nursing unit. He required extensive assistance with personal hygiene, toilet use, dressing and bed mobility, with supervision required for eating. At the time of the assessment, he was documented as occasionally incontinent of bladder and frequently incontinent of bowel. A review of Resident #5's Care Plan, revealed focus areas including Falls and ADL (Activities of Daily Living) Self-Care Performance Deficit. Toileting and/or incontinence was not among the focus areas addressed in the resident's Care Plan. On 6/13/2023 at 1:11 p.m., Resident #6 was observed sitting in her room. She stated she was in the facility for short-term rehabilitation. When asked about toileting, she stated she was continent. The facility required her to wear incontinent briefs because they didn't want her to put any pressure on her foot. She didn't want to wear the brief and preferred to use the bedside commode. She was asked if she had been offered a bedpan for use. She stated no. She stated she was agreeable to using a bedpan. The facility staff had not offered any alternate toileting means; she had been wearing the incontinence briefs since her admission. A record review revealed that Resident #6 was admitted to the facility on [DATE]. Her diagnoses included effusion right knee; cerebral infarction; acute kidney failure; atrial fibrillation and a need for assistance with personal care. At the time of the survey the resident's MDS assessment had not been completed. A review of the Baseline Care Plan, initiated on 6/10/2023, revealed the following: FOCUS: Resident has urinary incontinence GOAL: Resident will not develop complications associated with urinary incontinence. INTERVENTIONS/TASKS: Resident has or is at risk for urinary incontinence. Check every 2-3 hours and/or as required for incontinence. Provide incontinence care as needed. If the resident has some control, check with resident every 2-3 hours for need to toilet. Encourage to ask for assistance in advance of need and not wait until need to urinate is urgent. During an interview with DOR B on 6/13/2023 at 2:23 p.m., she stated there was never a reason a resident should not be permitted to use the bathroom. She added that the resident's safety would be taken into consideration. Regarding Resident #5, she stated he was currently receiving therapy. He was starting to progress with moderate assistance and recently started walking a distance of 35 feet. She confirmed she had been speaking with his Case Manager regarding his progress and toileting concerns. She denied knowledge of reasons that would prohibit Resident #5 from having a urinal or being assisted to the bathroom. She stated the nursing department provided residents with urinals and they were stored in the central supply room. Regarding Resident #6, DOR B stated she was a readmission. The resident required total assistance from staff at this time with use of a mechanical lift. She stated the use of the incontinence brief was a recommendation based on safety; however, alternatives should be offered. She added the recommendation was always to offer an alternative to voiding on the sheets or in a brief. The bedpan was an option for use. There was nothing preventing the resident from using the bedpan. She should not be forced to wear a brief. During an interview with Registered Nurse (RN) A on 6/13/2023 at 2:40 p.m., she stated she was familiar with Resident #5. She referred to him as incontinent; however, she was unsure if he was able to alert staff when he had to use the bathroom. She stated on 6/12/2023 she spoke with his Case Manager about him using the urinal. The facility was addressing that request. She confirmed that nursing did provide the urinals. When advised about the urinal being removed from Resident #5's room, she stated she was not aware that it had been removed again. She stated she would speak with the CNAs about it. She was somewhat familiar with Resident #6. If Resident #6 activated her call light and asked to use the bathroom, she should have been permitted to use the bedpan. A review of the facility's policy for Standards and Guidelines Perineal/Incontinence Care Manual: Nursing Date Implemented: 3/1/2021: Dated 3/1/2021 revealed: Guidelines: #5 The facility must ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

Based on staff and resident interviews, observations and record review, the facility failed to ensure a resident requiring respiratory care, received such care in accordance with professional standards of practice, by failing to 1) Properly monitor and report to the physician the non-usage of the bilevel positive airway pressure ([CONDITION(S)]) device, and 2) Maintain an operable [CONDITION(S)] device to carry out physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #38) of one resident reviewed, from a total of 38 residents in the sample. The findings include: During an interview conducted on 01/03/22 at 12:22 PM, Resident #38 stated, My [CONDITION(S)] machine was inoperable for several months, and I haven't had an appointment with the pulmonologist. It's been about a year since I've used the [CONDITION(S)] machine. During an interview on 01/04/22 at 12:00 PM, Licensed Practical Nurse (LPN) G/Unit Manager, stated, I'm very familiar with [Resident #38] and the [CONDITION(S)] machine. It doesn't work. [Resident #38] has had four machines this year. I don't know how or why her machines keep breaking, but she finds a way to have a broken machine. On 01/05/22 at 11:55 AM, Resident #38's [CONDITION(S)] device was checked to see whether it was operable, but the device did not come on. Resident #38 stated, It may be unplugged because it doesn't work. The device was observed to be unplugged. It was plugged into the receptacle, and it remained inoperable. During a 01/05/22 interview with LPN F at 2:46 PM, she stated, The CNAs (certified nursing assistants) lay eyes on it ([CONDITION(S)] device) first. I check [CONDITION(S)] usage when I do med (medication) passes. I'm familiar with [Resident #38]. She has a lot of medical concerns. She goes to the doctor every week for multiple issues. She's not on oxygen, and I'm not sure if she is still on her [CONDITION(S)] or not. Mostly everyone that I've seen on [CONDITION(S)] machines is independent. They take them off themselves or put them back on. If a shift nurse told me that they (residents) had one ([CONDITION(S)]), then I would check the machine to see if it's working. I don't know if she (Resident #38) is using it or not. She doesn't use it on my shift. I don't know if she has had multiple machines. No one has complained to me about issues with the [CONDITION(S)] machine. I know that most of the time if there are issues with equipment, we go to the Unit Manager and ask her if she knows anything about it. The Unit Manager would pursue repair options. Once we have checked the [CONDITION(S)] for use or if it's working, we sign off on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During a 01/06/22 interview with Certified Nursing Assistant (CNA) C at 10:54 AM, he stated, I've worked the 100 hall before when I first started here. I know [Resident 38]. I don't ever remember her saying that her [CONDITION(S)] machine was not working. In that situation, when a [CONDITION(S)] is not working, I would report it to my nurse, and I guess the nurse will go with her procedures. I have worked night shifts before, and I have seen [Resident #38] with her [CONDITION(S)] on before, but that was a long time ago. During a 01/06/22 interview with CNA H at 1:46 PM, she stated, I'm familiar with [Resident #38], but I haven't worked with her in a while. She hasn't told me her [CONDITION(S)] wasn't working. It's been a while, but I haven't seen her with her [CONDITION(S)] on. If a machine is not working, I go tell the nurse. If a resident tells me a machine is not working, I'll go and look and then go tell the nurse. When asked whether she had been provided any training about what to do if she found a device that was not operating properly, she replied, No, I haven't had any training on what to do if machines are not working. During a 01/06/22 interview with LPN G/Unit Manager at 2:02 PM, she stated, The [CONDITION(S)] is inspected on a daily/weekly basis. The CNAs and the resident will inform you if there is something wrong. I would go to the Central Supply person to have something ordered. In regard to [Resident #38], I've asked several times for the replacement of the [CONDITION(S)]. According to the Central Supply person, the supply company would not send another machine until the resident saw a pulmonologist. I don't know if the former Central Supply person made notes as to the request. I did the chain of command. (I was informed by a CNA that the [CONDITION(S)] wasn't working. I informed my Unit Manager and I let Central Supply know.) This happened in 2021 but I am unsure when this took place. A new machine was received yesterday (01/05/2022) evening in operable condition. It was ordered by the Regional Nurse. A review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No documented evidence was found since 02/02/2021 to indicate that an appointment was made with or that the resident was seen by a pulmonologist. No documented evidence was found since 02/02/2921 to indicate that the resident's physician was made aware that the resident's [CONDITION(S)] was not working, and she was therefore, not utilizing the device as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the resident's care plan, initiated on 11/12/2021, revealed a focus area for Altered Respiratory Status/Difficulty Breathing related to [CONDITION(S)], CHF, and sleep apnea with [CONDITION(S)] as ordered. Elevate head of bed as needed (PRN) to facilitate breathing, encourage sustained deep breathing, monitor/document changes in orientation, increased restlessness, anxiety, and air hunger. Monitor for signs and symptoms of respiratory distress and report to physician. Monitor/document/report abnormal breathing patterns. Oxygen as ordered, Respiratory Treatment, Equipment Cleaning and Functioning. A review of the Treatment Administration Record (TAR) revealed that the [CONDITION(S)] usage monitoring was being performed every day from 10/01/2021 to 01/04/2022 despite conflicting interviews with Resident #38 and staff members as noted above. (Photographic evidence obtained) A review of the facility's Environmental Equipment Care Policy (Implemented on 01/15/2021) revealed: - Paragraphs (8) Mechanical, electrical, and patient care equipment shall be maintained in safe operating condition (9) Equipment or other maintenance related needs should be communicated with the Supervisor, Maintenance Director or Executive Director. Communication may be done verbally if the appropriate personnel are present and able to remedy the concern. A communication system and/or maintenance tracking log can be utilized to communicate maintenance or repair needs for off shift or other desired needs. According to British Journal of Anaesthesia (M. [NAME], U. Freo, A. S. BaHammam, D. Dellweg, F. [NAME], R. Cosentini, P. Feltracco, A. Vianello, C. [NAME], A. Esquinas, Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials, BJA: British Journal of Anaesthesia, Volume 110, Issue 6, June 2013, Pages 896-914, https://doi.org/10.1093/bja/aet070) the utilization of a [CONDITION(S)] Non-Invasive Ventilator can greatly reduce the overall distress for patients, practical complications, and mortality with proper settings and diligent monitoring.

Based on observations, interviews, and record review, the facility failed to treat a resident's pain to the extent possible, by failing to identify and treat pain that persisted beyond the resident's current pain regimen for one (Resident #85) of three residents reviewed for pain management from a total of 38 sampled residents. The findings include: A review of Resident #85's medical record revealed an admitted [DATE]. His primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #85 required extensive assistance from staff for activities of daily living. On 1/4/2022 at 8:39 a.m., an interview was conducted with Resident #85. He stated his left knee had been hurting really bad for about three days. He stated he had chronic pain, but this pain started during a transfer in which his left knee was twisted. He stated he had received [MEDICATION(S)] (narcotic pain medication for moderate to severe pain) but that it was not working. A review of Resident #85's comprehensive care plan revealed a focus area for Actual Pain that was related to diabetic [CONDITION(S)] and impaired mobility. The first intervention directed staff to anticipate the resident's needs for pain relief and respond immediately to any complaint of pain. The second intervention directed staff to evaluate the effectiveness of pain interventions and to review for compliance, symptom alleviation, dosing schedules, resident satisfaction with results, and impacts on functional ability and cognition. The third intervention directed staff to monitor and document the probable cause of each pain episode and remove or limit causes where possible. The seventh intervention directed staff to notify the physician if interventions were unsuccessful or if the current complaint was a significant change from the resident's past experience of pain. (Photographic Evidence Obtained) On 01/05/2022 at 1:35 p.m., a second interview was conducted with Resident #85. He rated his current pain as an 8 on a 0-10 verbal scale, with zero equaling no pain and 10 equaling the most severe pain. He described the pain as sharp, stabbing, and constant. He stated he didn't feel like doing much of anything because of the pain. Resident #85 was asked what the facility was doing to treat his pain. He stated he was receiving pain medication, but that it did not work at all and his knee had been hurting constantly since the incident. On 01/05/2022 at 3:16 p.m., an interview was conducted with Licensed Practical Nurse (LPN) B. She confirmed that she was assigned to Resident #85. She stated she had just come on shift and she was not aware of any pain concerns related to Resident #85's left knee. The nurse confirmed that she had not received any information about Resident #85's pain during the change-of-shift report. The nurse then explained that Resident #85 did not often verbally complain of pain, but He uses the call light a lot and asks for repositioning all the time. Sometimes I think that is his way of complaining of pain. The nurse added that the resident did receive [MEDICATION(S)] every eight hours, but that she did not think it was effective. A review of Resident #85's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A second order was noted for acetaminophen two tablets to be given orally every four hours as needed for pain or fever. The order did not include a dosage. A review of the medication administration records (MARs) for November 2021 through January 2022 revealed documentation of administration of the [MEDICATION(S)] but no documentation of its efficacy. (Photographic Evidence Obtained) Continued review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic Evidence Obtained) Further review of the medical record revealed no documentation that the consultation had been scheduled or that the resident had attended it. On 01/06/2022 at 1:07 p.m., an interview was conducted with the Nurse Practitioner. She confirmed that she was familiar with Resident #85. She stated she was very familiar with the resident's complaints of pain. She added that the resident was receiving [MEDICATION(S)] every eight hours, but that the pain seems unrelieved. The Nurse Practitioner stated she had requested the resident be evaluated by neurology for neuropathic pain and twitching because she wasn't sure what was causing the pain. When asked about the original order for a neurology consult on 11/18/2021, the Nurse Practitioner stated she had asked the facility why the appointment had not been scheduled but never could get a definite answer. She added that she reordered the consultation on 01/05/2022. When asked whether the resident had been considered for evaluation by a pain management physician, the Nurse Practitioner stated she thought that would be a good idea, because she was unable to determine the cause of the resident's pain and the resident had not been seen by a pain management physician that she was aware of. On 01/06/2022 at 1:45 p.m., an interview was conducted with Certified Nursing Assistant (CNA) D. She stated she had worked in the facility since August 2021 and was employed by a staffing agency. She confirmed that she was assigned to Resident #85 and was familiar with his care. When asked whether the resident ever complained of pain, she stated, He complains of pain to his abdomen area a lot. When asked whether the resident ever complained of knee pain, the CNA stated, sometimes he does. The CNA added that she had reported the resident's complaints of pain to the nurses several times. On 01/06/2022 at 1:52 p.m., an interview was conducted with the Unit Manager. He confirmed that he was familiar with Resident #85. He identified the resident as having a lot of concerns and requiring a lot of attention. The Unit Manager confirmed that the resident had chronic pain concerns. When asked to describe the facility's interventions to manage the resident's chronic pain, he stated, On different days he complains of different types of pain all over his body. I know he gets [MEDICATION(S)] every eight hours. When asked how the pain management interventions were monitored for effectiveness, the Unit Manager stated, Well, we go back in and check to see if it worked. If it didn't work, we call the nurse practitioner. I know the nurse practitioner just ordered a neurology consult to see if we can figure out where the pain is coming from. When asked whether he was aware that an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . I will call the office and schedule an appointment. On 01/06/2022 at 5:55 p.m., an interview was conducted with the Director of Nursing (DON). He stated he was not very familiar with Resident #85, as he had just started working at the facility a few weeks ago. The DON stated he had not reviewed Resident #85's pain regimen prior to the survey. Regarding the monitoring of pain medication effectiveness, the DON explained that nurses would be expected to monitor the efficacy of the medication and document the findings. He stated for as-needed (PRN) medications, the electronic record system prompted the nurses to enter the effectiveness after a specific time frame, but he was unsure of whether the system had the same function for medications scheduled to be given routinely. Regarding Resident #85's neurology appointment, the DON explained that Someone outside of the facility schedules the appointments. He stated, It doesn't work that good. The facility's Pain Management policy, titled Pain Screening and Management directed staff to monitor residents receiving ongoing pain management interventions and to document those findings to include observation of intensity and location of pain, frequency of as-needed [MEDICATION(S)] use, effectiveness of pain medications, and potential need for review by the physician for potential medication regimen review. The policy also directed staff to consider the resident's goals and preferences when developing the pain management regimen. (Photographic Evidence Obtained)

Based on observations, record review, and staff and resident interviews, the facility failed to meet the needs of residents in accordance with established national guidelines for five (Residents #83, #79, #2, #139, and #145) from a total of 38 sampled residents. Specifically, the facility failed to ensure that with reasonable efforts, the residents' allergies, food preferences, and therapeutic diets were honored/followed. The findings include: A review of the Resident Council Minutes dated 10/21/2021, documented that residents had a new concern with the dietary department. Residents stated the kitchen was out of items often or they weren't getting items on their trays. This concern was noted to have been submitted to the dietary department for resolution. A review of the Resident Council Minutes dated 11/18/2021, documented that residents had a new concern with the dietary department. Residents stated, The meat (pork, beef, and occasionally chicken) is tough and hard to cut with a knife. This concern was noted to have been submitted to the dietary department for resolution. There was no documentation indicating a resolution to the dietary concern from 10/21/2021. 1. A review of Resident #83's medical record revealed that she was admitted on [DATE] with diagnoses including cerebral infarction, type 2 diabetes mellitus, recurrent depressive disorder, anxiety disorder, hypertension, gastrointestinal reflux disease, protein malnutrition, dysphasia, dementia with behavioral disturbances, and [CONDITION(S)]. A review of quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #83 had a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 points, indicating moderate cognitive impairment. She was documented with a consistent carbohydrate diet of a mechanical soft texture and a regular liquid consistency, as well as medications including [MEDICATION(S)] (insulin) and [MEDICATION(S)] (antidiabetic medication) for diabetes. Resident #83's care plan included a food allergy to strawberries, a need for a specialized diet to address glucose levels due to type 2 diabetes mellitus (low concentrated sweets/mechanical soft/thin liquids). During an interview with Resident #83 on 01/03/2022 at 12:40 PM, she reported she had a food allergy to strawberries but had been given strawberry jelly at breakfast several times and strawberry short cake on her food tray. 2. During an interview with Resident #79 on 01/03/2022 at 2:22 PM, she complained that her breakfast was always wrong. She confirmed she had an allergy to egg yolk and pineapple, but received fruit cocktail with pineapple mixed on her food tray. She further stated she was allergic to the runny yolk of the egg but could have scrambled eggs, and had explained that to the kitchen staff. She stated she had only seen the choice menu twice in order to circle the items she wanted at mealtimes. During an interview with Certified Nursing Assistant (CNA) M on 01/06/2022 at 9:49 AM, she was asked whether she was familiar with Resident #79. She confirmed that she was familiar with this resident. She is a picky eater. CNA M stated the resident's egg allergy was on her food ticket, but she wanted scrambled eggs. She mostly drinks her own protein shakes. CNA M was asked to explain the process for how resident menu items were selected. She stated the menu came out on Sunday for the coming week, and the everyday menu came out during the 3-11 shift each day for the following day and was kept at the nurse's desk. Menus were also available hanging on the wall outside of the dining room. CNA M stated she was not sure if the everyday menus were provided to all residents or only to certain residents who requested them. She confirmed that it was the CNA's responsibility to provide the everyday menus to all residents. When asked to explain when and how the everyday menus were submitted to kitchen, CNA M stated any staff member could take the menu back to the kitchen. Once the resident selected and circled the items they wanted, the staff member could return the slip to the kitchen. All meal tickets should be returned before the kitchen closed. During an interview with Resident #79 on 01/06/2022 at 10:14 AM, she was asked which food items she was eating for breakfast most of the time. She replied, My own [MEDICATION(S)] Protein (protein drink). When asked whether she had spoken with the physician or registered dietitian (RD) regarding her egg preference, she stated she had spoken with them 4-5 times. I received a hard boiled egg today. I can have scrambled eggs or an omelet. I told them I'm allergic to egg yolks only when they are runny. Why not give me egg whites? When asked whether she had completed the everyday menu for today, Resident #79 replied that she had not received an everyday menu this week. During an interview with Licensed Practical Nurse (LPN) F on 01/06/2022 at 10:24 AM, she was asked whether she was familiar with Resident #79. LPN F stated she was and explained that the resident was alert, oriented and vocal. She fractured her left hip, had surgery and is here for rehab. She is progressing well. LPN F stated the resident had weight loss surgery a few years ago and had select items she would eat. She picks what she wants. When asked to explain the process for how the resident menu items were selected, LPN F stated, Sometimes [Resident #79] will request a sandwich in the morning, or if she doesn't want what is on her food tray, she will ask for something else. There is a meal ticket that comes on the tray for the residents to select their next meal, or the CNA will take the meal ticket to the resident for them to circle the items they want. I've seen it both ways. We have changed kitchen staff and it depends on who is working in the kitchen. LPN F stated most of the time, the everyday menus were provided only when a resident asked for them. A menu was provided for them to circle food items, then the staff member would take the menu right back to the kitchen. Menus should be returned before the kitchen closed. One copy of the everyday menu was observed on the desk at the nurse's station. LPN F was unsure of whether menus had been provided to residents for the next meal service. On 01/06/2022 at 11:51 AM, the Activities Director (AD) stated the facility's Food Committee met during the same time as Resident Council, every third Thursday at 10:30 AM. When asked who participated in the meeting, the AD replied, The DON (Director of Nursing), Regional Nurse, and the Kitchen Manager or Cook. On 01/06/2022 at 12:22 PM, a review of Resident #79's meal ticket revealed known food allergies to pineapple, egg, and citrus fruit. There was no choice meal ticket completed for the resident. On 01/06/2022 at 12:25 PM, a review of the Resident Council Minutes sign-in sheets and meeting notes revealed that the Regional Kitchen Staff was present during the September and December 2021 meetings. The October and November 2021 minutes identified concerns that the kitchen was often out of items or residents weren't getting items on their trays. (Photographic Evidence Obtained) A review of Resident #79's hospital Facesheet and Discharge Instructions, dated 11/10/2021 at 5:48 PM before her facility admission, revealed allergies to egg yolk and pineapple. During an interview with CNA J (Agency) on 01/06/2022 at 5:00 PM, she stated she had worked in this facility since October 2021, usually on the 3-11 shift. When asked whether she asked residents what they wanted on the menu, she replied No, I don't ask residents about their meals. I think the 7-3 shift does. When asked if she worked with any diabetic residents receiving special diabetic diets, she replied that there were no residents on the unit that were receiving diabetic diets. I check with the nurse to see if there are any diet concerns. I don't ask about diets. I expect it to be what they wanted. I serve whatever is on the tray. If the resident asks for a certain item when dinner arrives and they want a change, the CNAs will go to the kitchen and get what is requested. CNA J confirmed resident allergies were listed on the meal tickets. During an interview with Certified Dietary Manager (CDM) K on 01/06/2022 at 5:02 PM, she stated she was a full-time next level staff member and had been here at the facility 3-4 days per week since October 2021. When asked to describe the process for determining what residents wanted on the menu, she stated that upon admission, residents were interviewed by the RD or CDM. Residents and/or family members were provided menus to complete. A review of the facility's Diet Requisition Form revealed diet ordered nutrient content choices. CDM K stated it was up to the physician and RD regarding what diet to provide. Menus were updated as needed. Snacks were stocked in the pantry. We follow a CCHO (consistent carbohydrate diet for diabetes) diet. We don't carry sugar-free snacks. When asked how the facility would respond if a resident requested sugar-free Jell-O, CDM K stated, I would have to provide it. It would have to be up to the physician and RD. I can't change diets. When asked if a resident had requested a diet they had previously received, how their choice was honored, CDM K replied, I can honor preferences. I would turn it over to the RD and do a follow-up call to the physician. I can replace food items; whole milk to skim, sugar to sugar free. CDM K stated the choice menus went out with the dinner meal during the 3-11 shift. Sometimes the menus came back on the food tray, and some were placed in the dietary box on the door. CDM K stated she interacted with residents daily, and no concerns from Resident #79 had been brought to her attention. She confirmed she had no meeting with the resident regarding her meal requests. (Photographic Evidence Obtained) 3. A review of the medical record revealed that Resident #2 was admitted on [DATE] with diagnoses including unspecified calorie malnutrition, diabetes type 2, vitamin deficiency, and acute kidney failure. A review of the Physician's Order Sheets for December 2021 and January 2022 revealed current physician's orders for insulin and blood glucose monitoring. Resident #2 was documented as receiving a regular, NAS (no added salt) diet and double all entrees. Resident #2 was interviewed on 01/03/2022 at 9:45 AM regarding his dietary needs and choices. He said the meat, especially the pork chops, were too tough to eat. He also stated he was not being provided a diabetic meal as requested. Resident #2 was interviewed again on 01/03/2022 at 1:30 PM. He said he had just completed his lunch. He stated it was good but was not a diabetic diet. He had asked for a diabetic meal but stated the RD told him diabetic diets were not available. He was aware of the always available food choices, but stated they were mostly sandwiches. He said he liked the BLT (bacon, lettuce, tomato), but it was too much bread. The breakfast meal was powdered eggs. He said he loses weight when he is here. Resident #2 was interviewed on 01/04/2022 at 1:00 PM. He said he had ham, potatoes, two cups of pudding and apple pie. He was unaware that he did not have a physician's order for a diabetic meal. Resident #2 was observed on 01/05/2022 at 11:00 AM requesting a diabetic meal for lunch. The nurse stated she would make note of his request. A record review on 01/06/2022 at 12:25 PM, revealed the resident's meal ticket for 01/06/2022. He was not offered a diabetic diet as requested. Resident #2 was interviewed on 01/06/2022 at 2:35 PM with his spouse. The spouse said her husband had informed her that he was not getting a diabetic diet, but he should be. During an interview with CNA J on 01/06/2022 at 5:00 PM, she said the staff on the 7:00 a.m. to 3:00 p.m. shift managed the residents' meal choice tickets each day. She said she worked on the 3:00 p.m. to 11:00 p.m. shift. She discusses with the nurse each day whether there have been any resident care or dietary changes. She was unaware of any residents on her shift that had a diagnosis of diabetes. She said there were no sugar-free snacks, and she would normally not suggest any snack items. The residents would usually come up with the choice themselves, often a grilled cheese sandwich. She said Resident #2 often received food from family, and she was unaware of his need for a diabetic diet. She said he had not asked her for diabetic diet. An interview was conducted with CDM K on 01/06/2022 at 5:15 PM. She said the residents were given the diet that was established by the registered dietitian (RD) and physician. She was not able to adjust a resident's diet. They offered a carbohydrate diet for some residents, but did not have sugar-free or low-sugar menu items to offer. She said she did not always receive all of the menu choice forms each day. The menu choice forms were sent out with the dinner meal for the next day's options. She said the 3:00 p.m. to 11:00 p.m. shift was responsible for this. She said the facility had options that should be offered to the residents, but they did not have sugar-free snacks. She said there might be a need to do additional education with the CNAs so that when they offered the food choices to the residents each day, they were sure they knew what to offer. She said this would be especially true of any items the resident may want that were not on the food lists. She said she was aware that Resident #139 was a vegetarian. The facility had soy patties or other alternate protein choices. She said mashed potatoes did get offered a lot, but if the CNAs were not offering other vegetarian options, they probably just needed more education. She said that not all daily meal choice forms were turned back in to the dietary department each day. An interview with the Director of Nursing (DON) was conducted on 01/06/2022 at 5:45 PM. He said a restricted sugar and carbohydrate (RSC) diet was available to residents with diabetes. The diet did not include no sugar items, but some foods such as unsweetened tea were available. The DON said he was not aware of any concerns with Resident #2 or his diet choices. 4. An interview was conducted with Resident #139 on 01/04/2022 at 10:05 AM. She stated she was a vegetarian. She said that since her admission to the facility on [DATE], she had not spoken to anyone from the kitchen or the registered dietitian (RD) regarding her meal choices. She said she received mashed potatoes all the time with an additional rotating selection of carrots, peas, and green beans. She said it was over and over again. If she asked for something else to eat, they would give her a peanut butter sandwich. Sometimes they would offer her another item, but it she had requested on many occasions to receive something other than mashed potatoes. She said she did not eat meat, but she would like other options such as pasta or salad. She said no one had helped her resolve this problem. A record review revealed a 12/17/2021 physician's order for a vegetarian/vegan only, regular diet. An interview was conducted with LPN G on 01/06/2022 at 3:45 PM. She said the CNAs asked the residents what choices they wanted from the menu the day before that meal was scheduled. She said the CNAs did not necessarily know, or were able to easily tell, how the menus met dietary restrictions, preferences, or the needs of the residents. She said none of the residents were on restricted or therapeutic diabetic diets. Instead, as an example, she said residents on diabetic diets would receive snacks that were high in protein, not necessarily low in sugar. An interview was conducted with CNA A on 01/06/2022 at 4:08 PM. She said the CNAs on the 3:00 p.m. to 11:00 p.m. shift took a full meal choice list to each of the residents on their unit. She said the staff member would then circle the residents' food choices for the next day. An interview was conducted with CNA J on 01/06/2022 at 4:48 PM. She said she did not ask residents about their meal choices. She said she believed the CNAs on the 7:00 a.m. to 3:00 p.m. shift asked the residents. She said she would always check with the nurse on duty to see whether there were any dietary concerns, or possible changes in full status. She said she did not ask about diets. She did review what was on the resident's meal tray, but she said she expected what the resident was being served was what they wanted from their choice selection. She said she and the dietary department both reviewed for any allergy concerns. An interview was conducted with CDM K on 01/06/2022 at 5:40 PM. She said the residents were given the diet that was established by the registered dietitian (RD) and physician. She said she was not able to adjust a resident's diet. She said they had options that should be offered to the residents. She said they did not have sugar-free snacks. She said there might be a need to do additional education with the CNAs so that when they offered the food choices to the residents each day, they are sure they knew what to offer. She said this would be especially true of any items the resident may want that were not on the food lists. She said she was aware that Resident #139 was a vegetarian. The facility had soy patties and other alternate protein choices. She said mashed potatoes did get offered a lot, but if the CNAs were not offering other vegetarian options, they probably just needed more education. She said that not all daily meal choice forms were turned back into the dietary department each day. 5. Resident #145 was observed in bed on 01/03/2022 at 12:36 PM. The resident verbalized concerns with nutrition he was provided being of poor quality. Upon review of the weekly menu, Resident #145 stated, What you see is what you get. When he was asked about food alternatives, he said alternatives were not readily available. The resident was not aware of the always available menu which was posted in the hallways. The resident was not able to ambulate and required total care. Further, the resident stated the kitchen/cafeteria usually closed early, and it was not possible to get a cup of coffee at 9:00 p.m. or at 9:00 a.m. The resident was interviewed on 01/04/2022 at 9:31 AM. He stated the morning's meal was same, same. An interview was conducted with CNA M on 01/05/2022 at 11:09 AM. She was unable to explain the process of ensuring each resident received the appropriate and preferred meal items. Her response was that she did not know what process was used to inform the residents of food choices because she was only agency staff. An interview was conducted with LPN G on 01/05/2022 at 11:12 AM. She displayed a menu slip that the night nurses and CNAs were handed each evening. The evening staff were then responsible for delivering the menu slips to each resident for completion. This menu slip would be filled out to identify which food items the resident wished to receive the following day. Staff were to assist residents who needed help completing the form.

Based on record review and staff interviews, the facility failed to maintain accurately documented resident medical records by failing to accurately document the use of a bilevel positive airway pressure ([CONDITION(S)]) device during the evening and night shifts for one (Resident #38) of one resident reviewed, from a total of 38 sampled residents. Specifically, the nursing staff executed 137 Treatment Administration Record (TAR) entries indicating use of a [CONDITION(S)] device when the resident's [CONDITION(S)] device was inoperable. The findings include: During an interview conducted on 01/03/22 at 12:22 PM, Resident #38 stated, My [CONDITION(S)] machine was inoperable for several months, and I haven't had an appointment with the pulmonologist. It's been about a year since I've used the [CONDITION(S)] machine. During an interview on 01/04/22 at 12:00 PM, Licensed Practical Nurse (LPN) G/Unit Manager, stated, I'm very familiar with [Resident #38] and the [CONDITION(S)] machine. It doesn't work. [Resident #38] has had four machines this year. I don't know how or why her machines keep breaking, but she finds a way to have a broken machine. On 01/05/22 at 11:55 AM, Resident #38's [CONDITION(S)] device was checked to see whether it was operable, but the device did not come on. Resident #38 stated, It may be unplugged because it doesn't work. The device was observed to be unplugged. It was plugged into the receptacle, and it remained inoperable. A review of the Treatment Administration Records (TARs) for October, November and December 2021, revealed the nursing staff signed off the forms as having observed Resident #38 utilizing a [CONDITION(S)] device when the device was inoperable: 12/31, 12/28, 12/27, 12/26, , 12/25, 12/24, 12/22, 12/21, 12/11, 12/10, 12/09, 12/08, 12/07, 12/05, 12/04, 12/03, 12/01, 11/27, 11/26, 11/22 (device unavailable), 11/21, 11/19, 11/16, 11/13, 11/12, 11/11, 11/10, 11/06, 11/05, 11/04, 11/03, 11/02, 10/29, 10/28, 10/27, 10/23, 10/22, 10/21, 10/20, 10/19, 10/16, 10/14, 10/09, 10/08, 10/07, 10/06, 10/04, and 10/02. On 01/06/2022 at 11:36 AM, progress notes in Resident #38's record were reviewed and were documented as follows: Effective date 01/05/2022 at 4:28 PM, authored by Licensed Practical Nurse (LPN)/Unit Manager G, Spoke to the Advanced Practice Registered Nurse (APRN) this shift in regards to the resident's [CONDITION(S)], and got an order to place on hold until she is seen by pulmonology. No adverse effects noted from the nonuse of the machine. will continue to monitor. Effective date 01/05/2022 at 5:30 PM, authored by LPN/Unit Manager G, Orders obtained for new [CONDITION(S)]. Settings are 15/7. Provider and resident aware. Appointment with pulmonology will remain in place. Effective date 01/05/2022 at 10:43 PM, authored by LPN/Unit Manager G, [CONDITION(S)] on and working properly. Resident noted to be resting in bed with eyes closed. During a 01/06/22 interview with LPN G/Unit Manager at 2:02 PM, she stated, The [CONDITION(S)] is inspected on a daily/weekly basis. The CNAs and the resident will inform you if there is something wrong. I would go to the Central Supply person to have something ordered. In regard to [Resident #38], I've asked several times for the replacement of the [CONDITION(S)]. According to the Central Supply person, the supply company would not send another machine until the resident saw a pulmonologist. I don't know if the former Central Supply person made notes as to the request. I did the chain of command. (I was informed by a CNA that the [CONDITION(S)] wasn't working. I informed my Unit Manager and I let Central Supply know.) This happened in 2021 but I am unsure when this took place. A new machine was received yesterday (01/05/2022) evening in operable condition. It was ordered by the Regional Nurse.

Based on interview, review of medical records, and review of the facility policy and procedure for mechanical lifts, the facility failed to ensure it maintained an environment free of accident hazards for one (Resident #2) of three sampled residents. Failure to provide two-person assist for mechanical lift could result in an accidental fall and injury for any resident who had mechanical lift requirements that were not met. The findings include: On 6/29/2021 at 5:44 AM, an observation was made of Resident #2 seated in a motorized wheelchair and a mechanical lift device was in the room with Employee A, Certified Nurse Aide (CNA). An interview was conducted with Employee A, CNA on 6/29/2021 at 5:44 AM. The CNA confirmed that it was easier to move Resident #2 alone, especially when there is no one around to help. The CNA stated that she did move Resident #2 in the mechanical lift by herself. She confirmed that she was supposed to have 2 staff present, but no one was around. An interview was conducted with An interview was conducted with Employee B, RN Charge Nurse on 06/29/2021 at 5:46 AM. The charge nurse confirmed that two staff members are required to use the mechanical lift to move residents. An interview was conducted with Resident #2 on 06/29/2021 at 7:23 AM. Resident #2 confirmed that when the unit had only three nurse aides, staff would move the resident in the lift from the bed to the wheelchair with only one staff member present. He stated that it happened more than one time recently. He stated he allowed this to happen because he did not want to sit in bed too long, and if he had to wait for the aides to get help from another staff member, they may not get him out of bed when he wanted to get up. A review of the Minimum Data Set, dated dated dated [DATE] for Resident #2 was conducted. It was documented that Resident #2 was in need of two-person physical assist to move between surfaces. It was included from bed to chair, wheelchair, and standing position. The care plan was reviewed for Resident #2 and documented Resident #2 had an Activity of Daily Living (ADL) self-care performance deficit and required extensive assistance of two staff members. Also documented under ADL was mechanical lift for transfers (Sit to Stand) and transfer extensive assist of two staff members. Documented under incontinence related to [CONDITION(S)] was the intervention for the toileting program two staff members to assist with toileting at all times. Resident #2 had a focus as at nutritional risk related to obesity with a body mass index greater than 30. Documented at focus for ADL's for CNA to remind resident and reinforce safety awareness. Educate and remind resident to request assistance for transfers and ADL's. Documented in the care plan for at risk for falls, the intervention was documented, Use sit-to-stand lift assist of two. A review of the facility policy and procedure titled, Mechanical Lifts dated revised on 1/15/2021 under Guidelines #5 documented when using the mechanical lift, 2 staff members should assist with the procedure to ensure resident and staff safety.

Based on resident and staff interviews, observations and clinical record review, the facility failed to develop a care plan for the treatment of [REDACTED].#3) of seven residents with physician's orders [REDACTED]. Failure to develop an individualized comprehensive care plan may result in physician-ordered specialized treatment not being administered for the benefit of the resident. The findings include: During a 01/14/2020 interview with Resident #3 at 10:10 a.m., she stated she had swelling in her feet. Her bare feet were observed with swelling. She was wearing slippers and her feet were not elevated. She stated, I can't find any socks, usually. They have a hard time keeping socks in here. She stated she did not usually wear socks unless it was cold outside, and because it was unseasonably warm today, she did not have socks on. She stated she had not worn compression stockings for a long time. On 01/15/2020 at 10:20 a.m., Resident #3 was observed lying in bed with her eyes closed. She had no compression stockings on her feet. On 01/15/2020 at 12:34 p.m., Resident #3 was observed in a chair in her room. She was wearing slippers but had no compression stockings on her feet. Her feet were not elevated. She stated she still had no compression stockings for her feet. On 01/16/2020 at 10:23 a.m., Resident #3 was observed lying in bed. She had her eyes closed. She was dressed in shorts and a t-shirt. Her feet were bare, with no compression stockings observed. A review of the face sheet in the resident's clinical record revealed she was admitted on [DATE] and then readmitted on [DATE]. The comprehensive minimum data set (MDS) assessment, dated 12/20/2019, revealed the resident was assessed as having a brief interview of mental status (BIMS) score of 14 out of a possible 15, indicating she was cognitively intact. She was diagnosed with [REDACTED]. A review of the physician's orders [REDACTED]. The resident's [DIAGNOSES REDACTED]. A review of Resident #3's care plans, dated 09/26/2019, revealed no care plan had been developed to address [MEDICAL CONDITION] and the use of compression stockings as ordered by her physician. During an interview with Employee A, Unit Manager (UM), on 01/16/2020 at 10:24 a.m., she was asked whether Resident #3 was to have compression stockings on. She went into the resident's room and observed the resident, who was lying in bed with her eyes closed. Her feet were bare. The UM stated she would have to look at the physician's orders [REDACTED]. She further stated it might be that the resident was refusing to wear them. She went back to the resident's room and began looking in the resident's nightstand to see if she had compression stockings. The resident woke up, the UM explained what she was doing. She asked the resident whether she had compression stockings and if so, where they were. The resident stated she did not have any and had not had any for a long time. The resident stated she was willing to wear them at night and if she was going to stay in her room and not go out to an activity. During an interview with Employee B, Director of Utilization Review, on 01/16/2020 at 01:16 p.m., she reviewed Resident #3's care plan on the electronic clinical record. She confirmed that there was no care plan addressing the resident's condition of [MEDICAL CONDITION] in her lower extremities. She stated the facility should have developed a care plan for [MEDICAL CONDITION] based on her [DIAGNOSES REDACTED]. She confirmed that the use of compression stockings was an intervention for [MEDICAL CONDITION]. During an interview with the Director of Nursing (DON) on 01/16/2020 at 01:39 p.m., she stated she had been informed by the UM that the staff were not applying the compression stockings to Resident #3. She further stated the Certified Nursing Assistants (CNAs) or the nurses could apply the compression stockings, but the nurse was to verify that it had been done. She acknowledged that Resident #3 had a current order in place for the application of compression stockings, and they should be applied as a treatment for [REDACTED].#3 for the treatment of [REDACTED].

Based on resident and staff interviews, clinical record reviews and facility policy and procedure review, the facility failed to provide treatment and care in accordance with professional standards of practice by failing to follow physicians' orders for three (Residents #26, #41 and #77) of six residents sampled for medication review, who were not administered their medications in a timely manner. The findings include: 1. Resident #26 was observed on 01/13/2020 at 10:39 lying in bed with a neck roll cushion under her head. She was wearing a nasal cannula with oxygen running. She stated she thought she had a pill caught in her throat. No water was observed in her room. The nurse was alerted and took water in to the resident. The nurse later stated Resident #26 did not get up out of bed unless she had an appointment. Resident #26 was transported to the hospital on [DATE] with acute [MEDICAL CONDITION]. A review of Resident #26's face sheet revealed she was admitted on [DATE] and then readmitted on [DATE]. Her [DIAGNOSES REDACTED].(chronic) (peripheral), [MEDICAL CONDITION], diaphragmatic hernia without obstruction, [MEDICAL CONDITION], dyspnea, long-tern drug therapy and pneumonia. Review of the physician's orders [REDACTED]. [MEDICATION NAME] tablet 0.25 milligrams (mg). Give 1 tablet by mouth two times a day related to anxiety disorder. The medication was scheduled at 9:00 AM and 9:00 PM. A review of the Medication Administration Record [REDACTED] 01/01/2020 at 13:12 hours (1:12 PM). 01/02/2020 at 10:27 AM 01/03/2020 at 8:09 AM. Due on 01/02/2020 at 21:00 hours (9:00 PM). 01/04/2020 at 6:25 AM. Due on 01/03/2020 at 21:00 hours (9:00 PM). 01/08/2020 at 11:01 AM 01/09/2020 at 11:26 AM 01/10/2020 at 12:04 PM. 01/13/2020 at 10:13 AM 01/14/2020 at 11:18 AM [MEDICATION NAME] tablet 20 mg. Give 3 tablets by mouth two times a day related to heart failure. Scheduled at 9:00 AM and 9:00 PM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/01/2020 at 13:14 hours (1:14 PM). 01/04/2020 at 6:24 AM. Due on 01/03/2020 at 17:00 hours (5:00 PM). 01/04/2020 at 10:43 AM. 01/08/2020 at 10:58 AM. 01/09/2020 at 11:45 AM 01/09/2020 at 23:45 hours (11:45 PM). 01/10/2020 at 12:01 PM. 01/13/2020 at 10:15 AM 01/14/2020 at 11:19 AM Potassium Chloride ER tablet extended release 10 meq. Give 2 tablets by mouth on time a day related to heart failure. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered Potassium Chloride on: 01/01/2020 at 13:15 hours (1:15 PM). 01/02/2020 at 10:30 AM. 01/08/2020 at 10:59 AM. 01/09/2020 at 11:46 AM 01/10/2020 at 12:02 PM. 01/13/2020 at 10:16 AM 01/14/2020 at 11:20 AM [MEDICATION NAME] Diskus Aerosol Powder Breath Activated 100 micrograms (mcg)/blist (inhalant). 1 puff inhale orally one time a day related to [MEDICAL CONDITION]. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] Diskus Aerosol Powder Breath Activated inhalant on: 01/01/2020 at 13:14 hours (1:14 PM). 01/02/2020 10:28 AM. 01/08/2020 at 10:58 AM. 01/09/2020 at 11:45 AM 01/10/2020 at 12:01 PM. 01/13/2020 at 10:11 AM 01/14/2020 at 11:19 AM [MEDICATION NAME] tablet 1 mg. Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION]. Scheduled at 9:00 AM A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/01/2020 at 13:13 hours (1:13 PM) 01/02/2020 at 10:28 AM. 01/08/2020 at 10:58 AM. 01/09/2020 at 11:44 AM 01/10/2020 at 12:00 PM. 01/13/2020 at 10:15 AM 01/14/2020 at 11:19 AM Duloxetine HCI capsule delayed release particles 60 mg. Give 1 capsule by mouth two times a day related to major [MEDICAL CONDITION]. Scheduled at 9:00 AM and 5:00 PM. A review of the MAR for (MONTH) 2020 revealed the resident was administered Losartan on: 01/02/2020 at 10:29 AM. 01/03/2020 at 8:08 AM. Due on 01/02/2020 at 17:00 hours (5:00 PM). 01/04/2020 at 6:23 AM. Due on 01/03/2020 at 17:00 hours (5:00 PM). 01/08/2020 at 10:58 AM. 01/09/2020 at 11:45 AM 01/10/2020 at 12:00 PM. 01/13/2020 at 10:15 AM 01/14/2020 at 11:19 AM Losartan Potassium tablet 50 mg. Give 1 tablet by mouth one time a day related to hypertensive [MEDICAL CONDITION] with heart failure. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered Losartan on: 01/01/2020 at 13:14 hours (1:14 PM). 01/02/2020 at 10:29 AM. 01/03/2020 at 10:32 AM. 01/08/2020 at 10:58 AM. 01/09/2020 at 11:45 AM 01/10/2020 at 12:01 PM. 01/13/2020 at 10:16 AM 01/14/2020 at 11:19 AM [MEDICATION NAME] R Solution 100 unit/ milliliter (ml). Inject 4 units subcutaneously before meals related to diabetes mellitus. Scheduled at 11:30 AM and 16:30 hours (4:30 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] R insulin on: 01/01/2020 at 13:24 hours (1:24PM). 01/01/2020 at 17:50 hours (5:50 PM) 01/03/2020 at 8:08 AM. Due on 01/02/2020 at 16:30 hours (4:30 PM). 01/04/2020 at 6:23 AM. Due on 01/03/2020 at 16:30 hours (4:30 PM). 01/06/2020 at 12:46 PM. 01/08/2020 at 17:41 hours (5:41 PM). 01/09/2020 at 23:44 hours (11:44 PM). 01/10/2020 at 17:57 hours (5:57 PM). 01/13/2020 at 14:01 hours (2:01 PM). [MEDICATION NAME] R Solution 100 unit/ml. Inject as per sliding scale. Scheduled at 11:30 AM, 16:30 hours (4:30 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] R insulin on: 01/01/2020 at 13:24 hours (1:24PM). 01/01/2020 at 17:50 hours (5:50 PM) 01/03/2020 at 8:08 AM. Due on 01/02/2020 at 16:30 hours (4:30 PM). 01/04/2020 at 6:23 AM. Due on 01/03/2020 at 16:30 hours (4:30 PM). 01/06/2020 at 12:45 PM 01/08/2020 at 17:37 hours (5:41 PM). 01/09/2020 at 23:44 hours (11:44 PM). 01/10/2020 at 17:57 hours (5:57 PM). 01/13/2020 at 14:01 hours (2:01 PM). [MEDICATION NAME] Solution 100 unit/ml. Inject 25 units subcutaneously every 12 hours related to type II diabetes mellitus. Scheduled at 6:00 AM and 6:00 PM A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME]on: 01/03/2020 at 8:08 AM. Due on 01/02/2020 at 18:00 hours (6:00 PM). 01/04/2020 at 6:24 AM. Due on 01/03/2020 at 18:00 hours (6:00 PM). 01/09/2020 at 23:50 hours (11:50 PM). [MEDICATION NAME] HCI tablet 30 mg. Give 30 mg by mouth every 8 hours related to heart failure. Scheduled at 6:00 AM, 14:00 hours (2:00 PM) and 20:00 hours (10:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] HCI on: 01/03/2020 at 15:13 hours (3:15 PM). 01/07/2020 at 15:04 hours (3:04 PM). 01/03/2020 at 8:09 AM. Due on 01/02/2020 at 22:00 hours (10:00 PM). 01/04/2020 at 6:25 AM. Due on 01/03/2020 at 22:00 hours (10:00 PM). [MEDICATION NAME] capsule 100 mg. Give 1 capsule by mouth every 8 hours related to [MEDICAL CONDITION]. Scheduled at 6:00 AM, 14:00 hours (2:00 PM) and 22:00 hours (10:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/03/2020 at 15:13 hours (3:13 PM). 01/03/2020 at 8:09 AM. Due on 01/02/2020 at 22:00 hours (10:00 PM). 01/04/2020 at 6:25 AM. Due on 01/03/2020 at 22:00 hours (10:00 PM). 01/07/2020 at 15:04 hours (3:04 PM). 01/09/2020 at 23:24 hours (11:24 PM). [MEDICATION NAME] tablet 875-125 mg. Give 1 tablet by mouth two times a day related to pneumonia. Scheduled at 9:00 AM and 21:00 hours (9:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/04/2020 at 10:40 AM. 01/04/2020 at 6:25 AM. Due on 01/03/2020 at 21:00 hours (9:00 PM). 01/08/2020 at 10:57 AM. 01/09/2020 at 11:44 AM 01/10/2020 at 12:00 PM. 01/13/2020 at 10:14 AM [MEDICATION NAME] tablet 500 mg. Give 1 tablet by mouth two times a day for cough for 7 days. Scheduled at 9:00 AM and 21:00 hours (9:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/08/2020 at 10:57 AM. 01/09/2020 at 11:44 AM 01/10/2020 at 12:00 PM. 01/13/2020 at 10:14 AM Atorvastatin Calcium tablet 40 mg. Give 1 tablet by mouth at bedtime related to [MEDICAL CONDITION]. Scheduled at 21:00 hours (9:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered Atorvastatin on: 01/03/2020 at 8:09 AM. Due on 01/02/2020 at 21:00 hours (9:00 PM). 01/04/2020 at 6:25 AM. Due on 01/03/2020 at 21:00 hours (9:00 PM). 01/09/2020 at 23:24 hours (11:24 PM). 2. Resident #41 was observed on 01/13/2020 walking very slowly using her walker in her room. She was morbidly obese and was struggling to breathe. She had no nasal cannula on during the observation. There was an oxygen tank attached to the walker. During an interview with Resident #41 on 01/14/20 at 1:34 PM, she stated there were times when she had not received her medications and often received them late. She had mentioned it to several staff members, but the situation did not seem to get better. A review of the face sheet in the clinical record revealed Resident #41 was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. [MEDICATION NAME] HCI tablet 25 mg. Give three tablets by mouth three times a day for hypertension. Scheduled at 9:00AM and 13:00 hours (1:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/02/2020 at 10:09 AM. 01/02/2020 at 14:54 hours (2:54 PM). 01/03/2020 at 8:03 AM. Due 01/02/2020 at 21:00 hours (9:00 PM). 01/04/2020 at 6:10 AM. Due on 01/03/2020 at 21:00 hours 9:00 PM). 01/04/2020 at 15:02 hours (3:02 PM). 01/06/2020 at 10:30 AM. 01/07/2020 at 14:34 hours (2:34 PM). 01/09/2020 at 14:49 hours (2:49 PM). 01/14/2020 at 10:42 AM. 01/14/2020 at 14:05 hours (2:05PM). 01/16/2020 at 14:11 hours (2:11PM). Aspirin EC tablet delayed release 81 mg. Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION]. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered Aspirin on: 01/02/2020 at 10:09 AM. 01/14/2020 at 10:42 AM. [MEDICATION NAME] tablet 20 mg. Give 1 tablet by mouth two times a day related to [MEDICAL CONDITION]. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/02/2020 at 10:09 AM. 01/06/2020 at 10:30 AM. [MEDICATION NAME] tablet 325 mg. Give 1 tablet by mouth two times a day related to [MEDICAL CONDITION]. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/02/2020 at 10:09 AM. 01/06/2020 at 10:30 AM. 01/14/2020 at 10:42 AM. [MEDICATION NAME] tablet 10 mg. Give 1 tablet two times a day related to hypertension. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/02/2020 at 10:09 AM. 01/06/2020 at 10:30 AM. 01/14/2020 at 10:42 AM. [MEDICATION NAME] tablet 2.5mg. Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION]. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/02/2020 at 10:09 AM. 01/06/2020 at 10:30 AM. 01/13/2020 at 11:07 AM. 01/14/2020 at 10:42 AM. [MEDICATION NAME] Chloride ER tablet extended release 24-hour 5 mg. Give 1 tablet by mouth one time a day related to overactive bladder. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] Chloride on: 01/02/2020 at 10:09 AM. 01/06/2020 at 10:30 AM. 01/14/2020 at 10:42 AM. [MEDICATION NAME] HCI tablet 10 mg. Give 1 tablet by mouth one time a day related to anxiety disorder. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/02/2020 at 10:09 AM. 01/06/2020 at 10:30 AM. 01/14/2020 at 10:42 AM. [MEDICATION NAME] tablet 20 mg. Give 1 tablet by mouth two times a day related to hypertension. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/02/2020 at 10:09 AM. 01/06/2020 at 10:30 AM. 01/14/2020 at 10:42 AM. [MEDICATION NAME] Oxalate tablet. 10 mg. Give 1 tablet by mouth one time a day related to major [MEDICAL CONDITION]. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/02/2020 at 10:09 AM. 01/06/2020 at 10:30 AM. 01/14/2020 at 10:42 AM. [MEDICATION NAME] Solution 100 unit/ml. Inject 32 units subcutaneously two times a day related to type II diabetes mellitus. Scheduled at 6:00 AM and 18:00 hours (6:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME]on: 01/01/2020 at 19:12 hours (7:12 PM) 01/03/2020 at 8:03 AM. Due 01/02/2020 at 18:00 hours (6:00 PM). 01/04/2020 at 6:09 AM. Due on 01/03/2020 at 18:00 hours (6:00 PM). 01/04/2020 at 6:09 AM. Due on 01/03/2020 at 18:00 hours (6:00 PM). 01/04/2020 at 19:06 hours (7:06 PM). 01/09/2020 at 21:20 hours (9:20 PM). 01/10/2020 at 21:35 hours (9:35 PM). 01/14/2020 at 19:54 hours (7:54PM). [MEDICATION NAME] Solution 100 unit/ milliliter (ml). Inject 13 units subcutaneously with meals related to type II diabetes mellitus. Scheduled at 8:00 AM, 12:00 PM and 17:00 hours (5:00 PM) A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME]on: 01/12/2020 at 9:43 AM. 01/12/2020 at 13:06 hours (1:06 PM). 01/14/2020 at 19:54 hours (7:54PM). [MEDICATION NAME]-[MEDICATION NAME] tablet. 5-325 mg. Give 1 tablet by mouth every 6 hours for moderate pain. Scheduled at 12:00 AM, 6:00 AM, 12:00 PM and 18:00 hours (6:00 PM), A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME]-[MEDICATION NAME] on: 01/01/2020 at 19:12 hours (7:12 PM) 01/03/2020 at 8:03 AM. Due 01/02/2020 at 18:00 hours (6:00 PM). 01/04/2020 at 6:09 AM. Due on 01/03/2020 at 18:00 hours (6:00 PM). 01/04/2020 at 6:09 AM. Due on 01/03/2020 at 18:00 hours (6:00 PM). 01/04/2020 at 19:06 hours (7:06 PM). 01/09/2020 at 21:20 hours (9:20 PM). 01/10/2020 at 21:34 hours (9:34 PM). 01/10/2020 at 01:16 hours (1:16 AM). 01/14/2020 at 19:56 hours (7:56 PM). [MEDICATION NAME] tablet 100 mg. Give 2 tablets by mouth at bedtime related to gout. Scheduled at 21:00 hours (9:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/03/2020 at 8:03 AM. Due 01/02/2020 at 21:00 hours (9:00 PM). 01/04/2020 at 6:10 AM. Due on 01/03/2020 at 21:00 hours (9:00 PM). Atorvastatin Calcium tablet 80 mg. Give 1 tablet by mouth at bedtime related to [MEDICAL CONDITION]. Scheduled at 21:00 hours (9:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered Atorvastatin on: 01/04/2020 at 6:10 AM. Due on 01/03/2020 at 21:00 hours (9:00 PM). Latanoprost Solution 0.005%. Instill 1 drop in both eyes at bedtime related to [MEDICAL CONDITION]. Scheduled at 21:00 hours (9:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered Latanoprost on: 01/03/2020 at 8:03 AM. Due 01/02/2020 at 21:00 hours (9:00 PM). 01/04/2020 at 6:10 AM. Due on 01/03/2020 at 21:00 hours 9:00 PM). 01/04/2020 at 6:10 AM. Due on 01/03/2020 at 21:00 hours (9:00 PM). [MEDICATION NAME] Aerosol 160-4.5 mcg/act. 2 puff inhale orally two times a day related to [MEDICAL CONDITION]. Scheduled at 9:00 AM and 9:00 PM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/06/2020 at 10:30 AM. 01/14/2020 at 10:42 AM. 01/14/2020 at 19:55 hours (7:55 PM). 3. Resident #77 was observed and interviewed on 01/13/2020 at 11:38 AM. He was seated in his motorized wheelchair. He stated his medications were scheduled for 4:00 PM and 8:00 PM. Sometimes they bring them all at once. Sometimes he did not receive them at all. Sometimes they were very late. His pre-operation eye drops were not given on time unless he asked for them. Review of the resident's face sheet revealed he was admitted on [DATE] and most recently readmitted on [DATE]. He was diagnosed with [REDACTED]. A review of the physician's orders [REDACTED]. Artificial Tears Solution 04%. Instill 1 drop in both eyes four times a day related to dry-eye syndrome. Scheduled at 13:00 hours (1:00 PM), 1700 hours (5:00 PM) and 21:00 hours (9:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered Artificial Tears Solution on: 01/01/2020 at 14:30 hours (2:30 PM). 01/04/2020 at 6:02 AM. Due on 01/03/2020 at 21:00 hours (9:00 PM). 01/06/2020 at 14:11 hours (2:11 PM). 01/07/2020 at 15:27 hours (3:27 PM). 01/10/2020 at 19:20 hours (7:20 PM). 01/11/2020 at 00:44 hours (12:44 AM). 01/16/2020 at 14:09 hours (2:09 PM). 01/16/2020 at 1:28 AM. Due on 01/15/2020 at 21:00 hours (9:00 PM) [MEDICATION NAME] Ointment 0.3%. Instill 1 application in both eyes at bedtime for infection related to dry eye syndrome. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] Ointment on: 01/04/2020 at 6:02 AM. Due on 01/03/2020 at 21:00 hours (9:00 PM). 01/11/2020 at 00:44 hours (12:44 AM). 01/16/2020 at 1:29 AM. Due on 01/15/2020 at 21:00 hours (9:00 PM) [MEDICATION NAME]-[MEDICATION NAME] B Ointment. Apply to both eyelids topically at bedtime for irritation. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME]-[MEDICATION NAME] B Ointment on: 01/04/2020 at 6:02 AM. Due on 01/03/2020 at 21:00 hours (9:00 PM). 01/11/2020 at 00:44 hours (12:44 AM). 01/16/2020 at 1:28 AM. Due on 01/15/2020 at 21:00 hours (9:00 PM) [MEDICATION NAME] tablet 10 mg. Give 1 tablet by mouth two times a day for muscle spasms. Scheduled at 9:00 AM and 21:00 hours (9:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/04/2020 at 6:02 AM. Due on 01/03/2020 at 21:00 hours (9:00 PM). 01/06/2020 at 11:58 AM. 01/11/2020 at 00:44 hours (12:44 AM). 01/16/2020 at 1:29 AM. Due on 01/15/2020 at 21:00 hours (9:00 PM) [MEDICATION NAME] tablet 100 mg. Give 1 tablets by mouth at bedtime related to gout. Scheduled at 21:00 hours (9:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/04/2020 at 6:02 AM. Due on 01/03/2020 at 21:00 hours (9:00 PM). 01/11/2020 at 00:44 hours (12:44 AM). 01/16/2020 at 1:28 AM. Due on 01/15/2020 at 21:00 hours (9:00 PM) [MEDICATION NAME] Sodium tablet 10 mg. Give 1 tablet by mouth at bedtime for [MEDICAL CONDITION]. Scheduled at 21:00 hours (9:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] Sodium on: 01/04/2020 at 6:02 AM. Due on 01/03/2020 at 21:00 hours (9:00 PM). 01/11/2020 at 00:44 hours (12:44 AM). [MEDICATION NAME] capsule 50 mg. Give 1 capsule by mouth one time a day for pre operation for cataract surgery. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/06/2020 at 11:58 AM. 01/13/2020 at 12:27 PM [MEDICATION NAME] tablet 10 mg. Give 1 tablet by mouth one time a day related to allergic rhinitis. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/06/2020 at 11:58 AM. Folic Acid tablet 1 mg. Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION]. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered Folic Acid on: 01/06/2020 at 11:58 AM. [MEDICATION NAME] tablet 10 mg. Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION]. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/06/2020 at 11:58 AM. [MEDICATION NAME] Suspension 0.6%. Instill 1 drop in right eye three times a day for pre-operation (pre-op). Start 2 days prior to surgery, surgery date 01/06/2020. Scheduled at 9:00 AM A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/06/2020 at 11:58 AM. 01/06/2020 at 14:11 hours (2:11 PM). BromSite Solution 0.075%. Instill 1 drop in right eye two times a day for pre-op. Start 2 days prior to surgery until 07/08/2020. Start 2 days prior to surgery. Surgery date 01/06/2020. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered BromSite Solution on: 01/06/2020 at 11:58 AM 01/13/2020 at 11:12 AM 01/11/2020 at 00:44 hours (12:44 AM). 01/16/2020 at 1:29 AM. Due on 01/15/2020 at 21:00 hours (9:00 PM) [MEDICATION NAME] Solution 1%. Instill 1 drop in right eye three times a day for pre-op 3 days prior to surgery. Surgery date 1/06/2020. Scheduled at 13:00 hours (1:00 PM) A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] Solution on: 01/06/2020 at 11:58 AM. 01/06/2020 at 14:11 hours (2:11 PM). 01/07/2020 at 15:28 hours (3:28 PM). [MEDICATION NAME] 0.05%. Instill drop in right eye three times a day for pre-op. Surgery date 01/06/2020. Scheduled at 9:00 AM, 13:00 hours (1:00 PM) and 2100 hours (9:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/06/2020 at 11:58 AM. 01/06/2020 at 14:11 hours (2:11 PM). 01/07/2020 at 15:27 hours (3:27 PM). 01/10/2020 at 19:21 hours (7:21 PM). 01/11/2020 at 00:44 hours (12:44 AM). 01/16/2020 at 1:29 AM. Due on 01/15/2020 at 21:00 hours (9:00 PM) [MEDICATION NAME] tablet 20 mg. Give 1 tablet by mouth one time a day related to hypertension. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/06/2020 at 11:58 AM. Potassium tablet 20 meq. Give 1 table by mouth one time a day related to hypertension. A review of the MAR for (MONTH) 2020 revealed the resident was administered Potassium on: 01/06/2020 at 11:59 AM. [MEDICATION NAME] Solution 0.5%. Instill 1 drop in left eye one time a day for post-operation (post-op) cataract surgery. Scheduled at 9:00 AM A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] Solution on: 01/06/2020 at 11:59 AM. [MEDICATION NAME] tablet 20 mg. Give 1 tablet by mouth two times a day related to hypertension. Scheduled at 9:00 AM. A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] on: 01/06/2020 at 11:59 AM. 01/10/2020 at 19:21 hours (7:21 PM). Besifloxacin HCI Suspension 0.6%. Instill 1 drop in right eye every 4 hours for post-op surgery. Scheduled at 2:00 AM, 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM 10:00 PM. A review of the MAR for (MONTH) 2020 revealed the resident was administered Besifloxacin HCI on: 01/07/2020 at 11:10 AM. 01/07/2020 at 5:25 AM. 01/07/2020 at 15:28 hours (3:28 PM). 01/10/2020 at 19:20 hours (7:20 PM). [MEDICATION NAME] Sodium tablet 10 mg. Give 1 tablet by mouth at bedtime for [MEDICAL CONDITION]. Scheduled at 21:00 hours (9:00 PM). A review of the MAR for (MONTH) 2020 revealed the resident was administered [MEDICATION NAME] Sodium on: 01/16/2020 at 1:29 AM. Due on 01/15/2020 at 21:00 hours (9:00 PM) During an interview with Employee C, Licensed Practical Nurse (LPN), on 01/16/20 at 2:35 PM, she demonstrated the way the electronic MAR indicated [REDACTED]. The electronic MAR indicated [REDACTED]. She brought up Resident #41's medications and reviewed them. She explained that some of them had been given outside of the parameters. She stated that nursing was to document a reason for late medication administration. She looked at the screen at a medication that was given outside the parameters and stated if the nurse had made a note it would show a small box with a PN in it to indicate a progress note had been made to justify the late administration. No notes were documented for any of the late administration times. An interview was conducted with the unit manager on 01/16/2020 at 2:51 PM regarding the gaps in the MAR for resident medication administration on 01/03/2020 and 01/04/2020. She stated she had researched the issue and could not find any reason the medication was not given timely. No documentation was completed on those dates. During a second interview with the DON on 01/16/2020 at 3:39 PM, she stated the medications should be administered either one hour before the scheduled time or within one hour after the scheduled time. She stated she had not been auditing for medication administration times. She confirmed that the nurses had not documented a reason for administering medication outside the parameters. A review of the facility's policy and procedure entitled SG Medication Administration #12.07.09.032 (revised last on 11/01/2016) revealed: Standard: It will be the standard of this facility to administer medications in a timely manner and as prescribe by the physician. 3. Medications should be administered in a timely manner and in accordance with the physician's orders [REDACTED]. Medications should be administered within one (1) hour before or after their prescribed time. 8. After successfully identifying the resident to receive medication administration, the individual administering the medication should ensure that the right medication, right dosage, right time and right method of administration are verified. 12. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication must initial and circle the MAR indicated [REDACTED]. .

Based on observations, staff interviews and record reviews, the facility failed to maintain appropriate infection control practices related to contact precautions for two of six residents on contact precautions from a sample of 36 residents. (Residents #304 and #55) The findings include: An observation of Resident #304's room on 01/15/2020 at 12:52 p.m., revealed the resident was on contact-based precautions. Employee D, Certified Nursing Assistant (CNA), was observed entering the room at this time with a meal tray in her hands. She was not wearing personal protective equipment (PPE). She proceeded to shift items on the resident's bedside table before putting his food tray on the bedside table. As Employee D was leaving the room, she was asked about wearing PPE when entering an isolation room. She replied, No, we only wear PPE if we're going to stay in there. I was only putting a tray down. Employee D left Resident #304's room and was observed speaking with Employee A, unit manager, in the doorway of another resident's room. Employee #D was not observed washing her hands. She was overheard asking the unit manager whether she should wear PPE when she entered an isolation room to deliver a meal tray. The unit manager replied that she was only to don PPE if she was going to stay in the resident's room, not if she was simply delivering a meal tray. On 1/13/20 at 11:30 a.m., the advanced registered nurse practitioner (ARNP) was observed in Resident #55's room. A sign on the resident's door instructed staff/visitors/residents to See nurse before entering. PPE (gowns/gloves) was available in a hanging bag on the door. The ARNP was not wearing PPE. As she was leaving, she used hand sanitizer and then proceeded to see other residents A record review revealed Resident #55 was on isolation precautions for ESBL (Extended Spectrum Beta-Lactamase) in the urine. According to the Public Health Agency at www.publichealth.hscni.net/sites/default/files/ESBL_Leaflet_04_16.pdf, Anyone can get an ESBL producing bacteria. Patients in hospital/care homes with open wounds, urinary catheters, drainage tubes and those who are ill are at a higher risk of getting an ESBL bacteria. Anyone who has had contact with a patient/client that already has an ESBL producing bacteria is also at higher risk. ESBL bacteria can be spread from person to person on contaminated hands of both patients and healthcare workers. Care staff should wear a disposable plastic apron and disposable gloves, and it is important they wash their hands when these are removed. During an interview with the Infection Control Nurse on 1/15/20 at 2:16 p.m., she was asked when PPE was to be worn with residents on isolation precautions. She stated, All staff should wear PPE upon entering isolation rooms. CNAs are supposed to check with the nurse to know if any additional PPE over standard precautions should be used. During an interview with the Director of Nursing (DON) on 1/15/20 at 3:31 p.m., she was asked what staff should do prior to entering an isolation room. She replied, Wear PPE, a gown and gloves at least. A review of the facility's tracking forms for infections during (MONTH) 2019 revealed nine urinary tract infections (UTIs) A review of the tracking forms for (MONTH) 2019 revealed 28 UTIs. A review of the tracking forms for (MONTH) 2019 revealed 13 UTIs. During an interview with the infection control nurse on 1/15/20 at 2:16 p.m., she stated she realized from the facility's high number of infections, that there had been some breaches in staff's infection control practices, so she initiated education for the staff. She produced documentation verifying that staff were last educated on PPE and transmission-based precautions on 1/7/2020. A review of the facility's Standards and Guidelines for Transmission-Based Precautions (Policy number 21.08.002 issued 3/2018), revealed on page 3: Contact precautions are intended to prevent transmission of infectious agents that can be transmitted by direct contact i.e. hand or skin to skin or indirect contact touching with environmental surfaces Health Care personnel caring for residents on contact precautions should wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident environment. Donning PPE before room entry and discarding before exiting the resident's room is done to contain pathogens.

Resident #1 Pain Management Based on observations, interviews and record reviews, the facility failed to provide or refer one (Resident# 1) of two sampled residents for specialized services for pain management. According to a research paper by Dr(NAME)Katz themed, The Impact of Pain Management On Quality Of Life in the journal of Pain and Symptom Management, vol 24, IS (MONTH) 2002, pain is not only a noxious experience, but it can also have an overwhelmingly negative effect on nearly every other aspect of life. A study by the World Health Organization indicated that individuals who live with persistent pain are four times more likely than those without pain to suffer anxiety ( www.jpsmjournal.com accessed 9/13/2018 at 3:08 PM ). The findings Include: A review of the clinical record revealed that Resident #1 was a [AGE] year-old female born on 06/19/1927. She was admitted to the facility on [DATE]. Her Brief Interview for Mental Status (BIMS) score was 12 out of a possible 15 points, indicating mild cognitiev impairment. She had the following medical Diagnoses: [REDACTED]. The resident was observed on 09/10/2018, at 1:20 pm sitting in her chair, grimacing and fidgeting. The resident was asked about her current pain, and she reported that she was in excoriating pain most of the time. She reported that she had back pain all of the time, and she currently had a pain patch applied to her back, but it was not managing her pain effectively. On 09/13/2018, at 10:50 am, the resident was observed sitting in her chair and was grimacing while she was reading. When the resident was asked how she was doing, she reported that she was feeling horrible. She had horrible back pain that never seemed to go away. When asked what the facility staff was doing to manage her pain, she reported that she had Tylenol available. She stated, I ask the nurses for something for pain, but sometimes they don't bring it to me when I ask for it. When asked what her pain score was on a scale of 1 to 10, with 10 being the worst pain experienced, she reported that her pain score was a 10. Employee E, Licensed Practical Nurse (LPN) was immediately made aware that Resident #1 had a current pain score of 10, and that she was requesting pain medication. Employee E stated that she would get Resident #1 something for pain. Employee A, Certified Nursing Assistant (CNA) was interviewed on 09/13/18, at 11:00 am regarding the resident's pain, and she stated, (Resident# 1) has a lot of pain most of the time. During an interview with Employee B, Occupational Therapist (OT), Employee C, Physical Therapist (PT), and Employee D, Physical Therapy Assistant (PTA) on 09/13/2018, at 11:15 am, they each attested that the resident had chronic pai[DIAGNOSES REDACTED]. Employee F, Registered Nurse, Director of Nursing (RN/DON), was interviewed on 09/13/2018 at 11:37 am. When she was asked why Resident#1 was not referred for an evaluation and management of chronic pain, Employee F stated that she was unaware of Resident #1's chronic pain. She further stated that a referral for pain management could be made. Employee F stated that the Nurse Practitioner was in the facility today and encouraged the surveyor to speak with that party. During an interview with the Nurse Practitioner on 09/13/2018, at 1:05 pm, she reported that the resident had various physical complaints, and she acknowledged that the resident had chronic pai[DIAGNOSES REDACTED]. She further stated that she would consider making a referral to a pain specialist after speaking with the resident's daughter. Employee H, LPN, Unit Manager, entered the conference room with Employee G. When they were asked why alternative pain management measures had not been made, Employee H stated that Resident #1 complains about different things frequently and says she can't take a lot pain medications. A review of the pain screening conducted on 08/18/2018, revealed that the resident's verbalized expressions of distress/crying and pain intensity was described as moderate. A review of the neurosurgical notes for her post-operative visit on 07/26/2018, revealed that the the plan stated medical management of back pain. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. A review of the pain assessment on the MAR for (MONTH) 10, (YEAR) for the entire day, the resident's pain was documented as a zero. A review of the MAR for 09/13/2018, revealed that Tylenol 325 mg (milligrams), give 2 tabs every 6 hours as needed for mild pain 1-3, not to exceed 3 grams in 24 hours had been administered, and the pain level recorded was 8 out of 10 at 10:58 am. Further review of the clinical record revealed that the resident had a medical complexity of multiple allergies [REDACTED]. A review of the resident's care plan, revised on 06/22/2018, stated that nursing was to administer [MEDICATION NAME] as prescribed and report to the physician if interventions were ineffective. A review of the nursing notes for (MONTH) (YEAR), revealed no indication that the physician had been contacted regarding pain management for this resident. Further review of the physician's orders [REDACTED]. [MEDICATION NAME] Gel 1%, apply 1 application tansdermally every 6 hours as needed and [MEDICATION NAME] Gel 1% apply 1 application [MEDICATION NAME] two times a day for pain, apply to lower back was started on 09/11/2018. Review of the facility's Pain Management, section 6, part i stated, Residents with more advanced, complex or poorly controlled pain may benefit from other interventions administered under the close supervision of expert practitioners such as referrals to pain management clinics and/or pain specialists.

Based on observations and interviews, the facility failed to ensure food was prepared and served in a safe and sanitary manner to prevent foodborne illness for the 32 residents that reside in the facility. The findings include: During a visit to the kitchen on 7/31/2017 at 9:15 AM, a dietary cook (Employee E) was observed preparing raw chicken. The chicken was in the sink and she was using her gloved hands to transfer the chicken from the sink into a large aluminum bowl. She was asked what she was making and she stated, Lemon pepper chicken. On 7/31/2017 at 9:20 AM, Employee E's blue hair net was observed approximately an inch up past her hairline. Employee E was observed pulling her hair net down with her gloved hands. She was observed then using her gloved hands to mix the lemon pepper on the chicken. She did not change gloves after arranging her hairnet and using her hands to mix the lemon pepper into the chicken. During an observation in the kitchen on 8/2/2017 at 12:03 PM, a dietary cook (Employee D) was observed behind the tray line. He was wearing black plastic gloves. He was observed using his gloved hands to take a hamburger bun out of a gallon sized zip lock bag that was on the counter to his right when facing the steam table. He used his hands to open the bun, place it on a plate, and to put the top of the bun back on after he placed the hamburger on the bottom of the bun. He continued to plate food on the tray line. He was observed picking up trays and dishes, and adjusting the temperature dials on an oven/warmer that was behind the steam table. He was also observed putting his gloved hand in a fabric oven mitt to remove a metal container from another oven/warmer that was also located in back of the tray line. Employee D continued to work the tray line. He again used his gloved hand to remove a second hamburger bun from the plastic bag and place it on a plate. He removed the top of the bun. He then used his gloved hand to remove the lids off of three containers with sliced tomatoes, lettuce, and onions. He used his gloved hand to remove the items and place them on the burger he had placed on the bun and then used his gloved hand to place the top of the bun back on the hamburger. He continued to work the tray line. He used tongs to place garlic toast on plates, but then used his gloved hand to arrange it on the plate. At no time during the observation did Employee A change his gloves or wash his hands. On 8/2/2017 at 12:20 PM, the Kitchen Manager was asked to observe Employee D working behind the tray line. She was notified that Employee D had been using his gloved hands to make direct contact with food and had touched numerous items in the kitchen and then continued to use the same gloved hands to make direct contact with food. She stated she would provide some training.

Based on interviews and record review, the facility failed to accurately complete the admission Minimum Data Set (MDS) Resident Assessment Instrument for 3 of 5 residents reviewed for unnecessary medication use in a sample of 18 residents (Residents #3, #14, and #34). The findings include: 1. Record review for Resident #3 found an admitted to the facility of 6/28/2017, and [DIAGNOSES REDACTED]. Record review for Resident #3 found physician orders [REDACTED]. Record review of the 7/2017 Medication Administration Record [REDACTED]. Record review of the July 7, 2017 admission Minimum Data Set (MDS) found under Section N N0410 - Medications A. Antipsychotic, the medication was documented as given 0 days in the 7 day lock back period. Further record review of the MDS found under Section I Active [DIAGNOSES REDACTED].#3. During an interview with the Director of Nursing (DON) on 8/2/2017 at 11:00 AM, she stated the MDS Coordinator was not available to be interviewed, and that she would assist the surveyor. She looked at the admission MDS in the computer, and confirmed that the [DIAGNOSES REDACTED]. She confirmed that Resident #3 was administered the Quetiapine [MEDICATION NAME] Tablet 25 milligrams (MG) one time a day at 9:00 AM from 7/1/2017 through 7/31/2017, and Quetiapine [MEDICATION NAME] Tablet 50 MG at 5:00 PM for the [DIAGNOSES REDACTED]. 2. Record review for Resident #14 found an admission date of [DATE], and [DIAGNOSES REDACTED]. Record review for Resident #14 found physician orders [REDACTED]. Record review of the 6/2017 Medication Administration Record [REDACTED]. Record review of the 7/2017 MAR found Resident #14 received the Quetiapine [MEDICATION NAME] Tablet 25 milligrams (MG) from 7/1/2017 through 7/31/2017. Record review of the 7/5/2017 admission MDS found under Section N0410 Section N - Medication Received. A. Antipsychotic had 0 days entered as received during the last 7 days. During an interview with the DON on 8/2/2017 at 11:04 AM, she confirmed the resident received the antipsychotic medication the 7 days of the look back period, and the MDS did not show the resident received the medication at all during the 7-day look back period. 3. A record review conducted for Resident #34 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of the facility demographic sheet for Resident #34 revealed a [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. A review of the July Medication Administration Record [REDACTED]. A review of Resident #34's admission Minimum Data Set (MDS) assessment, dated 7/29/2017, revealed that during the 7-day look back period, the resident was not coded with a [DIAGNOSES REDACTED]. A review of Resident #34's care plans, dated 7/20/2017, revealed the resident was at nutritional risk related to heart failure, obesity, and diabetes mellitus. Interventions included but were not limited to check finger stick serum glucose per protocol, diabetic medications as ordered by medical provider, eats meals in room, honor good choices, encourage resident to make healthier food choices, monitor intake at meals, monitor side effects and or ineffectiveness. An interview on 08/03/2017 at 9:11 AM with Employee A, Registered Nurse (RN), confirmed Resident #34 was not listed as a diabetic on her admission MDS. She stated, I am very cautious about coding a [DIAGNOSES REDACTED]. I will check the progress notes and see if the doctor listed her as a diabetic. Employee A did confirm the resident received 7 days of injectable insulin. A review of the physician's progress notes, dated 7/20/2017, revealed Resident #34 was listed as having diabetes mellitus type 2. (Photographic evidence obtained) An interview on 08/03/2017 at 9:12 AM with Employee A, RN, confirmed she reviewed the record for Resident #34 and a progress note, dated 7/20/2017 from the Advanced Registered Nurse Practitioner (ARNP) listed Resident #34 as having diabetes mellitus type 2. She said, She is listed as a diabetic, and I will go and change the MDS now.

Based on resident record review and staff interviews, the facility failed to provide or arrange services as outlined by the resident's comprehensive care plan for Resident #34, one of 18 residents sampled. The findings include: A record review conducted for Resident #34 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of physicians' orders revealed the resident received the following medications: [REDACTED]. A review of the July Medication Administration Record [REDACTED]. The resident also received [MEDICATION NAME] 5 mg 1 qd and [MEDICATION NAME] 20 mg 1 po q HS since admission on 7/21/2017. (Photographic evidence obtained) A review of Resident #34's admission Minimum Data Set (MDS) assessment, dated 7/29/2017, revealed that during a 7-day look back period the resident received 7 days of anti-psychotic ([MEDICATION NAME]) and anti-depressant ([MEDICATION NAME]) medications and 2 days of anti-anxiety ([MEDICATION NAME]) medication. A review of Resident #34's care plan, dated 7/20/2017, revealed Resident #34 received [MEDICAL CONDITION] medications related to depression, anxiety, and [MEDICAL CONDITION] disorder. Interventions included but were not limited to: Administer medications as ordered, monitor for target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, and document per facility protocol. Monitor and report to medical doctor as needed for side effects and adverse reactions of psychoactive medications, such as unsteady gait, tardive dyskinsia, EPS, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression. A review of the July and August Medication Administration Record [REDACTED]. An interview was conducted on 08/02/2017 at 1:32 PM with the Director of Nursing, who confirmed she did not see any documentation confirming the facility staff were documenting behavioral monitoring for Resident #34, and that should have been in the resident's record. A review of the facility's Policy and Procedure for Behavior Assessment and Monitoring, dated 11/29/2016 and revised on 11/29/2016, read, For any patients taking anti-psychotic /[MEDICAL CONDITION] medications, the nurses shall monitor for and report to the physician side effects such as sedation, Orthostatic [MEDICAL CONDITION], lightheadedness, dry mouth, blurred vision, constipation, [MEDICAL CONDITION], increased psychotic symptoms, extrapyramdical effects, akathisia (agitation, distress, restlessness,), [DIAGNOSES REDACTED], tremor, rigidity, akinesia or tardive dyskinesia. An interview with Employee B, Licensed Practical Nurse on 08/03/2017 at 9:29 AM confirmed that behavioral monitoring should be conducted for each resident who receives anti-psychotic medications. She confirmed she administered anti-psychotic medication to Resident #34 and did not document behaviors.

Based on observations, record review, staff interviews and facility policy review, the facility failed to ensure two of forty-one sampled residents (Residents #115 and #96) received necessary care and services to properly maintain catheter bags and tubing. The findings include: 1. On 4/25/2015 at 11:30 a.m., Resident #115 was observed on the East Wing Hall in her wheelchair. She was observed with a Foley catheter bag which was placed in a blue privacy bag. The tubing from the catheter bag was observed lying on the ground (approximately four inches) under the wheelchair seat. At 11:35 a.m., an aide came and assisted Resident #115 to the dining room in her wheelchair and the catheter tubing remained on the floor. At 12:01 p.m., the resident was observed in the main dining room seated at a table with the tubing on the floor. Review of the current physician's orders [REDACTED].#115, dated 4/2016, revealed orders to include, but not limited to, in-dwelling catheter size: 16 French for bladder outlet obstruction. Further review revealed the POS, dated 12/24/15 with end date 12/31/15, administer 1- capsule [MEDICATION NAME] 100mg by mouth every 12 hrs for UTI for 7 days, hold [MEDICATION NAME] for 7 days. Give 1-tablet [MEDICATION NAME] 300 mg by mouth every 12 hrs for 7 days, hold [MEDICATION NAME] for 7 days. Review of the current care plan, dated 10/18/13 with revision on 4/11/16, documented Resident #115 has an indwelling catheter 16 French and was at risk for signs and symptoms of urinary infections; per hospice, Foley to remain in place related to history of pressure ulcer to buttocks. In addition, she will remain free from catheter related trauma and will show no signs/symptoms of urinary infection. Interventions included: position catheter bag and tubing below the level of the bladder and away from entrance room door, administer antibiotic as/ if ordered per MD, change catheter bag monthly and PRN, change catheter PRN, check tubing for kinks each shift, provide catheter care every shift. 2. On 4/25/16 at 3:20 p.m., Resident #96 was observed in the main dining room participating in an activity in her wheelchair. She was observed with a Foley Catheter with the catheter bag and tubing on the floor. Review of the current physician's orders [REDACTED].#96, dated for the month of 4/2016, documented an in-dwelling catheter size: 16 French for bladder outlet obstruction. In addition, POS, dated 4/1/16, [MEDICATION NAME] 250 mg by mouth twice times daily for UTI for 7 days. Review of the current care plan, dated 2/8/16 with revision on 3/16/16, documented Resident #96 has a Foley Catheter in place for her bladder outlet obstruction and she will remain free from catheter related trauma, with interventions that included position catheter bag and tubing below the level of the bladder and away from entrance room door, administer antibiotic as/ if ordered per MD, change catheter bag monthly and PRN, change catheter PRN, check tubing for kinks each shift, provide catheter care every shift. 3. Review of the facility's policy related to Catheter Care, Urinary, revised October 2010, revealed that the purpose of this procedure is to prevent infection of the resident's urinary tract. The general guidelines included in maintaining unobstructed urine flow #1 revealed, Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. In addition, guideline included in infection control #2(B) indicated, Be sure the catheter tubing and drainage bag are kept off the floor. 4. On 4/26/2015 at 3:32 p.m., an interview with the Assistant Director of Nursing confirmed that catheter tubing should not be dragging or lying on the floor under the resident, and that nursing staff should routinely assess to see if the tubing is properly positioned.

Based on observations and interviews, the facility failed to provide current professional standard of labeling to include medication expiration dates for 2 of 2 controlled substance Emergency Drug Kits (EDK) located within the facility's Medication Storage Rooms. The findings include: On 4-27-16 at 9:10 a.m., an observation was conducted of the West Wing Medication Storage Room with Employee E. The controlled substance EDK box was reviewed. There was a controlled substance medication inventory list in a plastic sleeve secured to top of the EDK box. The medication names and dosage were listed, but the expiration date information for each medication was not provided. The controlled substance EDK was then opened by Employee E to observe the expiration dates of the medications contained in the EDK. The expiration dates were current. Employee E stated the controlled substance EDK should have current expiration dates of the medications documented and displayed on the outside of the kit. Employee E stated she would notify the pharmacy to provide new controlled substance EDK with an inventory list to include current expiration date information for each medication listed. On 4/27/16 at 9:40 am, an observation was conducted of the East Wing Medication Storage Room with Employee E. The EDK medication inventory list had medication names and dosages, but no expiration date information was provided on the inventory list. Employee E stated the expiration date information should be provided on the controlled substance inventory list. Employee E stated she would contact the pharmacy regarding replacement of the controlled substance EDKs for the East and West Wings to provide expiration date information on the medication inventory lists to be displayed and secured to exterior of the EDK.

Based on record review, staff interviews, and facility policy and training review, the facility failed to ensure that Advance Directives for 1 resident (Resident #1, who did not have a Do Not Resuscitate, DNR, order in place) out of 5 residents who died in the facility were honored, by failing to initiate cardiopulmonary resuscitation (CPR, initiated when the heart stops or there is no breathing) after finding Resident #1 cold and unresponsive. The facility failed to immediately verify Resident #1's wishes regarding resuscitation, failed to call 911, and failed to initiate CPR when a nurse found the resident without pulse or respirations. The nurse asked two other nurses who were on duty at the time if she needed to get the crash cart. The nurses assumed the resident had a DNR order, and did not initiate CPR. None of the three nurses on duty checked the resident's record, per facility policy, to verify whether he had a DNR order. Due to the facility's failure to initiate CPR for Resident #1, the resident expired in the facility on [DATE]. This resulted in past noncompliance immediate jeopardy occurring on [DATE]. The Director of Nursing (DON), who was also the facility's Risk Manager, was notified of Resident #1's death on the morning of [DATE]. The facility identified the immediate jeopardy on [DATE], when the DON reviewed the resident's record and did not find a DNR order. The Administrator was notified immediately, and an emergency Quality Assurance (QA) meeting was called to review the event and plan of correction. The facility conducted interviews with the 3 staff nurses who worked on [DATE], and all 3 nurses were terminated for not following the facility policy to check the DNR status of a resident who was found unresponsive. The facility notified law enforcement, who found no criminal activity had occurred. The facility immediately developed and implemented a plan of correction, including the following measures: The facility contacted all residents and their families to verify the residents' current Advance Directives and resuscitation status. All family contact was completed by [DATE]. The facility reviewed all current residents' medical records to verify correct documentation of the residents' Advance Directives, including DNR orders if desired by the resident. The facility conducted staff education on all shifts until all employees were re-educated regarding the facility policies for Advance Directives and DNR orders, and where to locate the information in the residents' records. All full time employees were educated by [DATE]. All as needed (PRN) staff were educated on their next scheduled work day. The last PRN employee was educated on [DATE]. No employee was allowed to work until they had completed the education on Advance Directives and DNR orders. The facility held a Resident Council meeting on [DATE], to discuss Advance Directives and DNR orders. The facility sent out invitations and held a Family Council meeting on [DATE] to discuss Advance Directives and DNR orders. The facility conducted surprise mock codes on [DATE], [DATE], and [DATE] on all shifts, using various scenarios to test the staff's knowledge of Advance Directives and DNR orders. The facility will continue mock codes quarterly. The facility held QA meetings on [DATE] and [DATE] to review the plan of correction progress. The Medical Director has been involved in the correction process. The facility will continue to audit and update residents' Advance Directives, due to possible changes in health status of the residents. The facility is checking physicians' orders daily for any changes in residents' code status (whether to initiate CPR). The facility updated the electronic medical record system so that staff could access residents' code status at the kiosks in the hallways, on the top of the residents' care plans. The facility correction date for the deficient practice was [DATE]. Substandard quality of care was identified at F309 (S/S J). Cross reference to F281 (S/S J). The findings include: Review of Resident #1's closed medical record revealed that he was admitted to the facility from the hospital on [DATE] for short term rehabilitation. His [DIAGNOSES REDACTED]. Review of a Social Services progress note for the resident dated [DATE] at 12:29 PM revealed he had an Advance Directive that included a Living Will and a Healthcare Surrogate designation. The medical record did not contain a DNR order. On the night of [DATE], a nurse found the resident unresponsive and cool to the touch. The nurses working on the unit at that time did not initiate CPR or call 911 for Emergency Medical Service (EMS). The facility staff notified the family and physician that the resident had died in the facility. Review of the facility's records and Corrective Action Plan revealed that the facility filed an adverse incident report for Resident #1's death. The facility audited all current residents' records to ensure accurate documentation of code status. The facility re-trained 100% of facility staff on Advance Directives, and verification of code status in the event of finding a resident whose heart stopped or who has stopped breathing. Interview on [DATE] at 12:41 PM with the Social Service Director (SSD) confirmed that Resident #1 did not have a DNR order in the chart at the time of his death. The resident had always been a full code status (initiate CPR if no heart beat or respirations), but he had a recent rapid decline and the family started to discuss hospice and a change to DNR status. Hospice had made initial contact with the resident the day before he died , but the resident had not signed the paperwork for hospice care yet. Hospice was waiting for the resident's family to come in before making the final decision about the DNR status. The SSD stated that the only document the facility accepted for a DNR was the yellow DNR form that is signed by the resident and physician, and placed in the Advance Directive section of the resident ' s chart. Interview on [DATE] at 4:08 PM with the Director of Nursing (DON) confirmed that Resident #1 died in the facility on [DATE], when the nurses found him unresponsive and did not start CPR. The DON stated that staff failed to check the resident's chart to verify his code status. The DON said that because an aide had seen hospice visit the resident, and a priest had given the resident last rights, the nurses "assumed" he was a DNR. The DON said she was notified of the resident's death the next morning on [DATE]. She said that when she reviewed the resident ' s medical record, she did not find a DNR order and "knew this was an immediate jeopardy situation." Review of the facility policy for Advance Directives revealed that it defined DNR as direction that no CPR or other life-saving methods are to be used in the case of respiratory or cardiac failure. Review of the facility training for Advance Directives revealed that a resident ' s Advance Directives did not have to include a DNR order (this was the case for Resident #1). The doctor could put a DNR in the medical record. Unless given other instructions, the facility staff will try to help any patient whose heart has stopped or who has stopped breathing. If you find your resident not breathing always check the resident ' s chart first for a yellow copy of the DNR paper under the Advance Directive tab. An interview on [DATE] at 3:51 p.m. with Employee A, Licensed Practical Nurse (LPN), revealed that when asked what training she had received after [DATE] concerning residents' Advance Directives and DNR status, she stated that she attended an in-service on what to do during a code. Employee A stated that she learned to go to the resident ' s room as soon as possible, and proceed as if we will be doing CPR every time we go to a room. She said that the staff person nearest the nurses ' station should get the resident ' s chart and the crash cart. She said staff should verify the resident ' s code status in the chart. Depending on whether or not the resident has a DNR order in the chart, staff will either proceed with CPR or not. Employee A said the chart is opened up so that everyone in the room can see whether or not the resident has a DNR order. The staff person who brings the chart into the room is opening it on the way to the room, and leaves it open for others to see. The DNR order should be under the Advance Directives tab in the front of the chart. More than one staff person has to verify the DNR status. An interview on [DATE] at 3:56 p.m. with Employee B, LPN, revealed that when asked what training she had received after [DATE] concerning residents' Advance Directives and DNR status, she stated that a staff person who finds a resident unresponsive calls for the nurse. The nurse gets the resident ' s chart and the crash cart, and checks the resident ' s code status on the way to the room. Once in the room, the resident ' s code status is shown to the other staff in the room. Employee B said that if the resident does not have a DNR order, staff call a code blue (alerts other staff that CPR is needed) and start resuscitation measures. We call 911 and send the resident to the hospital with paramedics, or the paramedic pronounces the resident dead at the facility. At that point we call the physician and the family. If the resident is determined to be a DNR, two nurses assess the resident for respirations and heart rate, the physician and the family are called, and we proceed as appropriate. An interview on [DATE] at 4:07 p.m. with Employee C, LPN, revealed that when asked what training she had received after [DATE] concerning residents' Advance Directives and DNR status, she stated that the facility conducted mock codes for 3 weeks after the incident. She said that if a resident is found unresponsive, the staff person in the room calls a code blue, and whoever is closest to the desk gets the resident ' s chart and the crash cart. If the resident has a DNR order, 2 nurses have to assess the resident for respirations and heart rate. When both nurses have done that, then a call is made to the doctor, and he pronounces the resident dead. If the resident does not have a DNR order, we call a code blue on the intercom, and start CPR. We keep going until the paramedics get here. The paramedics either take the resident to the hospital or pronounce them dead. An interview on [DATE] at 4:19 p.m. with Employee D, LPN, revealed that when asked what training she had received after [DATE] concerning residents' Advance Directives and DNR status, she stated that staff are supposed to be familiar with the residents ' code status. If a code blue is called, everyone runs to the room. The staff person at the desk gets the chart and the crash cart. She said that all staff have to check the resident ' s code status in the record. If the resident has a DNR order, two nurses check the resident ' s vital signs before calling the doctor. If there is no DNR order, then we start CPR. Another staff person is sent to call 911, and we continue CPR until 911 arrives. An interview on [DATE] at 11:40AM with Employee E, LPN, revealed that when asked what training she had received after [DATE] concerning residents' Advance Directives and DNR status, she said that if staff find a resident who is without pulse or respirations, staff must check the resident ' s DNR information. Employee E said that this information can be found in the resident ' s electronic record, or if the computer is not handy, you would send another employee to check the resident ' s chart and see if the resident is a full code or DNR. Employee E stated that it only takes a couple of seconds to get that information from the resident ' s record. She said she knows her residents ' code status when she comes on duty. She stated, " If you do CPR on a DNR you are going to get into trouble, and if you don't do CPR on a full code, you are going to be in bigger trouble. " .

Based on record review, staff interviews, and review of facility policy and training content, the facility failed to ensure that Advance Directives for 1 resident (Resident #1, who did not have a Do Not Resuscitate, DNR, order in place) out of 5 residents who died in the facility were honored, by failing to initiate cardiopulmonary resuscitation (CPR, initiated when the heart stops or there is no breathing) after finding Resident #1 cold and unresponsive. The facility failed to immediately verify Resident #1's wishes regarding resuscitation, failed to call 911, and failed to initiate CPR when a nurse found the resident without pulse or respirations. The nurse asked two other nurses who were on duty at the time if she needed to get the crash cart. The nurses assumed the resident had a DNR order, and did not initiate CPR. None of the three nurses on duty checked the resident's record, per facility policy, to verify whether he had a DNR order. Due to the facility's failure to initiate CPR for Resident #1, the resident expired in the facility on [DATE]. This resulted in past noncompliance immediate jeopardy occurring on [DATE]. The Director of Nursing (DON), who was also the facility's Risk Manager, was notified of Resident #1's death on the morning of [DATE]. The facility identified the immediate jeopardy on [DATE], when the DON reviewed the resident's record and did not find a DNR order. The Administrator was notified immediately, and an emergency Quality Assurance (QA) meeting was called to review the event and plan of correction. The facility conducted interviews with the 3 staff nurses who worked on [DATE], and all 3 nurses were terminated for not following the facility policy to check the DNR status of a resident who was found unresponsive. The facility notified law enforcement, who found no criminal activity had occurred. The facility immediately developed and implemented a plan of correction, including the following measures: The facility contacted all residents and their families to verify the residents' current Advance Directives and resuscitation status. All family contact was completed by [DATE]. The facility reviewed all current residents' medical records to verify correct documentation of the residents' Advance Directives, including DNR orders if desired by the resident. The facility conducted staff education on all shifts until all employees were re-educated regarding the facility policies for Advance Directives and DNR orders, and where to locate the information in the residents' records. All full time employees were educated by [DATE]. All as needed (PRN) staff were educated on their next scheduled work day. The last PRN employee was educated on [DATE]. No employee was allowed to work until they had completed the education on Advance Directives and DNR orders. The facility held a Resident Council meeting on [DATE], to discuss Advance Directives and DNR orders. The facility sent out invitations and held a Family Council meeting on [DATE] to discuss Advance Directives and DNR orders. The facility conducted surprise mock codes on [DATE], [DATE], and [DATE] on all shifts, using various scenarios to test the staff's knowledge of Advance Directives and DNR orders. The facility will continue mock codes quarterly. The facility held QA meetings on [DATE] and [DATE] to review the plan of correction progress. The Medical Director has been involved in the correction process. The facility will continue to audit and update residents ' Advance Directives, due to possible changes in health status of the residents. The facility is checking physicians' orders daily for any changes in residents' code status (whether to initiate CPR). The facility correction date for the deficient practice was [DATE]. Substandard quality of care was identified at F309 (S/S J). Cross reference to F155 (S/S J). The findings include: The American Heart Association guidelines for CPR found at <http://circ.ahajournals.org> recommend that all patients in [MEDICAL CONDITION] receive resuscitation unless the patient has a valid DNR order, or the patient has signs of irreversible death: rigor mortis (stiffness), decapitation, or dependent lividity (pooling of blood). The Florida Nurse Practice Act, Chapter 464.003 defines the "practice of professional nursing" as "the performance of those acts requiring substantial specialized knowledge, judgment and nursing skill based upon applied principles of psychological, biological, physical and social sciences" which shall include, but not limited to: The administration of medications and treatments as prescribed by a duly licensed practitioner "practice of practical nursing" as the performance of selected acts, including the administration of treatments and medications in the care of the ill, injured or infirmed and the promotion of wellness, maintenance of health and prevention of illness of others, under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician of a licensed dentist. Review of Resident #1's closed medical record revealed that he was admitted to the facility from the hospital on [DATE] for short term rehabilitation. His [DIAGNOSES REDACTED]. Review of a Social Services progress note for the resident dated [DATE] at 12:29 PM revealed he had an Advance Directive that included a Living Will and a Healthcare Surrogate designation. The medical record did not contain a DNR order. On the night of [DATE], a nurse found the resident unresponsive and cool to the touch. The nurses working on the unit at that time did not initiate CPR or call 911 for Emergency Medical Service (EMS). The facility staff notified the family and physician that the resident had died in the facility. Review of the facility's records and Corrective Action Plan revealed that the facility filed an adverse incident report for Resident #1's death. The facility re-trained 100% of facility staff on Advance Directives, and verification of code status in the event of finding a resident whose heart stopped or who has stopped breathing. The facility updated the electronic medical record system so that staff could access residents' code status at the kiosks in the hallways, on the top of the residents' care plans. Interview on [DATE] at 12:41 PM with the Social Service Director (SSD) confirmed that Resident #1 did not have a DNR order in the chart at the time of his death. The resident had always been a full code status (initiate CPR if no heart beat or respirations), but he had a recent rapid decline and the family started to discuss hospice and a change to DNR status. Hospice had made initial contact with the resident the day before he died , but the resident had not signed the paperwork for hospice care yet. Hospice was waiting for the resident's family to come in before making the final decision about the DNR status. Interview on [DATE] at 4:08 PM with the Director of Nursing (DON) confirmed that Resident #1 died in the facility on [DATE], when the nurses found him unresponsive and did not start CPR. The DON stated that staff failed to check the resident's chart to verify his code status. The DON said that because an aide had seen hospice visit the resident, and a priest had given the resident last rights, the nurses "assumed" he was a DNR. The DON stated that the only document the facility accepted for a DNR was the yellow DNR form that is signed by the resident and physician, and placed in the Advance Directive section of the resident's chart. The DON said she was notified of the resident's death on the morning of [DATE]. She said that when she reviewed the resident's medical record, she did not find a DNR order and " knew this was an immediate jeopardy situation. " Review of the facility policy for Advance Directives and staff training content revealed that unless given other instructions, the facility staff will try to help any patient whose heart has stopped or who has stopped breathing. If you find your resident not breathing always check the resident's chart first for a yellow copy of the DNR paper under the Advance Directive tab. An interview on [DATE] at 3:51 p.m. with Employee A, Licensed Practical Nurse (LPN), revealed that when asked what training she had received after [DATE] concerning residents' Advance Directives and DNR status, she stated that she attended an in-service on what to do during a code. Employee A stated that she learned to go to the resident ' s room as soon as possible, and proceed as if we will be doing CPR every time we go to a room. She said that the staff person nearest the nurses ' station should get the resident ' s chart and the crash cart. She said staff should verify the resident ' s code status in the chart. Depending on whether or not the resident has a DNR order in the chart, staff will either proceed with CPR or not. Employee A said the chart is opened up so that everyone in the room can see whether or not the resident has a DNR order. The staff person who brings the chart into the room is opening it on the way to the room, and leaves it open for others to see. The DNR order should be under the Advance Directives tab in the front of the chart. More than one staff person has to verify the DNR status. An interview on [DATE] at 3:56 p.m. with Employee B, LPN, revealed that when asked what training she had received after [DATE] concerning residents' Advance Directives and DNR status, she stated that a staff person who finds a resident unresponsive calls for the nurse. The nurse gets the resident ' s chart and the crash cart, and checks the resident ' s code status on the way to the room. Once in the room, the resident ' s code status is shown to the other staff in the room. Employee B said that if the resident does not have a DNR order, staff call a code blue (alerts other staff that CPR is needed) and start resuscitation measures. We call 911 and send the resident to the hospital with paramedics, or the paramedic pronounces the resident dead at the facility. At that point we call the physician and the family. If the resident is determined to be a DNR, two nurses assess the resident for respirations and heart rate, the physician and the family are called, and we proceed as appropriate. An interview on [DATE] at 4:07 p.m. with Employee C, LPN, revealed that when asked what training she had received after [DATE] concerning residents' Advance Directives and DNR status, she stated that the facility conducted mock codes for 3 weeks after the incident. She said that if a resident is found unresponsive, the staff person in the room calls a code blue, and whoever is closest to the desk gets the resident ' s chart and the crash cart. If the resident has a DNR order, 2 nurses have to assess the resident for respirations and heart rate. When both nurses have done that, then a call is made to the doctor, and he pronounces the resident dead. If the resident does not have a DNR order, we call a code blue on the intercom, and start CPR. We keep going until the paramedics get here. The paramedics either take the resident to the hospital or pronounce them dead. An interview on [DATE] at 4:19 p.m. with Employee D, LPN, revealed that when asked what training she had received after [DATE] concerning residents' Advance Directives and DNR status, she stated that staff are supposed to be familiar with the residents ' code status. If a code blue is called, everyone runs to the room. The staff person at the desk gets the chart and the crash cart. She said that all staff have to check the resident ' s code status in the record. If the resident has a DNR order, two nurses check the resident ' s vital signs before calling the doctor. If there is no DNR order, then we start CPR. Another staff person is sent to call 911, and we continue CPR until 911 arrives. An interview on [DATE] at 11:40AM with Employee E, LPN, revealed that when asked what training she had received after [DATE] concerning residents' Advance Directives and DNR status, she said that if staff find a resident who is without pulse or respirations, staff must check the resident ' s DNR information. Employee E said that this information can be found in the resident ' s electronic record, or if the computer is not handy, you would send another employee to check the resident ' s chart and see if the resident is a full code or DNR. Employee E stated that it only takes a couple of seconds to get that information from the resident ' s record. She said she knows her residents ' code status when she comes on duty. She stated, " If you do CPR on a DNR you are going to get into trouble, and if you don't do CPR on a full code, you are going to be in bigger trouble. " .

Based on record review, staff interviews, and review of facility policy and training content, the facility failed to ensure that the necessary care and services were provided for 1 resident (Resident #1, who did not have a Do Not Resuscitate order in place) out of 5 residents who died in the facility were honored, by failing to initiate cardiopulmonary resuscitation (CPR, initiated when the heart stops or there is no breathing) after finding Resident #1 cold and unresponsive. The facility failed to immediately verify Resident #1's wishes regarding resuscitation, failed to call 911, and failed to initiate CPR when a nurse found the resident without pulse or respirations. The nurse asked two other nurses who were on duty at the time if she needed to get the crash cart. The nurses assumed the resident had a Do Not Resuscitate (DNR) order, and did not initiate CPR. None of the three nurses on duty checked the resident's record, per facility policy, to verify whether he had a DNR order. Due to the facility's failure to initiate CPR for Resident #1, the resident expired in the facility on [DATE]. This resulted in past noncompliance immediate jeopardy occurring on [DATE]. The Director of Nursing (DON), who was also the facility's Risk Manager, was notified of Resident #1's death on the morning of [DATE]. The facility identified the immediate jeopardy on [DATE], when the DON reviewed the resident's record and did not find a DNR order. The Administrator was notified immediately, and an emergency Quality Assurance (QA) meeting was called to review the event and plan of correction. The facility conducted interviews with the 3 staff nurses who worked on [DATE], and all 3 nurses were terminated for not following the facility policy to check the DNR status of a resident who was found unresponsive. The facility notified law enforcement, who found no criminal activity had occurred. The facility immediately developed and implemented a plan of correction, including the following measures: The facility contacted all residents and their families to verify the residents' current Advance Directives and resuscitation status. All family contact was completed by [DATE]. The facility reviewed all current residents' medical records to verify correct documentation of the residents' Advance Directives, including DNR orders if desired by the resident. The facility conducted staff education on all shifts until all employees were re-educated regarding the facility policies for Advance Directives and DNR orders, and where to locate the information in the residents' records. All full time employees were educated by [DATE]. All as needed (PRN) staff were educated on their next scheduled work day. The last PRN employee was educated on [DATE]. No employee was allowed to work until they had completed the education on Advance Directives and DNR orders. The facility held a Resident Council meeting on [DATE], to discuss Advance Directives and DNR orders. The facility sent out invitations and held a Family Council meeting on [DATE] to discuss Advance Directives and DNR orders. The facility conducted surprise mock codes on [DATE], [DATE], and [DATE] on all shifts, using various scenarios to test the staff's knowledge of Advance Directives and DNR orders. The facility will continue mock codes quarterly. The facility held QA meetings on [DATE] and [DATE] to review the plan of correction progress. The Medical Director has been involved in the correction process. The facility will continue to audit and update residents' Advance Directives, due to possible changes in health status of the residents. The facility is checking physicians' orders daily for any changes in residents' code status (whether to initiate CPR). The facility correction date for the deficient practice was [DATE]. Substandard quality of care was identified at F309 (S/S J). Cross reference to F155 (S/S J). The findings include: Review of Resident #1's closed medical record revealed that he was admitted to the facility from the hospital on [DATE] for short term rehabilitation. His [DIAGNOSES REDACTED]. Review of a Social Services progress note for the resident dated [DATE] at 12:29 PM revealed he had an Advance Directive that included a Living Will and a Healthcare Surrogate designation. The medical record did not contain a DNR order. On the night of [DATE], a nurse found the resident unresponsive and cool to the touch. The nurses working on the unit at that time did not initiate CPR or call 911 for Emergency Medical Service (EMS). The facility staff notified the family and physician that the resident had died in the facility. Review of the facility's records and Corrective Action Plan revealed that the facility filed an adverse incident report for Resident #1's death. The facility re-trained 100% of facility staff on Advance Directives, and verification of code status in the event of finding a resident whose heart stopped or who has stopped breathing. The facility updated the electronic medical record system so that staff could access residents' code status at the kiosks in the hallways, on the top of the residents' care plans. Interview on [DATE] at 12:41 PM with the Social Service Director (SSD) confirmed that Resident #1 did not have a DNR order in the chart at the time of his death. The resident had always been a full code status (initiate CPR if no heart beat or respirations), but he had a recent rapid decline and the family started to discuss hospice and a change to DNR status. Hospice had made initial contact with the resident the day before he died , but the resident had not signed the paperwork for hospice care yet. Hospice was waiting for the resident's family to come in before making the final decision about the DNR status. Interview on [DATE] at 4:08 PM with the Director of Nursing (DON) confirmed that Resident #1 died in the facility on [DATE], when the nurses found him unresponsive and did not start CPR. The DON stated that staff failed to check the resident's chart to verify his code status. The DON said that because an aide had seen hospice visit the resident, and a priest had given the resident last rights, the nurses "assumed" he was a DNR. The DON stated that the only document the facility accepted for a DNR was the yellow DNR form that is signed by the resident and physician, and placed in the Advance Directive section of the resident's chart. She confirmed that this document was not in the resident's record. The DON said she was notified of the resident's death on the morning of [DATE]. She said that when she reviewed the resident's medical record, she did not find a DNR order, and she " knew this was an immediate jeopardy situation. " Review of the facility policy for Advance Directives and staff training content revealed that unless given other instructions, the facility staff will try to help any patient whose heart has stopped or who has stopped breathing. If you find your resident not breathing always check the resident's chart first for a yellow copy of the DNR paper under the Advance Directive tab. An interview on [DATE] at 3:51 p.m. with Employee A, Licensed Practical Nurse (LPN), revealed that when asked what training she had received after [DATE] concerning residents' Advance Directives and DNR status, she stated that she attended an in-service on what to do during a code. Employee A stated that she learned to go to the resident ' s room as soon as possible, and proceed as if we will be doing CPR every time we go to a room. She said that the staff person nearest the nurses ' station should get the resident ' s chart and the crash cart. She said staff should verify the resident ' s code status in the chart. Depending on whether or not the resident has a DNR order in the chart, staff will either proceed with CPR or not. Employee A said the chart is opened up so that everyone in the room can see whether or not the resident has a DNR order. The staff person who brings the chart into the room is opening it on the way to the room, and leaves it open for others to see. The DNR order should be under the Advance Directives tab in the front of the chart. More than one staff person has to verify the DNR status. An interview on [DATE] at 3:56 p.m. with Employee B, LPN, revealed that when asked what training she had received after [DATE] concerning residents' Advance Directives and DNR status, she stated that a staff person who finds a resident unresponsive calls for the nurse. The nurse gets the resident ' s chart and the crash cart, and checks the resident ' s code status on the way to the room. Once in the room, the resident ' s code status is shown to the other staff in the room. Employee B said that if the resident does not have a DNR order, staff call a code blue (alerts other staff that CPR is needed) and start resuscitation measures. We call 911 and send the resident to the hospital with paramedics, or the paramedic pronounces the resident dead at the facility. At that point we call the physician and the family. If the resident is determined to be a DNR, two nurses assess the resident for respirations and heart rate, the physician and the family are called, and we proceed as appropriate. An interview on [DATE] at 4:07 p.m. with Employee C, LPN, revealed that when asked what training she had received after [DATE] concerning residents' Advance Directives and DNR status, she stated that the facility conducted mock codes for 3 weeks after the incident. She said that if a resident is found unresponsive, the staff person in the room calls a code blue, and whoever is closest to the desk gets the resident ' s chart and the crash cart. If the resident has a DNR order, 2 nurses have to assess the resident for respirations and heart rate. When both nurses have done that, then a call is made to the doctor, and he pronounces the resident dead. If the resident does not have a DNR order, we call a code blue on the intercom, and start CPR. We keep going until the paramedics get here. The paramedics either take the resident to the hospital or pronounce them dead. An interview on [DATE] at 4:19 p.m. with Employee D, LPN, revealed that when asked what training she had received after [DATE] concerning residents' Advance Directives and DNR status, she stated that staff are supposed to be familiar with the residents ' code status. If a code blue is called, everyone runs to the room. The staff person at the desk gets the chart and the crash cart. She said that all staff have to check the resident ' s code status in the record. If the resident has a DNR order, two nurses check the resident ' s vital signs before calling the doctor. If there is no DNR order, then we start CPR. Another staff person is sent to call 911, and we continue CPR until 911 arrives. An interview on [DATE] at 11:40AM with Employee E, LPN, revealed that when asked what training she had received after [DATE] concerning residents' Advance Directives and DNR status, she said that if staff find a resident who is without pulse or respirations, staff must check the resident ' s DNR information. Employee E said that this information can be found in the resident ' s electronic record, or if the computer is not handy, you would send another employee to check the resident ' s chart and see if the resident is a full code or DNR. Employee E stated that it only takes a couple of seconds to get that information from the resident ' s record. She said she knows her residents ' code status when she comes on duty. She stated, " If you do CPR on a DNR you are going to get into trouble, and if you don't do CPR on a full code, you are going to be in bigger trouble. " .