Every finding on record at PruittHealth- Conway At Conway Medical Center

Based on review of facility policy, record review and interview, the facility failed to develop a comprehensive care plan for Resident (R)25, for 1 of 37 sampled residents.Findings include: Review of the facility policy titled, Care Plans revealed, Policy Statement: It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and patient/resident choice.admission Comprehensive Plan of Care:.3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, an psychosocial needs that are identified in the comprehensive assessment. Review of R25's clinical record indicated R25 was admitted to the facility on [DATE], with diagnoses including but not limited to cerebral infarction due to occlusion or stenosis of small artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, respiratory failure, and atrial fibrillation. Review of R25's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 02/12/26, indicated a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive decline. Review of Section O (Special Treatments, Procedures, and Programs) of the MDS, indicated R25 received oxygen therapy. Review of R25's Physician Orders revealed an order for oxygen at two liters per minute via nasal canula as needed to maintain pulse ox equal to or greater than 90%. Review of R25's Care Plan last with a reviewed/revised date of 04/05/26, indicated no care plan was in place to address R25's use of oxygen. During an interview on 05/08/26 at 10:02 AM, the Minimum Data Set (MDS) Coordinator indicated she was responsible for ensuring care plans were in place to ensure oxygen was addressed. The MDS Coordinator confirmed that R25 did not have a care plan in place to address oxygen use. She stated she was not sure how this was overlooked. During an interview on 05/08/26 at 10:10 AM, the Administrator and Director of Nursing (DON) acknowledged R25 should have a care plan in place to address oxygen use, and confirmed there was no care plan related to oxygen use in place at the time of review.

Based on review of facility policy, record review, observation, and interview, the facility failed to ensure respiratory equipment was maintained in a sanitary manner and in accordance with facility policy, and failed to ensure physician orders were in place for oxygen equipment maintenance for 1 of 12 residents reviewed who receive oxygen, Resident (R)25. Findings include: Review of the facility policy titled, Oxygen Administration indicated, Policy Statement: It is the policy of [NAME] Health Hospice and Healthcare Centers/Veterans Homes to provide oxygen safely and accurately to appropriate patients/residents. Infection Control Policy of O2 (oxygen) Humidifier Bottles.4. Change all oxygen tubing when there is visible soiling with respiratory secretions and mucous and weekly.10. Clean exterior of concentrators weekly and between each patient/resident use with bactericidal surface cleaner. Review of R25's clinical record indicated R25 was admitted to the facility on [DATE], with diagnoses including but not limited to cerebral infarction due to occlusion or stenosis of small artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, respiratory failure, and atrial fibrillation. Review of R25's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 02/12/26, revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive decline. Review of Section O (Special Treatments, Procedures, and Programs) of the MDS, indicated R25 received oxygen therapy. Review of R25's Physician Orders indicated an order for oxygen at two liters per minute via nasal canula as needed to maintain pulse ox equal to or greater than 90%. During an observation on 05/06/26 at 1:39 PM, R25 was observed lying in bed receiving oxygen via nasal canula. The oxygen tank was visibly dusty. No date was found on the oxygen tubing indicating when it was last changed. A nebulizer machine was sitting on the dresser in the room with a mask that was not in a bag or dated. Additionally, the facility did not provide additional evidence of tracking when the last time the oxygen machine was cleaned or the tubing changed. During an interview on 05/08/26 at 10:10 AM, the Administrator and Director of Nursing (DON) acknowledged nursing staff was expected to clean the oxygen tank and change the oxygen tubing and water bottles weekly on Sundays. They stated, this should be included in resident orders. They confirmed there were no orders to clean the oxygen tank and change the tubing/humidifier bottle. They did not provide evidence of tracking when the oxygen tank and tubing was cleaned or changed.

Based on observation, interview, facility policy review, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (5) out of five (5) sampled residents (Resident (R)33, R37, R73, R75 and R188). Findings include: Review of the facility policy titled, Infection Prevention and Control Program Surveillance Reporting dated 11/30/23, revealed, It is the policy of this facility to establish and maintain an Infection Control Program than includes detection, prevention and control of the transmission of disease and infection among patients/residents and partners . Review of the facility policy titled, Enhanced Barrier Precaution (EBP) dated 04/30/24, stated, It is the policy of this facility to implement EBP for the prevention of transmission of multidrug-resistant organisms . 2. Initiation of EBP i.indwelling medical devices (e.g. feeding tubes .) Review of the policy titled, Medication Administration: Enteral Tubes dated 01/06/25, stated, 15. Clean feeding syringe and return to bedside stand. Syringes will be replaced after 24 hours or as required by state regulations. Review of the facility policy titled, Glucometer Cleaning and Disinfecting dated 06/18/24, revealed, A blood glucose monitor measure the concentration of glucose in a person's blood. The Centers for Disease Control and Prevention recommends refraining from sharing blood glucose monitors among residents whenever possible. If one device must be used to monitor several residents, it must be cleaned and disinfected after every use following the manufacturer's instructions to prevent carryover of blood and infectious agents . 1. Clean and disinfect glucose meter before and after each patient use. 2. Wash hands with soap and water. Put on a pair of single use of disposable gloves. 3. Inspect for blood, debris, dust or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. 4. Clean and disinfect the meter by using the EPA approved germicidal/virucidal disinfectant wipes. Wipe all external areas of the meter including both the front and back surfaces until visible clean . 5. Ensure that the surface of the meter remains wet at room termination for the contact time listed on the wipe's directions for use. Allow to air dry. Review of the facility policy titled, Handwashing dated 10/09/23, revealed, It is the policy of (facility) that partners will clean their hands by either using soap and water or antiseptic hand sanitizer. Cleaning your hands reduces the spread of germs and decreases the spread of infection. When to perform hand hygiene: Before and after any direct patient's skin contact, after contact with blood, body fluids, excretions, mucus membranes, non-intact skin or wound dressings. After any contact with objects/medical equipment on the vicinity of the patient. If your hands move from a contaminated body site to a clean body site. After removing gloves. After using the restroom. 1. Review of R75's Residents Face Sheet revealed the resident was admitted to the facility on [DATE], with diagnoses including but not limited to: Paraplegia Incomplete, Benign Neoplasm of Brain, Major Depressive Disorder, Seizures, Essential Primary Hypertension, Legal Blindness, Hyperlipidemia, and Overactive Bladder. Review of R75's clinical record revealed a current Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/26/25,which revealed R75's Brief Interview for Mental Status (BIMS) score was 12 out of 15, which indicated the resident's cognition was moderately impaired. During an observation on 04/16/25 at 9:10 AM, during medication administration, Licensed Practical Nurse (LPN)1 dispensed an eye drop medication and four (4) oral medications for administration to R75. LPN1 did not sanitize or wash his/her hands before he/she dispensed medications for R75. LPN1 opened a new container of Miralax by using his/her left thumb to remove the seal. LPN1 poured the medication into the container's cap of Miralax, after he/she mixed the Miralax with water, LPN1 opened and placed a straw in the Miralax/water mixture. Then LPN1 locked the medication cart, entered the resident's room with the medication. LPN1 administered the oral medication with the Miralax mixture to R75. Then LPN1 washed his/her hands and applied gloves. LPN1 administered the eye drops to R75, removed his/her gloves, returned the eye drops to the medication cart, and documented the administration of medications. LPN1 did not wash or sanitize his/her hands after he/she removed the gloves. During an interview on 04/16/25 at 9:25 AM, the surveyor asked LPN1 what should be done before entering a resident's room and leaving a resident's room that is on Enhanced Barrier Precautions. LPN1 stated to apply gown and gloves before entering the room and upon exit, remove all personal protective equipment and wash hands. The surveyor asked was that what he/she did. LPN1 stated he/she was not always told to do that with medication administration, and he/she did not wash or sanitize hands before he/she entered the resident's room, nor did he/she wash or sanitize hands before he/she started R75's medication pass. 2. Review of R33's Resident Face Sheet revealed the resident was admitted on [DATE], with diagnoses included but was not limited to: Acute Posthemorrhagic Anemia, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Type 2 Diabetes Mellitus, Morbid Obesity, Polyneuropathy, Hypokalemia, Essential Primary Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Bilateral Primary Osteoarthritis of Knee, Chronic Sinusitis, Sprain of Left Rotator Cup Capsule, Obstructive Sleep Apnea, Dyspnea, Vitamin D Deficiency, Ventricular Tachycardia, and Irritable Bowel Syndrome. Review of R33's current Annual MDS, with an ARD of 12/03/24, revealed R33's BIMS score was 15 out of 15, which indicated the resident's cognition was intact. During an observation on 04/16/25 at 9:55 AM, during medication administration, revealed LPN2 dispensed 15 oral medications, two (2) nasal sprays, an inhaler, and an insulin pen. LPN2 then exited the hallway and returned to the cart with a container of Acidopholus for administration to R33. LPN2 punched the seal with his/her right thumb. LPN2 did not wash or sanitize his/her hands before removing the container's seal. LPN2 placed his/her left index and middle finger inside a 30 ml (milliliter) cup after he/she removed the cup from a stack of cups and poured liquid medication into the cup. Then LPN2 removed several pre-packaged medication packages from the medication cart. LPN2 placed his/her right index finger inside another 30 ml cup after he/she removed it from a stack of 30 ml cups. LPN2 dispensed the medication from the packages into the 30 ml cup. LPN2 then placed his/her left hand index finger inside of a 120 ml cup after he/she removed it from a stack of 120 ml cups and poured water into the cup. LPN2 placed his/her left index finger inside of the 120 ml cup container water and picked up the 120 ml cup containing water. As LPN2 picked up the cup containing the medications and the 30 ml cup containing the liquid medication, a small amount of water from the 120 ml cup spilled onto the floor. LPN2 placed all the medication on the medication cart, obtained a paper towel and wiped the water up. LPN2 sanitized his/her hands, stacked the 30ml cup containing the liquid medications on top of the 30 ml cup containing the pills, picked up both cups, picked up the 120 ml cup containing water, placed the boxed inhalers, nasal sprays and the insulin in his/her pocket and entered the resident's room. LPN2 administered the oral medications with the water. LPN2 handed the nasal sprays to the resident, and the resident administered both nasal sprays. LPN2 administered the remaining oral medications. LPN2 exited the room and obtained a needle for the insulin pen. LPN2 returned to the room and administered the Lantus injection to the resident's right abdominal quad. During an interview with LPN2 on 04/16/25 at 10:30 AM, the surveyor asked when opening a bottle of medication should fingers be placed inside of the container. LPN2 stated no, but he/she had used their thumb to peel the seal back and did not wear gloves. The surveyor asked when removing a medication cup and a water cup from a stack of cups, should fingers be placed inside of the cups after the cups are removed. LPN2 stated no, but when he/she pulled the cups he/she placed their index finger inside of the cup. The surveyor asked when should medication cups containing medication be stacked atop of each other. LPN2 stated, they should not, but he/she stacked the cups containing the liquid medication on top of the cup containing the pills. The surveyor asked when should staff sanitize or wash hands during the medication pass, LPN2 stated after each patient, but he/she did not sanitize or wash hands before the insulin injection and should have. During an interview on 04/18/25 at 8:07 AM, the Director of Nursing (DON) stated all staff should wash or sanitize hands before entering or exiting a room; staff should not touch the inside of a medication bottle with hands; staff should not place their fingers inside of any container; staff should never stack medications cups on top of each other because the outside of the medication cup was considered contaminated or dirty; staff should wash or sanitize hands before starting medication pass and before entering a room and upon exiting. The surveyor asked what about his/her expectations were for staff regarding hand hygiene with administration of injections with pens. The DON stated the same process was used for pens and needles, which included: hand hygiene, apply gloves, administer medications, remove gloves, and then hand hygiene after gloves were removed. 3. Review of R188's Resident Face Sheet revealed the facility admitted the resident on 02/21/25. Review of the Progress Note dated 04/03/25, revealed R188 had diagnoses including but not limited to: Atrial Fibrillation, Benign Prostatic Hyperplasia (BPH), and Generalized Weakness. During an observation of R188 on 04/15/25 at 11:10 AM, revealed the resident was awake, alert, and lying in his/her bed. During an observation of a medication pass for R188 on 04/15/25 at 11:00 AM, with Registered Nurse (RN)5 revealed the nurse removed a packet of three (3) medications from the medication cart drawer. As the nurse removed the packet of pills, one (1) of the pills came out of the top of the packet and the nurse caught the medication with his/her bare hands and placed the pill back into the packet. Continued observation of the medication preparation revealed the nurse then dropped two (2) more of the resident's pills onto the bare surface of the medication cart, used a split open medication packet to try and scoop the medications off the surface of the medication cart, and into a medication cup. RN5 was not observed to wash his/her hands at any time before the start of the medication preparation or at the end of the medication preparation. Continued observation revealed the nurse administered the contaminated medications to the resident. The nurse was not observed to do any hand sanitation before, during or after the medication administration. The nurse was observed to wear gloves he/she had donned (put on) in the resident's room out into the hallway and disposed of the gloves at the medication cart. Again, no hand hygiene or sanitation was observed. 4. Review of R37's Resident Face Sheet revealed the facility admitted the resident on 11/07/24. Review of the Progress Note dated 04/01/25, revealed the resident had diagnoses including but not limited to: Constipation, Chronic Kidney Disease, and Functional Quadriplegia. During an observation on 04/14/25 at 11:04 AM, R37's door frame, prior to entry into the resident's room, revealed signage was posted that noted, STOP ENHANCED BARRIER PRECAUTIONS (EBP) STOP EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities . Device care or use: feeding tube . During an observation of a medication administration pass on 04/14/25 at 11:15 AM, RN5 revealed the nurse had not sanitized his/her hands prior to the preparation of the resident's medications. Continued observation of the medication preparation revealed the nurse touched the inside of the packets used to crush the resident's medications and touched the inside of the medication cups with his/her bare hands. Continued observation of the medication pass via the resident's gastrostomy tube (Gtube) revealed the nurse failed to clean and date two (2) syringes used during the administration of the medications. The nurse was observed to leave the dirty syringes on the resident's bedside table. No handwashing was observed before, during or after the medication pass. During another observation on 04/14/24 at 11:17 AM, of RN5 administering medications via R37's gastrostomy tube (Gtube), revealed the nurse failed to don (put on) a gown prior to the administration of the medications. During an interview with RN5 on 04/15/25 at 3:00 PM, revealed he/she had not performed hand hygiene between the care he/she had delivered to R188, R37 or R73 even though he/she received education on hand hygiene from the facility. The nurse revealed washing hands before and after resident care could prevent the spread of germs. The nurse also stated he/she had received training on Enhanced Barrier Precautions (EBP) and should have donned a gown when care was provided to R37 because a gown would protect him/herself and others from germs. Continued interview with RN5 revealed he/she should have discarded R37's used syringes in the trash instead of placing them on the bedside table. 5. Review of R73's Progress Note dated 04/10/25, revealed the facility admitted the resident on 03/11/25, status post hospitalization from a fall at home which resulted in a Right Open Reduction Internal Fixation (ORIF). Continued review of the Progress Note revealed diagnoses including but not limited to: Pancreatic Cancer, Generalized Weakness, and Seasonal Allergies. Review of R73's Comprehensive MDS with an ARD of 03/24/25, revealed the resident's BIMS score was 14 out of 15, indicating R73 was cognitively intact, and the resident was interviewable. During an observation of a blood glucose monitoring on 04/14/25 at 11:15 AM, for R73 by RN5 revealed the nurse failed to sanitize the glucose monitor before and after he/she conducted the glucose check on the resident. Continued observation of the RN revealed he/she donned gloves in the resident's room per the resident's request, however, the nurse failed to dispose of the gloves in the resident's room but rather walked down the hallway several feet and disposed of the gloves at the medication cart. The nurse was not observed to perform any hand sanitation before or after he/she tested the resident's blood sugar; and was not observed performing hand hygiene after he/she had administered insulin to the resident. In addition, the nurse failed to perform hand sanitation after he/she removed the contaminated gloves at the medication cart. During an interview on 04/15/25 at 3:00 PM, RN5 revealed he/she received training on how to clean the blood glucose monitoring machine after each use. RN5 stated the machine should be cleaned with alcohol wipes, which was incorrect. The nurse also revealed that soiled gloves should not be worn in the hallway and should be discarded in the resident's room. During an interview on 04/18/25 at 8:13 AM, with RN7 revealed staff received training on EBP. The nurse stated EBP were used for residents with open wounds, and indwelling medical devices. He/she revealed the proper Personal Protective Equipment (PPE) worn during care of these residents included gowns and gloves. RN7 went on to state that handwashing should be performed between the care of each resident, and a negative outcome of improper handwashing might be that a resident or a staff person could get ill from the transmission of germs/bugs. RN7 stated the blood glucose monitoring machine was used on several different residents and must be cleaned with Sani-Wipes after each use. The nurse also stated that dirty syringes should be rinsed and left to dry air on a paper towel. He/she stated they should also be dated. The nurse revealed the syringes used during Gtube administration of medications should be changed out every day. During an interview with the DON, on 04/18/25 at 8:30 AM, he/she revealed the purpose of EBP was to protect the residents from the staff. The DON stated a resident with any indwelling medical device would be placed in EBP and staff who provided direct resident care should don a gown, and gloves. The DON stated the glucose monitoring machines should be cleaned between each resident with a Sani-Wipe and allowed to dry. He/She revealed alcohol swabs should not be used to clean the machine. The DON went on to state that used resident equipment, such as syringes, should be cleaned with water, labeled, and dated because staff should not use dirty equipment on the residents. He/She stated equipment such as syringes that were used to administer medication via Gtube should be discarded daily. As far as handling medications, the DON stated medications should never be touched by staff with bare hands. The DON also said that a medication that dropped onto the surface of the medication cart would be considered dirty. Handwashing should occur between each resident and dirty gloves should never be worn out into the hallway but rather disposed of in the resident's room with hand hygiene to follow. The DON stated all the facility nurses had to complete a skills checklist related to infection control upon their hire, and annually.

Based on observation, interview, policy review, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences for one (1) of 39 sampled residents, (Resident (R)39). The resident could not access his/her call light during three (3) different observations. Findings include: Review of facility policy titled, Nursing: Patient/Rights, Accommodation of Needs, dated 12/01/23, stated, It is the policy of this healthcare center to promote and protect the rights of the patients/residents residing in the center . Essential Points - Unless indicated in the care plan, each patient/resident, when in their room or in bed, must have the call light placed within reach at all times, regardless of staff assessment of patient/residents ability to use it. When the patient/resident is in bed, the call light should be fastened to the side rail he/she is facing. When out of the bed, the call bell is to be draped across the bed, so it is accessible from wheelchair, or bedside chair. Review of R39's Resident Face Sheet revealed the facility admitted the resident on 12/07/20. Review of R39's Progress Note Current Procedural Terminology (CPT) (Amended), dated 12/20/25, revealed the resident had diagnoses including but not limited to: Anxiety, Vascular Dementia, Unspecified Severity, with Anxiety, Type II Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia, Thrombocytopenia, Long-Term Use of Anticoagulants, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Left Non-Dominant Side. Review of R39's Care Plan, dated 12/20/20, stated, Resident at risk for falling related to (R/T) weakness limited mobility, history of (H/O) Cerebrovascular Disease (CVA) and COVID19. Approach- Keep call light in reach at all times. Review of R39's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/13/25, revealed the resident had a Brief Interview Mental Status (BIMS) score of 11 out of 15, which indicated moderate cognitive impairment. Further review of the MDS revealed R39 required Partial/moderate assistance to roll from left to right and the resident was always incontinent of bowel and bladder. During an observation of R39 on 04/16/25 at 8:55 AM, revealed the resident to be in his/her bed, alert, awake, and oriented to person, place, and time. R39's call light was on the floor, on the left side of his/her bed and below his/her shoulder line. During an interview with R39 on 04/16/25 at 8:56 AM, revealed he/she did not always get help from the staff quickly because he/she could not often find his/her call light. During an observation on 04/16/25 at 9:05 AM, revealed Certified Nursing Assistant (CNA)12 entered the resident's room to assist with the resident's breakfast meal. During an observation on 04/16/25 at 9:20 AM, revealed CNA12 had exited the resident's room and the call light was observed to still be lying on the floor, in the same position as observed on 04/16/25 at 8:56 AM. During an observation of R39, on 04/17/25 at 9:34 AM, revealed the resident to be awake, alert and oriented to person, place and time. The resident was in the bed, with the head of the bed (HOB) elevated approximately 40 degrees. The resident's call light was noted to be clipped to the upper right side of the bed's siderail. When asked if R39 could reach the call light, R39 tried to reach behind to access the call light but was unable to access it. During an interview on 04/17/25 at 9:36 AM, CNA3 revealed R39's call light should have been clipped on the resident and not on the side rail where the resident could not access it. CNA3 stated that he/she was unsure who had placed the call light like that, but it was wrong. CNA3 went on to state that the call lights were to be checked for correct placement upon every staff round. During an interview on 04/18/25 at 8:13 AM, Registered Nurse (RN)7 revealed that every hour or two, staff completed rounds on all the residents and at that time staff checked for the placement of the call lights so that the residents could have access to them. RN7 stated that he/she would expect staff to notice a call light was on the floor. During an interview on 04/18/25 at 8:30 AM, the Director of Nursing (DON) revealed that every time staff went into a resident's room, they should have looked to see where the call light was before an incident occurred because the resident could not reach their call light.

Based on observation, interview, facility policy review, and record review, the facility failed to protect the personal privacy and confidentiality of personal and medical records for two (2) of five (5) sampled residents, (Resident (R)37 and R73). Specifically, the Electronic Medication Administration Records (EMR) were not minimized and/or concealed while the medication cart was left unattended by a Registered Nurse (RN). Findings include: Review of the facility's policy titled Privacy Practices: Use of Notice of Privacy Practices for Protected Health Information (PHI), dated 05/16/23, stated, Protected Health Information (or PHI) is individually identifiable health information. Health information means any information, whether oral or recorded in any medium, that: Is created or received by (facility) or an affiliated entity or business associate, and Relates to the past, present or future physical or mental health or condition of an individual: the provision of health care to an individual . Review of the facility's policy and procedure, titled, Medication Administration: General Guidelines, dated 07/22/24, stated, During routine administration of medications, the medication cart is kept in the doorway of the patient/resident's room, with open drawers facing inward and all other sides closed and locked . and all outward sides must be inaccessible to patients/visitors or other passing by. 1. Review of R37's Resident Face Sheet revealed, the facility admitted the resident on 11/07/24. Review of R37's Progress Note dated 03/31/25, revealed, the resident had diagnoses including but not limited to: Constipation, Chronic Kidney Disease, and Functional Quadriplegia. Review of R37's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/25, revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven(7) out of 15, which indicated the resident had severe cognitive impairment, and the resident was not interviewable. During an observation of a medication administration pass for R37, on 04/14/25 at 11:15 AM, by Registered Nurse (RN)5, revealed once he/she had completed the preparation of R37's medications, he/she failed to minimize and/or conceal the Electronic Medication Administration Record. Continued observation of the medication cart, at this time, revealed the cart was left sitting in the hallway, several doors down from R37's doorway, and was unattended by staff. One (1) resident was observed sitting in a wheelchair directly across from the unattended cart. 2. Review of R73's Progress Note, dated 04/10/25, revealed the facility had admitted the resident on 03/11/25, status post hospitalization from a fall at home, which resulted in a Right Open Reduction Internal Fixation (ORIF). Continued review of the Progress Note, revealed the resident had diagnoses including but not limited to: Pancreatic Cancer, Generalized Weakness, and Seasonal Allergies. Review of R73's Comprehensive MDS with an ARD of 03/24/25, revealed the resident's BIMS score was 14 out of 15, which indicated the resident was cognitively intact, and the resident was interviewable. During an observation of a medication administration pass for R73, on 04/14/25 at 11:50 AM, by RN5, revealed once RN5 had completed the preparation of the resident's medications, he/she failed to minimize and/or conceal the Electronic Medication Administration Record. Continued observation of the medication cart, at this time, revealed the cart was left sitting in the hallway, several doors down from R73's doorway, and was unattended by staff. One (1) resident was observed sitting in a wheelchair directly across from the unattended cart. During an interview on 04/15/25 at 3:00 PM, RN5 revealed he/she should have closed the screen on the Electronic Medical Record (EMR) once he/she had left the cart unattended due to privacy issues. During an interview on 04/18/25 at 8:13 AM, RN7 revealed that anytime a medication cart was left unattended, the Walk Away Button should be activated in order to protect resident records. RN7 revealed patients and/or visitors would be able to view residents' protected information if the screen was not shut down. RN7 also revealed that the medication cart should be placed in front of the resident's room when that specific resident was receiving their medications. During an interview on 04/18/25 at 8:30 AM, the Director of Nursing (DON) stated the medication cart should be placed at the doorway of the resident who received the medications, and the EMR screen should be minimized in order to be adherent to HIPAA laws. During an interview on 04/18/25 at 9:49 AM, the Administrator revealed it was his/her expectation that privacy was maintained on all residents, and that all staff had received education on this upon hire.

Based on review of facility policy, record review and interview, the facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS System for seven (7) out of 74 resident reviewed. Findings include: The facility's MDS Assessment policy dated 12/06/22 stated, It is the policy of this healthcare center that each Minimum Data Set (MDS) reflect the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. The assessment will be scheduled to accurately account for the acuity and complexity of the patient/resident. Each Assessment Reference Date (ARD) will be chosen to capture services rendered and reflect an accurate clinical profile of each patient/resident. The Interdisciplinary Team will be assessing based on a set ARD to maintain accuracy, timeliness, and consistency, and generate the most effective Plan of Care for each patient/resident. Review of resident records revealed Resident (R)32's MDS was assigned 03/04/25, due 03/05/25, and sent to the facility's corporate office on 04/17/25, which was greater than 14 days after completion. The most recent MDS was submitted to CMS on 12/04/24. R3's Quarterly MDS was assigned 02/28/25, due 02/27/25, and sent to the facility's corporate office on 04/17/25, which was greater than 14 days after completion. The most recent MDS for a significant change was submitted to CMS on 12/03/24. R16's Quarterly MDS was assigned 03/04/25, due 03/05/25, and sent to the facility's corporate office on 04/18/25, which was greater than 14 days after completion. The most recent MDS was submitted to CMS on 12/08/24. R18's Quarterly MDS was assigned 03/06/25, due 03/07/25, and sent to the facility's corporate office on 04/18/25, which was greater than 14 days after completion. The most recent MDS was submitted to CMS on 12/05/24. R33's Quarterly MDS was assigned 03/04/25, due 03/05/25, and sent to the facility's corporate office on 4/18/25, which was greater than 14 days after completion. The most recent MDS was submitted to CMS on 12/03/24. R44's Quarterly MDS was assigned 03/06/25, due 03/08/25, and sent to the facility's corporate office on 04/18/25, which was greater than 14 days after completion. The most recent MDS was submitted to CMS on 12/03/24. R61's Quarterly MDS was assigned 03/04/25, due 03/05/25, and sent to the facility's corporate office on 04/17/25, which was greater than 14 days after completion. The most recent MDS was submitted to CMS on 12/04/24. During an interview on 04/18/25 at 9:30 AM, the MDS Nurse confirmed that the MDS submissions were submitted late. The MDS Nurse stated they were supposed to complete the MDS and submit to the facility's headquarters; headquarters would then submit to CMS. The MDS Nurse stated that the facility lost the Admissions Director and Social Worker, and the facility hired a new Director of Nursing and a new Administrator. The MDS Nurse stated that they were filling in for several positions and with all the turnover, the MDS submissions got overlooked.

Based on observations, interviews, facility policy review, and record review, the facility failed to accurately reflect the resident's status for one (1) of five (5) sampled residents. Specifically, the Registered Nurse (RN) failed to accurately document an Accu-check (a device used to check blood sugars) result for Resident (R)73. Findings include: The facility did not provide a copy of the policy and procedure related to accuracy and documentation of resident assessment; however, review of the Evencare G3 Blood Glucose Monitoring System: Certified Instructor Record Competency Checklist revealed that staff should record the patient result accurately. Review of R73's Progress Note dated 04/10/25, revealed the facility admitted the resident on 03/11/25, status post hospitalization from a fall at home, which resulted in a Right Open Reduction Internal Fixation (ORIF). Continued review of the Progress Note, revealed diagnoses including but not limited to: Pancreatic Cancer, Generalized Weakness, and Seasonal Allergies. Review of R73's Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/24/25, revealed the resident's Brief Interview for Mental Status (BIMS) score was 14 out of 15, which indicated the resident was cognitively intact and interviewable. Continued review of the MDS revealed the resident had a diagnosis of Diabetes Mellitus and the resident had received seven (7) doses of insulin in the past seven (7) days or since admission/entry or re-entry if less than seven (7) days. Review of R73's Medication Administration History, dated 04/01/25 - 04/15/25, revealed the following prescriber's orders: Novolog Flexpen U-100 Insulin (insulin aspart u-100) Insulin pen; 100 units per milliliter (mL) Amount to administer per mL: . if Blood Sugar is 250 to 299 give six (6) units. Before meals and at bedtime. Start 3/11/25.[sic] During an observation of Registered Nurse (RN)5, on 04/15/25 at 11:45 AM, revealed the nurse checked the resident's blood sugar with the blood glucose monitoring machine and obtained a value of 262. Continued observation of RN5, upon arrival back to the medication cart, revealed the nurse could not remember the blood glucose value. The nurse was then observed to pick up the glucose machine, push a button, and stated, It was 264. Review of the View Vital screen, in the Electronic Medical Record (EMR), it was observed that RN5 had documented the blood glucose for R73 as a value of 264. During an observation on 04/16/25 at 9:30 AM, of the blood glucose monitoring re-call screen, with Unit Manager (UM)6 and the Director of Nurses (DON), revealed the actual value of R73's blood glucose on 04/15/25 was not 264, but rather 262. During an interview on 04/15/25 at 3:00 PM, RN5 revealed he/she had forgotten the actual blood glucose value by the time he/she had gotten back to the medication cart to draw up the resident's sliding scale insulin, and he/she should not have guessed on what the blood sugar actually had been. RN5 stated that he/she actually had no idea on how to recall a blood glucose value on the glucose machine. RN5 stated that he/she should have re-checked the resident's blood sugar again before any insulin had been administered and recorded that value in the EMR. During an interview with RN7 on 04/18/25 at 8:13 AM, RN7 revealed the glucose monitoring machine had a memory button on it so that previous blood sugar values could be re-called, and staff had received training on how to use it. RN7 stated if he/she had forgotten a blood sugar value, he/she would either recall the number on the machine, or re-check the value so the proper amount of insulin could be administered. RN7 stated he/she would then accurately record the value in the EMR. During an interview with the Director of Nursing (DON) on 04/18/25 at 8:30 AM, revealed there was a memory button on the glucose monitor the nurse had been trained to use. The DON stated RN5 should have asked for help with the machine, and not just blindly administer insulin to the resident, and record an inaccurate finding.

Based on observation, interview, facility policy review and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, Resident (R)39 did not have his/her call light within reach as outlined in the care plan. Additionally, R37 was not care planned for Enhanced Barrier Precautions (EBP). This affected two (2) of seven (7) sampled residents. Findings include: 1. Review of R39's Resident Face Sheet, revealed the facility admitted the resident on 12/07/20. Review of R39's Progress Note Current Procedural Terminology (CPT) (Amended), dated 12/20/25, revealed the resident had diagnoses including but not limited to: Anxiety, Vascular Dementia, Unspecified Severity, with Anxiety, Type II Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia, Thrombocytopenia, Long-Time Use of Anticoagulants, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Left Non-Dominant Side. Review of R39's Care Plan dated 12/20/20, stated, Resident at risk for falling related to (R/T) weakness limited mobility, history of (H/O) Cerebrovascular Disease (CVA) and COVID19. Approach - Keep call light in reach at all times. During an observation of R39, on 04/16/25 at 8:55 AM, revealed the resident in his/her bed, alert, awake, and oriented to person, place, and time. During an interview with R39, on 04/16/25 at 8:56 AM, revealed he/she did not always get help from the staff quickly because he/she could not often find his/her call light. During an observation on 04/16/25 at 8:56 AM, revealed the resident's call light was on the floor, on the left side of his/her bed, and below his/her shoulder line. During an observation on 04/16/25 at 9:05 AM, revealed Certified Nursing Assistant (CNA)8 entered R39's room to assist with the resident's breakfast meal. During an observation on 04/16/25 at 9:20 AM, revealed CNA8 exited R39's room and the call light was observed to still be lying on the floor, in the same position as observed on 04/16/25 at 8:56 AM. During an observation of R39 on 04/17/25 at 9:34 AM, revealed the resident to be awake, alert, and oriented to person, place and time. The resident was in bed, with the head of the bed (HOB) elevated approximately 40 degrees. R39's call light was noted to be clipped to the upper right side of the bed's siderail. When asked if he/she could reach the call light, the resident tried to reach behind him/herself to access the call light but was unable to access it. 2. Review of R37's Resident Face Sheet, revealed the facility admitted the resident on 11/07/24, with diagnoses including but not limited to: Constipation, Chronic Kidney Disease, and Functional Quadriplegia. Review of the R37's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/25, revealed a Brief Interview for Mental Status (BIMS) score of seven (7) out of 15, which indicated the resident had severe cognitive impairment, and the resident was not interviewable. During an observation on 04/14/25 at 11:04 AM, R37's door frame, prior to entry into the resident's room, had signage that stated, STOP ENHANCED BARRIER PRECAUTIONS (EBP) STOP EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities .Device care or use: feeding tube . During an observation of R37 on 04/14/25 at 11:05 AM, revealed the resident in his/her bed, watching television. During an observation of a medication administration pass with RN5, on 04/14/25 at 11:15 AM, revealed RN5 administered medications via R37's gastrostomy tube. The nurse did not wash his/her hands, and failed to don (put on) a gown. Review of the Individualized Care Plan for R37, revealed the resident did not have a Care Plan to address EBP. During an interview with the MDS Nurse, on 04/16/25 at 1:30 PM, revealed R37 should have been care planned for EBP but must have been missed. The MDS Nurse stated that she/he along with other licensed staff could develop and/or update a care plan. During an interview on 04/18/25 at 8:13 AM, RN7 revealed any licensed nurse could start or update a Care Plan. RN7 stated a Care Plan should be followed because it was the resident's preference, and for their safety. He/She revealed a Care Plan helped staff to provide the best care possible to the resident. During an interview on 04/18/25 at 8:30 AM, the Director of Nursing (DON) revealed all licensed staff could update the resident Care Plans, and that it was his/her expectations that staff followed the Care Plan in order to obtain the best possible outcomes for our residents.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a Physician's Order was followed for the administration of a medication patch, Lidocaine (used for the treatment of pain). This affected one (1) of six (6) residents (Resident (R)75) observed during medication administration. Findings include: Review of the facility's policy titled Medication Administration: General Guidelines with a revised date of 04/20/19, revealed: Medications are administered as prescribed, in accordance with good practices and only by persons legally authorized to do so . Procedure: 1. Medications are prepared, administered, and recorded only by licensed nursing, medical, or pharmacy personnel. 2. Medications are administered in accordance with written orders of the attending physician . 10. Medications are administered within 60 minutes before or after scheduled time, . Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the healthcare center . Review of R75's Resident Face Sheet revealed the resident was admitted to the facility on [DATE], with diagnoses including but not limited to: Paraplegia Incomplete, Benign Neoplasm of Brain, Major Depressive Disorder, Seizures, Essential Primary Hypertension, Legal Blindness, Hyperlipidemia, and Overactive Bladder. Review of R75's clinical record revealed a current Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/26/25. The assessment revealed R75's Brief Interview for Mental Status (BIMS) score was 12 out of 15, which indicated the resident's cognition was moderately impaired. Review of R75's Medication Administration History revealed, . Order Lidocaine (OTC) (Over the Counter) adhesive patch, medicated; 4 % Amount to Administer: right hip; topical Frequency Once a Day . Scheduled Date 04/16/2025 Scheduled Time 9:00 AM Charted Date 4/16/2025 10:50 AM Reason/Comments Late Administration: . During an interview on 04/18/25 at 8:07 AM, the Director of Nursing (DON) stated staff should follow the physician's orders within the guidelines. The DON confirmed the nurse did not administer the medication one hour before or one hour after the scheduled time, and that was a medication error.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that medications were properly stored for one (1) of six (6) residents (Resident (R)33) when staff left medications on top of a medication cart unattended and out of view. Findings include: A review of the facility's policy titled Medication Storage in the Healthcare Centers with a revised date of 11/01/24, revealed, . Policy Statement: Medications and biologicals are stored safely, securely, and properly following manufacturing recommendations or those of the supplier .16. During routine administration of medications, the medication cart is kept in the doorway of the patient/resident's room, with open drawers facing inward and all other sides closed and locked. No medications are kept on top of the cart, and all outward sides must be inaccessible to patients/residents or others passing by . A record review of R33's Resident Face Sheet revealed the resident was admitted on [DATE], with diagnoses including but not limited to: Acute Posthemorrhagic Anemia, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Type 2 Diabetes Mellitus, Morbid Obesity, Polyneuropathy, Hypokalemia, Essential Primary Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Bilateral Primary Osteoarthritis of Knee, Chronic Sinusitis, Sprain of Left Rotator Cup Capsule, Obstructive Sleep Apnea, Dyspnea, Vitamin D Deficiency, Ventricular Tachycardia, and Irritable Bowel Syndrome. A review of R33's current Annual Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 12/03/24, revealed R33's Brief Interview for Mental Status (BIMS) score was 15 out of 15, which indicated the resident's cognition was intact. During an observation on 04/16/25 at 9:55 AM, during medication administration, revealed Licensed Practical Nurse (LPN)2 dispensed 15 oral medications, two (2) nasal sprays, the Deep-Sea Nasal Spray and Flonase, a Trelegy/Elipta Inhaler, and an insulin pen. LPN2 then went down the hallway and returned to the cart with a container of Acidopholus for administration to R33. LPN2 left a Cetirizine bottle on top of the cart. LPN2 entered the resident's room to administer R33's medication. When LPN2 returned to the medication cart, LPN2 picked up the Cetirizine bottle and stated that he/she should not have left the medication on top of the medication cart but instead should have locked in the cart before leaving the medication cart and medicines unattended and unsecured. During an interview on 04/16/25 at 10:30 AM, LPN2 stated the Cetirizine (was left on top of the medication cart) and said that someone could have gotten the bottle and taken the pills. During an interview on 04/18/25 at 8:07 AM, with the Director of Nursing (DON), the surveyor asked when should staff leave medications on top of medication cart and unattended. The DON stated, never.

Based on review of facility policy, observations and interviews, the facility failed to ensure that medications were secured, that outdated medications were removed from active storage and that medications were labeled as to opened and/or expiration date for 6 of 8 medication storage areas with expired medications and/or unlocked medication carts. Finding include: Review of a facility policy titled, Medication Storage in the Healthcare Centers, with a reviewed date of 07/11/22, states, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendation or those of the supplier. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access . Multi-dose containers of injectables . and inhalers are to be dated (when opened) and Outdated . medications . are immediately removed from stock . During an observation on 07/24/23 at approximately 10:37 AM, of the crash cart revealed it was unlocked and contained two 10 ml (milliliter) syringes of Sterile NaCl (Sodium Chloride) 0.9% (percent), USP (United States Pharmacopoeia) with expiration dates of 10/31/22. These syringes were located in drawer 2. Review a document titled, 11p-7a. Nurses Daily check lists dated July 2023, located atop the crash cart, revealed that the crash cart had not been initialed as checked on 7/19/23, 7/22/23 and 7/23/23. During an interview on 07/24/23 at approximately 10:46 AM, registered nurse (RN)1 confirmed that the medications were outdated, the crash cart was unlocked, and had not be checked daily. During an observation on 07/24/23 at approximately 10:48 AM, of a treatment cart revealed that it was unlocked. During an interview on 07/24/23 at approximately 11:03 AM, RN1 confirmed that the treatment cart was unlocked. During an observation on 07/24/23 at approximately 10:54 AM, of the Care Lane treatment cart revealed that it was unlocked. This finding was verified on 07/24/23 at approximately 10:56 AM by an unidentified nurse. During an observation on 07/25/23 at approximately 11:05 AM, of the Care Lane medication cart revealed one opened (in use) and undated Novolog Flexpen and one opened (in use) and undated Incruse Ellipta 62.5 mg (milligram) for Oral Inhalation which was labeled by the manufacturer Discard INCRUSE ELLIPTA 6 weeks after opening the foil tray or when the counter reads 0 . whichever comes first. During an interview on 07/25/23 at approximately 11:08 AM, Licensed Practical Nurse (LPN)1 confirmed these findings and stated both medications were in use. During an observation on 07/25/23 at approximately 11:18 AM, of the Medstar medication cart revealed that it was unlocked and unattended with staff and visitors in the immediate area. During an interview on 07/25/23 at approximately 11:23 AM, RN1 confirmed the medication cart was unlocked and stated she had only left the medication cart unlocked for a few minutes. During an observation on 07/25/23 at approximately 11:26 AM, of the Medstar medication cart 2 revealed one opened bottle of Melatonin 200 mg by Nature Made with expiration date March, 2023 and one Albuterol Sulfate HFA (hydrofluoroalkane) Inhaler dated opened 6/01/23 and expired 07/04/23. During an interview on 07/25/23 at approximately 11:35 AM, RN1 confirmed these findings as outdated and stated that the Melatonin had been brought in by a resident. During an interview on 07/25/23 at approximately 12:38 PM, the Director of Nursing provided a copy of the facility's medication storage policy and stated there was no policy on crash carts and provided a copy of the AED (Automated External Defibrillator) Crash Cart Checklist, with a reviewed date of 05/25/21. Review of this policy did not include a check for outdated contents and did not list medications under Items on Crash Cart.

Based on review of facility policy, observations, and interviews, the facility failed to ensure an excessive build-up of lint was removed from 2 of 2 clothes dryers. Findings include: Review of the facility policy titled, Dryer Vent: Complete In-House System Cleaning, states, Confirm that the lint is removed from the stack and inside the dryer. It is a fire hazard and a code violation if this is not maintained. Inside and Behind Dryer and Drum: Pull the front covers off the dryers and clean the entire area. A shop vac or air compressor works best for this task. Lint Catch/Screens Lint Catchers should be cleaned after each load. Every few months, remove the lint catch and with a bristle brush, wash the screen clean. A fine layer of lint can form across the screen and stop the flow of clean air out of the dryer, hampering the speed of drying the items. During an observation of the laundry room on 07/26/23 at 8:45 AM, revealed 2 of 2 clothes dryers with excessive lint under the lint basket, on the sides and inside the lint compartment which hold the lint basket. During an interview on 07/26/23 at 8:50 AM, Laundry Worker (LW)1 and Environmental Services Manager (ESM) confirmed the excessive amount of lint. LW1 stated that she cleans the lint basket after each load. The ESM provided a Work History Report, and indicated that the dryer vents were cleaned of lint on 07/19/23.

Based on observations, interviews, and review of the facility policy, the facility failed to ensure foods that are stored in the freezer, dry storage, emergency storage and resident dietary rooms were labeled with contents and open date and discarded after the manufacturer's expiration date. Findings Include: Review of the facility ' s policy titled, Food Ordering, Receiving, and Storage, with an effective date of [DATE], reveals It is the policy of PruittHealth that food will be routinely ordered and received from approved corporate vendors who obtain food from regulated and reputable sources to ensure safety. Storage and Rotation Guidelines: FIFO: first in, first out. Stock should be rotated utilizing this principle. Old products should be moved to the front of the shelf, new products behind the old. Date all stock items with delivery date. An observation on [DATE] at approximately 10:55AM, revealed a half head of lettuce, a plastic square container with a green lid with chicken salad, a silver pan of penne pasta, covered in plastic wrap, a silver pan containing 2 chicken quarters, covered in plastic wrap, and a silver container of salad mix, also covered with plastic wrap, did not contain any labels or dates. There was also a pan of plain chicken that was not dated. These items were in the walk in refrigerator, labeled #3. An observation on [DATE] at approximately 11:00AM, in the reach in refrigerator, revealed two clear plastic containers with cheese not labeled or dated. A clear plastic Ziploc bag containing cheddar cheese slices and a bag containing swiss cheese slices were also observed as not having a label or date. An observation on [DATE] at approximately 11:05AM, in refrigerator #2, revealed a bowl of salad that was covered with plastic wrap, not labeled or dated. An observation on [DATE] at approximately 11:08AM, in the dry storage room, revealed two- five-pound containers of Creamy Peanut Butter with a best by date of [DATE]. A box containing six, 1.5lb bags of Homestyle Old Fashioned Biscuit Gravy Mix contained a date of [DATE]. An observation on [DATE] at approximately 11:15AM, in the kitchen, revealed a large white container on wheels with a white lid, that contained a substance similar to sugar, was not labeled or dated. The items observed were removed by the Dietary Aide and Facilities Director. An observation on [DATE] at approximately 3:29PM in the kitchenette of the East Wing, revealed a box of Lucky Charms with three packs of Oatmeal with an expiration date of [DATE]. There was also a five-pound container of Creamy Peanut Butter with a best by date of [DATE]. An observation on [DATE] at approximately 2:45PM in the emergency food storage closet revealed: 1. Six, 6.63lb cans of Beef Stew-not dates, expiration or received 2. Six- 6lb 8oz cans of Fruit Cocktail- with an expiration date of [DATE] 3. Twelve- 6.56 lb cans of Sliced Pears- not dates, expiration or received 4. Twenty-four- 14.75 oz cans of Portico Classic Pink Salmon-not dated, a received sticker with a date of [DATE] was attached to the box. 5. Six- 6.75lb cans of Sysco Reliane Applesauce- not dates, expiration or received 6.Six- 6.5lb cans of Sysco Classic Fruit Cocktail with a received sticker of [DATE], no expiration date observed on cans or box. 7. ,d+[DATE].5lb cans of Sysco Classic Vanilla Pudding-received date of [DATE], no expiration date observed on cans or box. 8. Six-6.5lb cans of Sysco Classic Evaporated Milk-received date of [DATE], no expiration date observed on cans or box. 9. Six 6.5lb cans of Sysco Classic Chocolate Pudding- received date of [DATE]- no expiration date observed on cans or box. All items were removed from storage area on [DATE], by the CDM and the Regional [NAME] Health Dietician. On [DATE] at approximately 12:00 PM, an interview with the Dietary Aide revealed that they have a list that details the shelf life for foods. Foods should be dated the day it is opened and according to the chart of how long it can be dated out before it has to be discarded. She includes that any food that comes in, they date it the day it was received. They do not have a policy or schedule to check for expired foods. 0n [DATE] at approximately 3:30 PM, an interview with the Certified Dietary Manager (CDM), revealed that they operate with the method of first in, first out method. When they receive a shipment every other week and they go through so much food on a daily basis, so there is not much that usually expires. Whenever any items are opened and used there should be a date that is placed on that item, on a daily basis. She also included that there has been a staffing challenge and that doesn ' t allow to complete all job duties in a timely manner. Her expectations include, that staff come in, on time, look at dates, label and date all items and if something needs to be corrected then they will have in-services. On [DATE] at 10:35AM, an interview with the Administrator, revealed that they have implemented a Performance Improvement Plan (PIP), as of Monday, [DATE] to implement daily checks to ensure that the don ' t miss any expired foods. Those included in this plan are the dietary staff, the maintenance director, and myself. She also includes that if there was an emergency, if the hospital wasn ' t able to provide food during an emergency, then they would defer to the hospital ' s emergency plan.

Based on review of facility policy, interviews, record review, and observation, the facility failed to ensure sufficient nursing staff for 19 of 30 days reviewed for sufficient staff needed to maintain the highest practicable physical, mental, and psychosocial health and safety of each resident. Findings include: Review of a facility policy titled, State Minimum Staffing for Healthcare Centers with a revision date of 07/15/16 documented, The facility will maintain the minimum staffing hours in accordance with federal law . Staffing shall be sufficient to meet the healthcare needs of each patient/resident as identified in the patient/resident's plan of care. Daily nursing hours will be posted at each facility accordance with federal regulations. Review of a document tilted, Daily Nursing Hours for Healthcare Centers Form from 06/26/23 - 07/25/23, revealed the following days the facility was short nursing staff: 06/26/23 06/30/23 07/01/23 - 07/02/23 07/04/23 - 07/09/23 07/12/23 07/14/23 - 07/17/23 07/20/23 - 07/22/23 07/25/23 During an interview on 07/27/23 at 8:57 AM, the Administrator revealed she recorded the dates for low staffing. She stated at this time they are working actively with recruitment. During an interview on 07/27/23 at 10:39 AM, the Director of Nursing (DON) acknowledged that there are staffing issues. During an interview on 07/27/23 at 10:43 AM, Certified Nursing Assistant (CNA)1 revealed that he is aware the facility is short staffed. He stated he tries his best to ensure that the residents are getting what they need, even if it does take him a while to get it. During an interview on 07/26/23 at 2:30 PM, members of the resdient council revealed there is not enough staff. The members stated due to this shortage they have long wait times to receive care, toileting needs/brief changes, and sometimes their food is cold when they receive it.

Based on review of facility policy, record reviews and interviews, the facility failed to ensure residents were offered the Pneumococcal Vaccinations, and to ensure residents had received the vaccination while a resident of the facility, if they chose to do so for 5 of 5 residents reviewed for immunizations. Findings include: Review of the facility policy titled, Pneumococcal Vaccinations, states under policy statement, All patients/residents who reside in this healthcare center are to receive the pneumoccal vaccine(s) within the current CDC guidelines unless contraindicated by their physician or refused by the patient/resident or the patient/resident's family. If the patient/resident is cognitively impaired as evidenced by scoring on the MDS, the responsible party will be contacted and their wishes will be followed in this matter. The Procedure states: 1. The admission process will include determining whether the patient/resident has received the pneumococcal vaccine in the past. This will be the responsibility of the Director of Health Services or designee. Every effort will be made to obtain documentation of the date of prior immunization and what type of vaccine. If reliable documentation of previous immunization is obtained, the date should be entered on the Immunization Record and made a part of the clinical record. If no reliable date of previous vaccination can be obtained, the patient/resident should be considered eligible for vaccination. 2. A Vaccination Information Sheet (VIS) will be provided to inform the patient/resident/family member of the side effects, benefits and risks of the vaccine. This education will be documented on the Interdisciplinary Teaching Record. 3. Permission or refusal to receive the vaccine within the CDC guidelines will be obtained on admission using the Pneumococcal Vaccine Consent/Refusal Form. A separate consent for each type of vaccine is required. 4. An order for each vaccine will be obtained from the physician, as necessary, to assure the vaccine is within the CDC guidelines of those patients/residents who wish to receive the vaccine. 5. The Immunization Record will be part of each patient/resident's clinical record and will be used to document the date of each pneumococcal vaccine previously received by the patient/resident and/or administered by the healthcare center. 6. If the vaccine is refused based on medical contraindications or side effects, there must be supporting documentation in the clinical record. 7. The Director of Health Services or designee will maintain a list of patients/residents with the date of administration of pneumococcal vaccine and make it available to state surveyors upon request. 8. Pneumococcal Vaccines are stored, prepared, and administered per manufacturer's guidelines. 9. Administration: Adults [AGE] years of age or older. Review of the Influenza, Pneumococcal and Covid -19 vaccines revealed 5 residents reviewed had no documentation to ensure they had been offered or received/declined the Pneomococcal vaccine. During an interview on 07/26/23 at an unspecified time, the Infection Control Preventionist revealed that she had not offered any residents a Pneumococcal vaccine.

Based on review of the facility policy, observations, interviews and record reviews, the facility failed to ensure that Resident (R)18 was provided a comfortable fitting bed for 1 of 1 residents reviewed for accommodation of needs. Findings include: A review of a facility policy titled, Procedure: Positioning Resident: Basic Body Positions Used in Bed, dated 2019, documented, Procedure: The basic body positions used for residents in bed are supine, semi supine, prone, semi prone, lateral, and several variations of the Fowler's position. 7. Sitting positions: b. Semi Fowler's-positioned with the head elevated 30 degrees and knees raised slightly. c. Fowler's-positioned with the head elevated 45 degrees and knees raised slightly. d. High Fowler's-positioned with the head elevated 60 degrees and knees raised slightly. Considerations: Be sure the body is well supported, and the resident is repositioned frequently to relieve pressure. Review of R18's Face sheet indicated the facility admitted R18 with diagnoses that included but no limited to; encounter for other orthopedic aftercare, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, other intraarticular fracture of lower end of left radius, subsequent encounter for closed fracture with routine healing, type 2 diabetes mellitus without complications, and encounter for prophylactic measures. Review of R18's admission Minimum Data Set (MDS) with an Assessment Reference Date of 07/05/23, revealed R18 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. The Staff Assessment of Mental Status (SAMS) indicated R18 had modified independence in cognitive skills for daily decision making. R18 required limited assistance with bed mobility and extensive assistance with transfers and toileting. Review of R18's Care Plan, dated 07/25/23, revealed R18 was at risk for falling related to healing fracture of left femur and healing fracture of left radius with history of falls. Interventions included to obtain Physical Therapy (PT) consult for strength training, toning, positioning, transfer training, gait training, mobility devices, and to provide the resident with safety device/appliance: walker, wheelchair (w/c). Further review of R18's Care Plan, dated 07/25/23, revealed R18 had Activities of Daily Living (ADLs) Functional Status/Rehabilitation Potential Resident's ability to transfer, walk in room, walk in corridor, dress, eat, toilet, maintain personal hygiene has deteriorated R/T hospital stay. Interventions included follow Occupational Therapy/Physical, Therapy/Speech Therapy, recommendations. Further review of R18's Care Plan, dated 06/27/23, revealed R18 was at risk for skin breakdown related to (r/t) weakness, limited mobility, and rom. Interventions included pressure relieving device to bed, and to report any signs of skin breakdown (sore, tender, red or broken areas). Review of R18's Physician Orders, for the month of 06/2023, revealed an order, dated 06/27/23, for nursing to document the need to keep head of the bed elevated and/or the need to use extra pillows to prevent shortness of breath when lying flat. During an observation on 07/24/23 at 11:09 AM, revealed R18's feet were hanging off the end of the bed, R18's feet were propped up on the footboard of the bed. R18's head of the bed was positioned at a 45-degree angle. R18's bed was observed not to be long enough to accomodate R18's comfort. During an observation on 07/25/23 at 9:07 AM, revealed R18's feet were hanging off the end of the bed. R18's head of bed was raised up at a 30-degree angle. R18 stated that the foot railing of the bed hurt the back of their legs and feet at night while they were trying to sleep. During an observation on 07/25/23 at 3:20 PM, revealed R18's head of bed was raised up at a 30-degree angle. R18's feet were observed at the bottom of the mattress and was touching the front of the footboard. R18's knees were not raised. During an observation on 07/26/23 at 10:22 AM, revealed R18 was in bed appeared to be sleeping, with the head of the bed at a 45-degree angle. R18's feet were observed hanging past the footrail of the bed. During an observation on 07/26/23 at 12:55 PM, revealed R18 was telling the Physical Therapy Assistant (PTA) that they sit sideways in the bed because their feet hang off the end of the bed and the footboard hurt their feet. During an interview on 07/25/23 at 3:20 PM, the Administrator stated they did not have a policy on bed assessments. During an interview on 07/26/23 at 12:49 PM, Licensed Practical Nurse (LPN)1, stated that most of the time R18's feet are not at the end of the bed. LPN1 stated that they scoot down in the bed to get comfortable. LPN1 just noticed that the bed looked too short for R18. LPN1 further stated that the Maintenance Director is responsible for getting R18 a longer bed. LPN1 concluded that she expected R18 to be in a bed that was long enough and comfortable. During an interview on 07/26/23 at 12:55 PM, the PTA stated that once she scooted R18 up in the bed and sat them up as the physician ordered, their feet were touching the end of the bed. The PTA further stated the bed needed to be longer for R18 so that their feet were not touching or hanging over the footboard of the bed. During an interview on 07/26/23 at 1:04 PM, the Director of Nursing (DON) stated that she was not aware of R18's bed being too short for their comfort. The DON stated that R18 had dementia. The DON further stated that she expected R18 to be comfortable in their bed and the bed to be long enough for their height and comfort.

Based on interviews and record reviews, the facility failed to ensure that Resident (R)54 had an accurate Level 1 Preadmission Screening and Resident Review (PASARR), for 1 of 1 residents reviewed for PASARR. Findings include: Review of R54's Face Sheet indicated the facility admitted R54 with diagnoses that included, but was not limited to, schizoaffective disorder, and unspecified dementia with psychotic disturbance. Review of R54's Discharge-Return Anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD)of 07/06/23, revealed R54's Brief Interview for Mental Status (BIMS) interview was not performed. The Staff Assessment for Mental Status (SAMS) score was two, indicating R54 was moderately impaired in cognitive skills for daily decision making. Further review of the MDS revealed R54 required extensive assistance with bed mobility and eating and was totally dependent on staff for toileting. Review of R54's Physician Orders, for the month of 07/23, revealed an order, dated 07/19/23, for quetiapine (an antimanic agent) 50 milligrams (mg), one tablet twice daily for schizoaffective disorder. Review of R54's electronic medical record (EMR) indicated a diagnosis of schizoaffective disorder, dated 02/10/23. Further review of the EMR did not reveal level one PASARR including the diagnosis of schizoaffective disorder. Review of R54's Level-1 PASARR dated 07/18/23, indicated R54 did not have a mental illness. However, R54 had a diagnosis of schizoaffective disorder, dated 02/10/23. During an interview on 07/26/23 at 9:08 AM, the Administrator stated that the Admissions Director (AD)amended R54's PASARR Level-1 to include the diagnosis of schizoaffective disorder on 07/25/23. The Administrator further stated the facility does not have a policy for assuring PASARRs are completed accurately. The Administrator stated they follow state regulations During an interview on 07/26/23 at 9:19 AM, the AD stated that she was the only person in the building that was trained to complete PASARRs. The AD attended a PASARR training seminar two years ago. She stated that R54 was admitted into the facility with a PASARR from the hospital that did not include a diagnosis of schizoaffective disorder. The AD does not change the resident's documents once the resident returns from the hospital. The hospital did not diagnosis R54 with schizoaffective therefore, the hospital did not add the diagnosis to the level-1 PASARR before discharging R54 back to the facility. The AD further stated that it was important to have the correct documentation on R54 so that they could receive the care and medications that they need for their mental illness. Residents with a mental illness diagnosis is documented on their level-1 PASARR so that a level-2 PASARR determination could be made. The facility's medical records department is responsible for uploading the PASARR into their EMR called Matrix. The PASARR Level-1 was then sent to the state for the determination of a level-2 PASARR. During an interview on 07/27/23 at approximately 10:37 AM, the Director of Nursing (DON) stated that she did not complete or review PASARRs. The DON expected PASARRs to be completed accurately. The DON stated that PASARRs are completed to determine a resident's level of care which would guide their care and services for mental illness. During an interview on 07/27/23 at approximately 10:42 AM, the Administrator stated that she expected the PASARRs to be obtained and updated per the state regulations.

Based on review of facility policy, observations, and interviews, the facility failed to follow procedure during wound care for Resident (R)12 to promote healing and to prevent or decrease the likelihood of infection for 1 of 2 residents reviewed with pressure ulcers. Findings include: Review of the undated facility policy tiled, Guidelines for Cleansing and Observing a Wound, under Procedure states: 4. Perform hand hygiene according to facility policy/protocol. 5. Don personal protective equipment as appropriate for procedure. 7. Gently clean the wound with the ordered cleanser or normal saline. 8. Work from clean areas to less clean areas. 9. To cleanse any injury or pressure ulcer, work in half circles or full circles, beginning in the center of the wound and working outward. Cleanse the skin at least on inch beyond the edge of the dressing. Use a new sponge for each circle. 10. Avoid rubbing back forth. Rinse using the same technique. 11. Use each gauze sponge once, then discard it. 14. As soon as you have finished removing the soiled dressing and cleaning the wound, remove and discard your gloves. Otherwise, everything you touch, including the faucet and handles, will be contaminated by microorganisms on your gloves. 16. Wash your hands (or use an alcohol cleanser) after removing and discarding the existing dressing. 17. Put on clean gloves before applying a new dressing. 18. Be sure soiled supplies do not come in contact with clean supplies. 19. Perform hand hygiene according to facility policy/protocol. Review of R12's Face Sheet revealed the facility admitted R12 with diagnoses including, but not limited to, stage 3 pressure ulcer of the sacral area, vascular dementia, major depressive disorder and functional quadriplegia. Review of R12's physician order revealed, Cleanse the sacral wound with wound cleanser, pat dry and fill the wound bed with gauze soaked in Acetic Acid and cover with and ABD pad and secure with tape. During an observation of wound care on 07/26/23 at 10:21 AM revealed the following: Registered Nurse (RN)4 started wound care directly after providing supra pubic catheter care to R12. RN4 did not cleanse or wash her hands before starting wound care. RN4 performed wound care and Licensed Practical Nurse (LPN)1 assisted. RN4 knocked on the door and the resident asked us in. RN4 explained the procedure and this surveyor asked if it was ok to observe wound care, R12 stated that it would be ok. Neither RN4 nor LPN1 washed their hands before providing care. Both RN4 and LPN1 applied gloves, pulled the covers off the resident, RN4 and LPN1 handled R12's catheter tubing and catheter bag, moving it to the other side of the bed. Both nurses assisted R12 in turning onto her left side. RN4 unfastened R12's brief, took wipes and cleaned the resident's bottom and then removed the soiled dressing. RN4 removed her gloves, RN4 did not clean her hands with hand sanitizer or wash her hands. RN4 then applied gloves, RN4 opened 3 packs of 4 x 4's and sprayed the wound cleanser into the pack and then rung out the excess wound cleanser. RN4 removed a soaked 4 x 4 from the package and wiped around the outer edges and then patted the wound bed with the same 4 x 4 a total of 3 times. RN4 removed her gloves and applied new gloves, RN4 opened the Acetic Acid and poured it on 3 opened 4 x 4s. RN4 proceeded to take the 4 x 4s one at a time and applied it to the wound bed, covering the entire area. RN4 then opened the ABD pad and taped it over the wound, pulled tape from the roll and took a marker from her pocket and wrote the date and her initials on the tape and applied it to the clean dressing. RN4 removed her gloves and applied new gloves, RN4 did not clean or wash her hands. RN4 proceeded to a cabinet in R12's room and got a clean brief, took a soiled chux from under R12 and went and placed it in the clothes hamper inside the resident's room door. RN4 and LPN1 applied the clean brief and made R12 comfortable. RN4 and the LPN1 removed their gloves and washed their hands before leaving R12's room. RN4 had not cleansed or washed her hands prior to completing would care and during wound care. During an interview on 07/26/23 at 10:40 AM, RN4 acknowledged that she had not cleansed or washed her hands at all while providing wound care.

Based on review of facility policy, observations, and interviews, the facility failed to follow procedure during suprapubic catheter care for Resident (R)12, to reduce the risk of infection for 1 of 3 residents reviewed for catheter care. Findings include: Review of the undated facility policy titled, Catheter Care, states under Procedure: 1. Identify resident. 3. Explain procedure to resident. 4. Perform hand hygiene according to facility policy/protocol. 5. Don personal protective equipment as appropriate for procedure. 6. Explain the reason for the procedure to the resident. 7. Wash your hands and pull the curtain. 8. Position the bed protector. 9. Drape the resident for modesty. Review of an undated facility document titled, Competency: Suprapubic Catheter Care, revealed the following: Greet patient and explain procedure, pull privacy curtains, close door and blinds. Gather supplies (disposable wipes, gloves and plastic bag), wash hands, drape resident, place clean trash bag at the foot of the bed. Use disposable cloth-with one stroke, wash the side away from you, cleansing skin and catheter outward (semi-circle. Use disposable cloth with one stroke, wash side closest to you, cleansing the skin and catheter outward (semi-circle). Gently slide fingers to grasp catheter close to the stoma. Wash hands. While holding catheter at stoma without tugging, clean at least four inches of catheter from stoma, moving in only one direction (away from the stoma) using a clean cloth with each stroke. Remove gloves and discard in a plastic bag. Wash or sanitize hands. Cover patient/resident and make the patient/resident comfortable. Secure catheter drainage bag at a level below the bladder and above the floor. Ensure the drainage bag is covered. Remove the trash bag and dispose of appropriately. Wash hands. Review of R12's Face Sheet revealed the facility admitted R12 with diagnoses including, but not limited to, neurogenic bladder, fever, vascular dementia, and a stage 3 sacral pressure ulcer. During an observation of supra pubic catheter care on 07/26/23 at 10:10 AM revealed the following: Registered Nurse (RN)4 performed supra cath care and Licensed Practical Nurse (LPN)1 assisted. At the treatment cart outside of R12's room in the hallway, RN4 cleaned her scissors with a Clorox wipe and then laid them directly on the top of the treatment cart. RN4 cleaned her hands while in the hallway with hand sanitizer. RN4 knocked on the resident's door and waited for R12 to ask us in. RN4 explained the procedure to R12 and this surveyor asked permission to observe RN4 performing the catheter care. R12 stated it was ok with her. LPN1 applied gloves and RN4 provided privacy and took out the wipes. RN4 did not wash her hands, applied gloves, and removed the covers from R12. RN4 then raised R12's gown, unfastened her brief and rolled it down below the suprapubic catheter insertion site. RN4 then removed the soiled dressing. The soiled dressing was wet and dark as RN4 stated the catheter was leaking at the insertion site. RN4 took a wipe and wiped around the insertion site once and discarded the wipe. RN4 got another wipe and wiped around the insertion site a second time and then discarded the wipe. RN4 did not removed her gloves and did not wash her hands after removing the soiled dressing from the leaking suprapubic catheter site. Using the same gloved hands, RN4 opened a 4 x 4 drain sponge and removed her gloves. RN4 applied new gloves, RN4 did not cleanse or wash her hands prior to applying the new gloves. RN4 then applied the drain sponge around the insertion site and removed her gloves. RN4 did not wash or cleanse her hands and proceeded to perform wound care for R12. During an interview on 07/26/23 at 10:40 AM, RN4 confirmed that she had not washed or sanitized her hands during suprapubic catheter care.

Based on record reviews, interviews, and review of facility policy, the facility failed to ensure Resident (R)24 received all doses of a drug prescribed for atrial fibrillation for 1 of 6 residents reviewed for unnecessary medications. Findings include: Review of a facility policy titled. Ordering Medications from the Pharmacy, with a reviewed date of 7/19/23, documented, The healthcare center will transmit physician orders to the pharmacy using facsimile or other technology in order to receive medication on a timely basis. and Medication orders requiring refill are recorded on Medication Reorder sheet . Medication should be reordered four (4) days in advance of need in order to maintain an adequate supply on hand. Review of a facility policy titled, Medication Administration: General Guideline with a reviewed date of 5/31/23, documented, Medications are administered as prescribed . Review of R24's Face Sheet revealed R24 was admitted to the facility on [DATE] with diagnoses including, but not limited to, atrial fibrillation and presence of cardiac pacemaker. Review of R24's physician orders dated 03/30/23 through 07/25/23, revealed an opened ended order dated 03/30/23 for dofetilide 500 mcg (microgram) to be administer twice a day at 9:00 AM and 9:00 PM with a diagnosis of atrial fibrillation. Review of R24's Medication Administration Record (MAR) dated 03/30/23 through 07/25/23, revealed that dofetilide 500 mcg had not been administered on 05/18/23 at 9:00 PM and on 05/19/23 at 9:00 AM and 9:00 PM with the Reason/Comments on 05/18/23 at 11:14 PM stating, Not Administered: Drug/Item Unavailable Comment: family provides, will have day nurse to call family and on 05/19/23 at 11:55 AM stating, Not Administered: Drug/Item Unavailable and on 05/19/23 at 3:28 AM stating, Not Administered: Drug/Item Unavailable. Review of R24's Resident Progress dated 05/19/23 at 5:02 PM, revealed res brought meds from home and asked to use them up before having Pharmacy provide the [sic]. Res ran out of Dofetilide. He receives it BID [twice a day]. Nurse mgr called Pharmacy and they stated the med would be in tonight. Res was very concerned and argued with this nurse about way I let it run out. Affirmed with Pharmacy of its arrival tonight. During an interview on 07/26/23 between 9:44 AM - 9:58 AM, Registered Nurse (RN)3 was unable to find a record of when dofetilide had been ordered from the pharmacy or requested from the family and Pharmacy. RN3 stated that the Pharmacy had been providing dofetilide since admission on 03/30/23. RN3 felt the Pharmacy was wrong since the family had at some point been providing the dofetilide. Further search by RN3 failed to provide proof of receipt from any party for dofetilide and after reviewing the MAR for May, 2023, RN3 acknowledged that three consecutive doses had not been administered because the drug was not available.

Based on record reviews and interviews, the facility failed to ensure Resident (R)1 was monitored to ensure safety during an outdoor, facility hosted, event and prevent elopement from the facility for 1 of 3 residents reviewed for elopement. On November 9, 2022 at 3:00 PM, the Administrator was provided an Immediate Jeopardy (IJ) Template indicating on November 5, 2022 at approximately 11:45 PM, R1 had a successful, unwitnessed elopement from the facility parking lot. R1 was attending a facility hosted event in the parking lot when he was left unsupervised. At approximately 11:45 AM on November 5, 2022, R1 was last seen at the facility's event. On November 5, 2022, at approximately 12:10 PM, R1 was found in the lobby of the Hospital's Emergency Department (ED). The ED was located opposite of the facility, across the parking lot and a road. Upon assessment, R1 was noted to be unharmed and at his baseline. R1 was noted to be hot and sweaty. He was then returned to the facility. R1 was noted to be dressed appropriately in long pants, shoes, and a shirt. The weather was noted to be approximately 68 degrees Fahrenheit. An acceptable Allegation of Compliance was presented on November 9, 2022, at 5:25 PM. Upon review of implementation, the AOC was accepted and the IJ was removed and lowered to a scope and severity level of D. The facility's failure constituted substandard quality of care and an extended survey was conducted on November 18, 2022. Findings include: The facility admitted R1 with diagnoses including, but not limited to, Dementia without behaviors and cognitive communication deficit. R1 has a Brief Interview of Mental Status (BIMS) obtained during a Quarterly Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 10/26/22, revealed R1 scored a 6 out of 15, indicating R1 was cognitively impaired. Review of R1's Electronic Medical Record (EMR) revealed he uses an electronic security system that was placed on his right wrist on 08/25/21 and it is checked each shift to ensure it is functioning properly. Review on 11/09/22 at 10:45 AM of R1's Medication Administration Record (MAR), confirmed that R1 was currently taking the medication, Donepezil 5 milligrams orally at bedtime for Dementia. He is not prescribed any behavior, or mind-altering drugs. Review on 11/09/22 at 11:00 AM of R1's Elopement Risk assessment dated [DATE] revealed the date of the elopement and completed on 11/08/22. R1 scored an 11 on the assessment, indicating he was high risk for elopement. Review on 11/09/22 at 11:15 AM of the Comprehensive Care Plan for R1 dated 08/25/21 included short- and long-term memory loss and risk for falls due to a status post hip fracture. The care plan for R1 also included risk for elopement and a goal to include that he will not exit the facility without supervision. Interventions were put into place. During an interview on 11/09/22 at 11:20 AM, the Administrator confirmed the elopement had occurred on 11/05/22 during an outside facility hosted event for the residents and staff had not had any in services or education on elopement since that time. The Administrator also confirmed that the facility did not have a policy on elopement. During an interview on 11/09/22 at 11:40 AM, the Director of Nursing (DON) gave an account of the elopement told to her by staff and the steps taken by the facility to find R1. The DON did confirm the outside area was roped off for the event, but the parking lot area was still utilized by all types of vehicles to include ambulances, that use the parking lot and emergency entrance of the hospital. During an interview on 11/09/22 at 12:10 PM, the Maintenance Director confirmed that he had taken the resident to the different attractions of the outside event and that another resident had asked for assistance to go back into the facility. The Maintenance Director assisted the other resident back in the facility while leaving R1 unsupervised. When the Maintenance Director returned, R1 was no longer sitting in the area, in which he was left. The Maintenance Director stated that Code Pink, was initiated and the staff started searching for R1. The resident was later found at the hospital emergency room . The facility presented an acceptable Allegation of Compliance on 11/09/22 at 5:25 PM. Verification of implementation of the facility's Allegation of Compliance was completed on 11/9/22 and the Administrator was notified the IJ was removed and lowered to a scope and severity of D. The Allegation of Compliance revealed the following: What corrective action will be accomplished for the residents found to have been affected by the deficient practice? Resident was admitted on [DATE]. Resident was escorted out of the facility by maintenance personnel to attend facility's fall festival on facility's property on 11/05/2022. While maintenance personnel was assisting another resident, the resident wheeled himself to the ER, on same property as facility (facility and hospital share common parking lot). Resident was last observed sitting in wheelchair at the petting zoo at 11:45 AM. At 11:50 AM maintenance personnel recognized that resident was missing and notified the administrator and code pink was initiated. During code pink, the facility nurse received a call from the ER at 12:00 PM notifying us that the resident was there. Administrator and DHS went to the ER and retrieved resident and returned him to facility at 12:15 PM. Upon return body audit completed with no injuries being noted. MD and Responsible party notified of incident. On 11/09/2022 partners were in serviced by the Director of Health Services, Clinical Competency Coordinator (CCC), Unit Managers, and the Administrator on assisting residents with an ESS bracelet out of facility - Education to all staff that anytime they assist a resident with an ESS bracelet out of the facility, they are to supervise the resident the whole time they are outside and they are to notify the charge nurse when they take them out and when they bring them back in. All other partners who are on FMLA or otherwise out will receive education prior to returning to work. The education will include elopement procedures, assisting residents with an ESS bracelet out of facility - Education to all staff that anytime they assist a resident with an ESS bracelet out of the facility, they are to supervise the resident the whole time they are outside and they are to notify the charge nurse when they take them out and when they bring them back in. This education will be conducted via telephone and or in-person prior to the start of his/her next scheduled shift. All department managers are responsible for keeping track of in-services in each department. New hires will be educated during orientation on the elopement procedure and assisting residents with an ESS bracelet out of the facility - Education to all staff that anytime they assist a resident with an ESS bracelet out of the facility, they are to supervise the resident the whole time they are outside and they are to notify the charge nurse when they take them out and when they bring them back in. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? Facility will continue to identify all residents utilizing ESS bracelets so that staff can supervise residents accordingly. What measures will be put in place, or what systemic changes will be made to ensure that the deficient practice will not reoccur? During any outdoor events, staff will be assigned to supervise residents with ESS bracelets at all times. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: An impromptu QAPI meeting was held 11/9/2022. Elopement incidents and controls were discussed. This includes assisting residents with ESS bracelets out of facility and their need to be supervised at all times. On going audits will be determined based on findings and corrective actions needed. Audit tools will be reviewed by the Administrator and/or DHS weekly and results will be presented during the monthly QAPI Committee meetings until all findings have been corrected. Date of completion: 11/9/2022

Based on record review, interview, and review of facility policy, the facility failed to address unplanned significant weight loss for Resident #218 (1 of 3 sampled residents reviewed for nutrition). The findings included: The facility admitted Resident #218 on 01/03/13 with [DIAGNOSES REDACTED]. Review of the electronic health record on 10/23/19 at approximately 1:49 PM revealed the following weights for Resident #218: 130.8 on 03/06/19; 136.8 on 04/02/19; 135.6 on 05/01/19; 132.4 on 06/03/19; 128.6 on 07/05/19; 133.8 on 08/01/19; 128.4 on 09/09/19; 131 on 09/19/19; and 121.2 on 10/01/19 for a decrease/loss of 11.4% in 182 days and a 7.48% decrease/loss in 12 days. Further review of the electronic health record at this time revealed Resident #218 had a [MEDICAL CONDITION] and wound debridement in the hospital on 09/11-19/19. Review of minutes from the facility's Weight Team Meeting held on 10/10/19 revealed Resident #218 was noted with a 11.4% weight loss due to poor appetite. Resident #218 was also noted to have a pressure wound to the sacrum, which was decreasing in size. In an interview on 10/23/19 at 4:16 PM, the Director of Nursing (DON) confirmed the minutes from the weight team meeting and that no interventions were taken to address or more closely monitor Resident #218 related to the weight loss. Interview with the Unit Manger at this time revealed Resident #218 was snacking less since coming back from the hospital which could account for some of the loss. The Unit Manager stated the Dietician would review today and they would weigh the resident today. The facility re-weighed Resident #218 on 10/24/19 which revealed a current weight of 118.9. Review of a nutritional note added on 10/23/19 at 4:09 PM revealed Resident #218 received SF (sugar free) Prostat BID (twice daily) with recommendations to add fortified juice at breakfast, increase SF Prostat to 30 ml (milliliters) TID (three times daily) and document intakes, give 60 ml of Standard 2.0 TID, and place on weekly weights. In an interview on 10/24/19 at approximately 2:27 PM, the Dietary Manager stated the Dietician comes to the facility twice monthly, residents were prioritized for review during these visits by recommendations from nursing, and that Resident #218 had not been referred to the Dietician for review related to the weight loss. Review of facility policy Weight Monitoring Program revealed it stated: Patients/residents will be placed on the Weight Monitoring Program, unless the weight loss is anticipated and/or planned. Patients/residents placed on the weight monitoring program will be weighed weekly. Also, a significant weight change is defined as 10% weight loss or gain in six months. The policy further stated in instances of unplanned/unanticipated significant weight loss, staff will complete weight loss/gain checklist, add to weekly weights, add to colored napkin program, weekly weight team documentation, update food preferences, update care plan, interventions will be added as needed.

Based on record reviews, interviews, and review of the facility policy titled, Falls Prevention Procedure, the facility failed to ensure supervision to prevent accidents when Resident #66, 1 of 2 sampled residents with falls, experienced a fall during staff transfer resulting in an injury. In addition, the facility to failed to monitor Resident #66 and #109 for 72 hours following a fall and to document the monitoring for 2 of 2 residents reviewed for accidents. The findings included: The facility admitted Resident #66 with [DIAGNOSES REDACTED]. Review on 4/11/2017 at approximately 12:09 PM of an event dated 1/11/2017 at 2:13 PM for Resident #66 states, Resident was being transferred from the geri chair to bed with a standing lift. Resident slid out of lift and was lowered to the floor with assistance at 13:30 PM. Resident has a skin tear to the right shin which was cleansed with soap and water and steri strips applied and wrapped with gauze because of the excess bleeding. The strap from standing lift left a mild abrasion on resident's right side of neck, under his/her chin right after the incident. No reddened areas at this time. Monitor for bruising. Doctor notified, called family left voice mail on cell and home number to call back. Resident is now to have an arjo lift 2 person assist at all times. Resident denied pain and or discomfort during PROM (passive range of motion). Resident is now back in bed. Bed lowered to floor and locked and call light within reach. Coordinator notified, and continue to monitor resident closely. Review on 4/11/2017 at approximately 3:10 PM of the facility policy dated 1/4/2016 titled, No Lift Requirement, under procedure states, To ensure that elders are cared for safely, while maintaining a safe work environment for employees, all employees shall use mechanical lifts with another trained person. #1. states, Use of all mechanical lifts shall be done with 2 persons assisting. During an interview on 4/12/2017 at approximately 9:45 AM with Certified Nursing Assistant (CNA) #1 stated, I was using the lift by myself, I knew I was not supposed to.I was getting him/her up out of the chair and going to put him/her to bed. I was using a standing lift at the time and the resident's legs gave away. Since then he/she has been reevaluated and is now transferred with a hoyer lift. CNA #1 was then asked, Did you know it was the policy of the facility to use 2 persons to transfer a resident using lifts? CNA #1 answered, yes, and went on to say that he/she had been in-serviced a year ago, when hired, on how to use the lift and for 2 to assist with the transfers. CNA #1 then stated, the resident received skin tears and bruising. Review on 4/12/2017 at approximately 10:40 AM of the facility policy titled, Abuse Prohibition, states under, Definitions, Number 8 reads, Neglect is the failure of the facility, it's employees or service providers to provide goods and services to an elder that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review on 4/13/2017 at approximately 11:14 AM of the progress notes for Resident #66 dated 1/13/2017 and 1/14/2017 concerning the fall on 1/11/2017, no documentation was found in the progress notes to ensure 72 hour monitoring following the fall. Review on 4/13/2017 at approximately 11:20 AM of the facility policy titled, Falls Prevention Procedure, states under section E. Documentation, 4. Record each occurrence of a fall in the nurse's notes with the following included. f. Follow-up documentation on post fall status for 72 hours after fall. During an interview on 4/13/2017 at approximately 11:36 PM with the Director of Nursing (DON) he/she confirmed that the 72 hour post fall monitoring for Resident #66 had not been done as required and set forth in the facility policy. The facility admitted Resident #109 with [DIAGNOSES REDACTED]. Review of Nurse's Notes on 04/11/17 at 3:00 pm revealed that on 02/27/17 Resident #109 was found on the floor in a puddle of urine and noted to have small red areas on both knees. There was one entry of post-fall monitoring in the Nurse's Notes. Review of the facility's Fall Prevention Procedure on 04/11/17 at 4:30 pm revealed that when an Elder is found on the floor, a fall is considered to have occurred. Further review indicated that staff was to monitor Resident #109 and enter Follow up documentation on post-fall status for 72 hours after fall. In an interview on 04/13/17 at 12:30 pm the Director of Nursing (DON) reviewed the Nurse's Notes and 24 Hour Reports for documentation of post-fall monitoring of Resident 109. The DON stated the documentation could not be found.

Based on record reviews, interviews, and review of the facility policy titled, No Lift Requirement, and, Abuse Prohibition, the facility failed to provide the necessary services for one of one resident reviewed for abuse/neglect to ensure Resident #66 did not receive a fall with skin tears and bruising during a mechanical lift transfer. The facility further failed to implement it's policies to ensure that elders are cared for safely during mechanical lifts with 2 persons assisting. The findings included: The facility admitted Resident #66 with [DIAGNOSES REDACTED]. Review on 4/11/2017 at approximately 12:09 PM of an event dated 1/11/2017 at 2:13 PM for Resident #66 states, Resident was being transferred from the geri chair to bed with a standing lift. Resident slid out of lift and was lowered to the floor with assistance at 13:30 PM. Resident has a skin tear to the right shin which was cleansed with soap and water and steri strips applied and wrapped with gauze because of the excess bleeding. The strap from standing lift left a mild abrasion on resident's right side of neck, under his/her chin right after the incident. No reddened areas at this time. Monitor for bruising. Doctor notified, called family left voice mail on cell and home number to call back. Resident is now to have an arjo lift 2 person assist at all times. Resident denied pain and or discomfort during PROM (passive range of motion). Resident is now back in bed. Bed lowered to floor and locked and call light within reach. Coordinator notified, and continue to monitor resident closely. Review on 4/11/2017 at approximately 2:46 PM of the Care Plan for Resident #66 indicated it was updated on 1/11/2017 after the incident. The plan of care now reads under interventions, Transfer in and out of bed with total arjo lift and 2 persons assisting and place resident on a fall prevention program. The care plan prior to the incident was not available for review per the Care Plan Coordinator. Review on 4/11/2017 at approximately 3:10 PM of the facility policy dated 1/4/2016 titled, No Lift Requirement, under procedure states, To ensure that elders are cared for safely, while maintaining a safe work environment for employees, all employees shall use mechanical lifts with another trained person. #1. states, Use of all mechanical lifts shall be done with 2 persons assisting. During an interview on 4/12/2017 at approximately 9:45 AM with Certified Nursing Assistant (CNA) #1 stated, I was using the lift by myself, I knew I was not supposed to. I was getting him/her up out of the chair and going to put him/her to bed. I was using a standing lift at the time and the resident's legs gave away. Since then he/she has been reevaluated and is now transferred with a hoyer lift. CNA #1 was then asked, Did you know it was the policy of the facility to use 2 persons to transfer a resident using lifts? CNA #1 answered, yes, and went on to say that he/she had been in-serviced a year ago, when hired, on how to use the lift and for 2 to assist with the transfers. CNA #1 then stated, the resident received skin tears and bruising. Review on 4/12/2017 at approximately 10:40 AM of the facility policy titled, Abuse Prohibition, states under, Definitions, Number 8 reads, Neglect is the failure of the facility, it's employees or service providers to provide goods and services to an elder that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.