Every finding on record at Pruitthealth - Covington

Based on observations, staff and resident interviews, record review, and review of the facility policies titled Oxygen Administration, the facility failed to obtain an oxygen order for one resident (R) out of 14 sampled residents that were on continuous oxygen. This deficient practice had the potential to cause hospitalization related to the resident potentially not being on a therapeutic oxygen setting.Findings include:Review of the policy titled Oxygen Administration revised 8/2/2023 and reviewed on 11/17/2025 policy statement revealed it is the policy of Pruitthealth Hospice and Healthcare Centers/Veteran Homes to provide oxygen safely and accurately to appropriate patients/residents. The scope states this policy is for nurses and respiratory therapists. The procedure section revealed oxygen will be administered by licensed personnel only when ordered by the physician, PA or NP. The physician order may be written PRN for comfort/dyspnea or may specify the number of liters, method of administration and length of time the oxygen is to be administered. Oxygen ordered PRN for comfort/dyspnea will be based upon the physician/licensed nurse assessmentof the patient/resident's condition including oxygen saturation levels, respiratory rate, effort used by patient/resident to breath, shortness of breath present, and respiratory distress.Review of the electronic medical record (EMR) revealed R 62 was admitted to the facility on [DATE] and pertinent diagnoses including but was not limited to chronic systolic (congestive) heart failure (Primary), urinary tract infection, site not specific, and Type 2 diabetes mellitus with diabetic neuropathy. Review of R62 admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of four, which indicates R62 has severe cognitive impairment. Section GG, functional status, revealed R62 is dependent with toileting hygiene, lower body dressing, and footwear. Section O revealed continuous oxygen therapy on admission.Review of R62 care plan dated 03/10/2026 indicated a problem of shortness of breath. Goals included but not limited to, resident will not exhibit signs of respiratory distress (restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis,crackles, bubbling, tachycardia, cyanosis, decreased breath sounds) through next review Interventions included but not limited to administer oxygen as indicated, observe oxygen precautions, keep room cool and free of irritants and provide calm environment free of stimuli to reduce/prevent anxiety.Review of the Physician's Orders for R62 did not reveal an order for oxygen therapy.An observation on 04/7/2026 at 11:51 AM revealed R62 is sitting in manual wheelchair in the hall outside her room. R62 is receiving oxygen via nasal canula per oxygen tank secured to back of wheelchair.An interview on 04/7/2026 at 1:41 PM with R62 resident representative (RR) revealed that R62 was walking prior to having a lung biopsy. Something happened during the biopsy and led to her mom decline in condition. She states she has been on oxygen since her biopsy and was admitted to the facility on oxygen.An observation on 04/8/2026 at 4:20 PM revealed R62 is sitting up in manual wheelchair inside her room. Her husband is at her bedside and states that the resident is on oxygen at all times since she has been sick. R62 is receiving oxygen at 3L. No distress noted.An observation on 04/9/2026 at 1:45 PM resident is sitting outside of room in manual wheelchair. R62 does not have on her oxygen tubing. Oxygen tank is low and the setting is 2L.04/9/2026 at 2:06 PM the nurse comes and checks the oxygen tank. On 04/9/2026 at 2:08 PM the nurse returns and exchanges the tank as well as place the oxygen tubing in the resident's nose. An interview on 04/9/2026 at 1:51 PM with certified nursing assistant (CNA) DD revealed R62 wears oxygen continuous although she sometimes removes it. The CNA's check the tanks periodically to ensure the tanks are not empty. If the tank is low, the nurse is notified. An interview on 04/9/2026 2:34 PM with the registered nurse (RN) LL revealed that R62 wears oxygen at all times. She also stated that R62 was admitted on oxygen. The CNAs will notify the nurse if the tank is low and the nurse will change the tank. An interview on 04/9/2026 at 2:44 PM with the Director of Nursing (DON) revealed the nurse should look at the electronic medical record (eMAR)to determine the oxygen rate. She also confirmed that anytime a resident is on oxygen the resident should have an order. She states that the nurses are responsible for putting in orders for new admits. An interview on 03/9/2026 at 3:10 PM with the administrator states that nurses are responsible for admission orders. The orders should be done at the time of admission to include any other admission documents per the admission process.

Based on observation, record review, policy review and interviews, the facility failed to ensure safe smoking for one of one resident (R) reviewed for smoking. The sample size was 47. Findings include:Review of the facility policy titled Smoke Free Policy with a revised date of 02/10/2026, revealed the policy statement to be as of January 1, 2015, smoking is not allowed on the Healthcare center premises by visitors, partners or patients/residents. Smoking will only be allowed in outdoor designated areas for those residents grandfathered in prior to January 1, 2015. Assessment and Care Planning section, 2. Each patient/resident will be assessed, utilizing the Smoking Observation Form, by a licensed nurse upon admission, re-admission, and/or with a Significant Change. An admission Smoking Care Plan shall be developed by the Licensed Nurse on the admission Interim Care Plan Form. 3. An assessment is completed at least quarterly thereafter only if the answer to either of the first two (2) questions indicate the resident either smokes or has a history of smoking. After completion of the assessment, the care planning team shall review and utilized the assessment when developing the resident's care plan. 8. Patients/residents will be assessed for risk/hazards prior to smoking in designated area and shall be supervised as necessary based on the Smoking Observation Form. 9. When the patient/resident is identified as an unsupervised smoker, the Administrator must be notified immediately.Review of the electronic health record for R12 revealed R12 was admitted to the facility on [DATE] with diagnosis of but not limited to acute respiratory failure, unspecified dementia, chronic kidney disease, glaucoma moderate intellectual disabilities.The resident's most recent Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, which indicated no cognitive impairment. Review of the last completed smoking observation Form for R12, dated 05/23/2023, revealed Question one Does the resident smoke? Yes column is checked. Question two: Does the residents have a past history of smoking? Yes column is checked. Review of admission Observation Form for R12 dated 09/17/2025, after a return from the hospital, revealed R12: current every day smoker. Based on review of R12's baseline care plan and current comprehensive care plan provided, documentation was found for smoking; subsequently interventions and goals were found. Observation on 04/07/2026 at 10:18 AM, R12 was observed smoking in the designated smoking area, along with one nursing assistant outside with him. He was wearing a smoking apron and appeared to be smoking safely. Observation of R12 on 04/09/2026 at 8:08 AM revealed R12 was waiting at back door to go out to designated smoking area. The Maintenance Director (MD) came and provided the resident with smoking materials to the resident and unlocked door and led resident to smoking area. R12 was observed to have a smoking apron. Interview on 04/09/2026 at 10:38 AM with Minimum Data Set (MDS) coordinator, revealed the nurses on the floor are responsible for filling out the Smoking observation form when assessments are due. Interview on 04/09/2026 at 1:35 PM with the director of nurses (DON( confirmed that R12 was last assessed for smoking on 09/17/2025 as indicated on admission Observation during R12 return from the hospital. She also confirmed that an assessment was overdue and should be completed quarterly. She stated that she expects that the nurse assigned to R12's hall/unit will fill out the smoking observation form when indicated by matrixcare system.

Based on interviews and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect a significant weight loss for one of five residents (R) (R46) reviewed for nutrition. This had the potential to result in unmet care needs due to the facility not recognizing weight loss and the need for interventions.Findings include:Record review revealed that resident (R)46 was admitted to the facility with the diagnosis included, but limited to encephalopathy, pneumonia, severe sepsis with septic shock, malignant neoplasm of oropharynx.Record review revealed that Resident R46 experienced a significant, unplanned downward weight trend. R46's weight decreased from 151.4 pounds on 10/01/2025 to 141.0 pounds on 01/02/2026, representing a 10.4-pound (6.9%) weight loss over approximately three months. This weight loss meets the criteria for significant weight change.Review of dietary progress notes from 01/12/2026 revealed: Resident's weight is trending down. varied intake of meals noted receiving ensure 1 carton BID (two times a day). Recommend liberalize diet by d/c (discharge) NAS (no added salt); continue with Regular.Review of the Quarterly MDS dated [DATE], Section K0300 (Weight Loss), indicated the resident was coded as: 1 - Yes, on physician-prescribed weight-loss regimen. Further record review did not identify evidence that the resident was on a physician-prescribed weight-loss regimen with the goal of intentional weight reduction.Interview with MDS Coordinator on 04/9/2026 at 11:12 AM confirmed that for R46's quarterly MDS dated [DATE], Section K0300 (Weight Loss) was coded as 1 - Yes, on physician-prescribed weight-loss regimen. The MDS Coordinator stated this coding was based on the resident receiving diuretic medication, which she considered a prescribed weight-loss regimen. Further review of the medical record revealed that R46 had been prescribed diuretic medication since 09/2/2022.Interview with the Director of Health Services (DHS) on 04/9/2026 at 12:12 PM confirmed inaccurate MDS coding for R46 and revealed that no care plan revisions had been made to address the R46's significant downward weight trend. Cross-Reference F656

Based on record review, staff interviews, and review of the policy titled Care Plan, revision date 10/21/2025, the facility failed to develop and to implement a care plan to address significant weight loss for one of five residents reviewed for nutrition. This had the potential to result in unmet care needs due to the facility not recognizing weight loss and the need for interventions.Findings include:Review of the facility policy titled Care Plan revealed: Care Plan Review and Update:4. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment.Record review revealed that Resident R46 was admitted to the facility with diagnoses including, but not limited to, encephalopathy, pneumonia, severe sepsis with septic shock, and malignant neoplasm of the oropharynx.Record review revealed that R46 experienced a significant downward weight trend. R26 weight decreased from 151.4 pounds on 10/01/2025 to 141.0 pounds on 01/02/2026, representing a 10.4-pound (6.9%) weight loss over approximately three months.Review of dietary progress notes revealed:On 1/12/2026: Resident's weight is trending down. Varied intake of meals noted. Receiving Ensure 1 carton BID. Recommend liberalize diet by discontinuing NAS (no added salt); continue with regular diet.On 3/23/2026: Resident's weight is trending down. Intake of meals varies. Resident is receiving a liberal regular diet. Recommend double eggs at breakfast, monitor weight per protocol, and f/u prn (follow up as needed).Review of the care plan for R46 revealed no evidence that R46 significant weight loss was addressed. The care plan lacked interventions, goals, and/or revisions related to the identified downward weight trend.Review of the Quarterly Minimum Data Set (MDS) dated [DATE], Section K0300 (Weight Loss), indicated the resident was coded as: 1 - Yes, on physician-prescribed weight-loss regimen. Further record review failed to identify evidence that the resident was on a physician-prescribed weight-loss regimen intended for intentional weight reduction.Interview with the MDS Coordinator on 04/9/2026 at 11:12 AM confirmed that Section K0300 was coded as 1 - Yes. The MDS Coordinator stated the coding was based on the resident receiving diuretic medication. Further interview revealed that the Interdisciplinary Team (IDT) is responsible for development and updates of care plans.Interview with the Director of Health Services (DHS) on 04/9/2026 at 12:12 PM revealed there were no care plan updates related to R46's downward weight trend. The DHS stated that nursing staff and/or the MDS Coordinator are responsible for updating care plans.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Medication Administration; General Guidelines, the facility failed to ensure that one of 30 sampled residents (R) (R36) did not have unauthorized and unsecured medications at the bedside. This failure created the potential for medication errors and unauthorized access to medications by other residents. Findings include: A review of the policy titled, Medication Administration: Guidelines review date 7/22/2024 under the section titled Procedure revealed, 3. Patients/residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 5. All current medications and dosage schedules, except topicals used for treatments, are listed on the patient/resident's Medication Administration Record (MAR)or within the e-MAR System for facilities using electronic charting of medications. 10. Medications are administered within 60 minutes before or after scheduled time, except for medications ordered to be taken with food and before or after meals, which are administered precisely as ordered. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the healthcare center. 11. After medication administration for facilities using paper MAR, the patient/resident's MAR is initialed by the person administering a medication in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are verified with a full signature in the space provided. After medication administration for facilities utilizing electronic MAR, the patient/resident's e-MAR is electronically signed off. 13. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the paper MAR for that dosage administration is initialed and circled and for facilities utilizing the e-MAR system the not administered button will be utilized with the appropriate reason given for the not administering medication at scheduled time. An explanatory note is entered is entered on the reverse side of the record provided for PRN indication and general medication notes and for e-MAR the note can be typed into the appropriate space provided within the electronic system. If more than two consecutive doses of a viral medication are withheld or refused, the physician is notified. Review of the electronic medical record (EMR) for R36 revealed diagnosis including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, coronary artery disease, hypertension, diabetes mellitus, aphasia, cerebrovascular accident (CVA), transient ischemic attack (TIA), or stroke, hemiplegia or hemiparesis, anxiety disorder, depression, asthma, and chronic obstructive pulmonary disease (COPD). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) score of 6 indicating R36 was not cognitively intact. Review the EMR revealed, R36 had not been assessed to determine if she was a candidate to self-administer medications. Review of the Medication Administration Record (MAR) dated 2/24/2025-2/28/2025 revealed, R36's 9 AM medications included: amlodipine 5 mg (milligram) tablet, aspirin tablet, chewable- 81 mg, buspirone Tablet- 7.5 mg, Colace (docusate sodium) capsule- 100 mg, Diovan HCT (valsartan-hydrochlorothiazide) tablet- 320-12.5 mg, duloxetine capsule, delayed release(DR/EC)- 60 mg, famotidine tablet- 20 mg, gabapentin capsule-400 mg, and metformin tablet- 500 mg; all documented as administered to R36 by the nurse. Observation and interview on 2/25/2025 at 10:46 am in R36's room revealed, one plastic medication cup sitting on R36's bedside table containing one pink oblong shaped tablet, one blue and white capsule, one orange capsule, one tan circular shaped tablet, two white circular shaped tablets, and two other odd shaped white tablets for a total of eight pills. R36 revealed, that the nurse had brought the medications and left it there. Observation on 2/25/2025 at 11:04 am revealed R36's lying in bed with the plastic medicine cup containing the same eight pills remaining at the bedside. Interview on 2/27/2025 at 10:13 am with Registered Nurse (RN) AA revealed that at times, R36 had to be prompted to take medications however it's never a problem. RN AA stated that if any resident refused their medication she would try again within a certain timeframe for example, before the last med pass within an hour. She stated that she would wait and confirm that the resident had ingested all medications before going on to the next resident or room. RN AA revealed, that she was not aware of any residents that had an order for self-administering medications at the facility. During an interview on 2/28/2025 at 3:48 pm with the Director of Nursing (DON) revealed, that medications should not be left in a resident's room. DON stated nurses should not leave medications at the bed side during the medication pass and her expectations was for the nurse to observe the residents ingesting the medications prior to leaving the room. DON confirmed that they did not have any residents in the facility that had been assessed to self-administer medications. Surveyor presented DON with the eMar via MatrixCare for review and was asked to verify information listed however, she was unable to provide a clear answer to what the initials/numbers meant. Interview on 2/28/2025 at 4:05 pm with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) CC revealed an explanation to the eMAR (electronic Medication Administration Record) coding. LPN CC pointed out the key near the bottom of the eMAR via MatrixCare and explained that the initials/numbers correspond with nurse that administers the medication to that resident within a two-hour timeframe. She stated that if the nurses code appears in the box that indicate that the medication was given within an hour before or an hour after scheduled time. LPN CC stated that if medication was not given then the nurses code would be in parenthesis. It was observed on the eMAR and confirmed by both DON and LPN CC that on 2/25/2025 the 9:00 am medications were documented as administered to R36 by the nurse.

Based on observations, staff and resident interviews, the facility failed to provide a safe, clean, comfortable, homelike environment for two out of 35 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]). Specifically, room [ROOM NUMBER] bathroom contained missing tiles on the left side of the toilet, the floor was sticky and malodorous with multiple large spiders and spider webs noted in the corners of the ceiling. In addition, a roach was observed crawling on the wall in room [ROOM NUMBER]. The sample size was 30 residents. Findings include: 1. Observation and interview on 2/25/2025 at 3:36 pm in room [ROOM NUMBER] revealed, multiple spiders and spider webs in the bathroom ceiling and broken tiles around the toilet bowl. The bathroom floor was sticky and malodorous. R52 who resided in room [ROOM NUMBER] revealed, he did not have a problem with rodents or pests, but the spiders had been there for a while. Observation on 2/26/2025 at 1:51 pm and at 4:30 pm in room [ROOM NUMBER] revealed, the spiders and spider webs remaining in the ceiling of the bathroom. The bathroom reeked heavily of urine, and the tiles remained missing from the bathroom floor on the left side back of the toilet. Observation on 2/28/2025 at 10:40 am in room [ROOM NUMBER] revealed, the spiders and spider webs had been removed from the ceiling. room [ROOM NUMBER] bathroom had been cleaned and did not [NAME] of urine odor; however, the missing tiles had not been replaced on the left side back of the toilet. 2. Observation on 2/28/2025 at 11:05 am in room [ROOM NUMBER] revealed, a roach crawling on the wall. Interview on 2/28/2025 at 11:35 am with the Maintenance Director (MD) revealed, the facility was contracted with [Name of business] for pest control. He stated that they came out monthly and was typically good at coming out for additional services as needed. The MD revealed, if there were additional concerns [Name of business] would leave the suggested recommendations in the pest control book. The MD confirmed the picture shown of the roach in room [ROOM NUMBER] and stated that it was an isolated occurrence because he had not seen any roaches. Interview on 3/1/2025 at 10:30 am with the Administrator revealed the documentation for the most recent pest control visit was done on 2/24/2025. The Administrator stated they were contracted with [Name of business] Pest Control and that they came out monthly to spray the facility and as needed. A policy for homelike environment was requested but not delivered by the exit. Instead, a goods and services agreement were provided.

Based on staff interviews and record review, the facility failed to ensure that a psychotropic medication, specifically an opioid medication, was not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of five sampled residents (R) R10 reviewed for the use of unnecessary medications. These deficient practices had the potential to affect the resident's highest practicable mental, physical, and psychosocial well-being. Findings include: Review of medical records revealed, R10 was admitted to the facility with a diagnosis that included but not limited to, generalized anxiety disorder and chronic pain. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C (Cognitive Patterns), a Brief Interview of Mental Status (BIMS) score of 15 indicating his cognition was intact; Section N (Medication) revealed R10 was taking antipsychotics, hypnotic, and opioid. Review of R10's Physicians Orders dated 8/27/2024 revealed oxycodone-acetaminophen (an opioid medication) 10-325 mg (milligram) one tablet by mouth every six hours as needed with no stop date. During an interview on 2/28/2025 at 3:32 pm with Licensed Practical Nurse (LPN) EE revealed, that R10 was currently taking oxycodone and that he had been taking it for a long time due to his chronic back pain. During an interview on 2/28/2025 at 4:14 pm with the Director of Health Services (DHS) confirmed R10 medical regimen put him at high risk for polypharmacy and stated that the pharmacy and physician monthly consult should be reviewed and evaluated.

Based on staff interviews, record review, and review of the facility's policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to report an allegation of abuse to the State Survey Agency within two hours for one of four Residents (R) (R2) reviewed for abuse. Findings include: Review of the facility's policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, dated 7/29/2019, indicated, 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. 2. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of patient property, within 2 hours after the allegation is made if the events upon which the allegation is based involve abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse and do not result in serious bodily injury. Review of R2's Resident Face Sheet revealed diagnoses that included but not limited to, metabolic encephalopathy (a brain disorder resulting from other organ system failures), diabetes mellitus with diabetic kidney complication, end stage renal disease, pain in left shoulder, and vascular dementia. Review of R2's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/22/2023, revealed Section C:Cognitve Patterns, a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment; Section GG: Functional Abilities and Goals revealed, functional limitations in range of motion on one side of their upper and lower extremities. Review of R2's Care Plan revealed a problem area initiated on 4/1/2023, that indicated R2 had frequent complaints of pain to their left shoulder. The Care Plan was updated on 11/15/2023 that indicated R2 had a left shoulder dislocation. R2's Care Plan also included a problem area, initiated on 4/1/2023, that indicated R2 had experienced a decline in their ability to perform activities of daily living (ADLs) related to a recent hospitalization secondary to metabolic encephalopathy, acute respiratory failure, acute cardiovascular accident (CVA, a stroke) with left-sided weakness, and dementia. An intervention started on 4/1/2023 directed staff to provide physical assistance with ADL care needs. Review of R2's Progress Notes revealed the following entries: - a note, dated 11/4/2023 at 2:37 pm, that indicated R2 complained of pain to their left shoulder blade. The note indicated that the resident rated their pain an 8 on a scale of 0-10, with 10 being the worst possible pain. The note indicated that the resident was given an as needed (PRN) pain medication; - a note, dated 11/5/2023 at 10:04 am, that indicated R2's left hand was swollen and was warm to the touch. The note indicated that R2 denied numbness but reported pain when touched. The note indicated that a PRN pain medication was given, and the resident's physician was notified of the resident's condition; - a note entered by Nurse Practitioner (NP) #17, dated 11/6/2023 at 11:55 am, that indicated R2 was evaluated for complaints of pain to left hand and arm; and - a note, dated 11/6/2023 at 2:00 pm, that indicated that the resident's left upper extremity and hand were swollen. The note indicated that a pain medication was given, and NP #17 evaluated the resident and ordered an ultrasound of the left upper extremity. Review of R2's Patient Report for the left upper extremity venous doppler ultrasound, dated 11/6/2023, revealed no evidence of a deep vein thrombosis or a superficial vein thrombosis. The report revealed R2 had a patent (open) dialysis shunt to their left arm. Review of R2's Progress Notes revealed a note entered by NP #17, dated 11/8/2023 at 1:00 pm, that indicated the resident was re-evaluated, and the resident reported their hand still hurt. Review of R2's Progress Notes revealed a note, dated 11/10/2023 at 2:55 pm, that indicated the resident had Slight swelling to their left upper arm. The note indicated the resident was unable to move their shoulder. Review of R2's Progress notes revealed a note, dated 11/11/2023 at 3:23 pm, that indicated the x-ray results were received and revealed an Acute anterior dislocation. Review of R2's Facility Incident Report Form, dated 11/14/2023, indicated the facility notified the state survey agency of an abuse allegation on 11/14/2023 at 10:51 am, six days after receiving the allegation from R2's family. The form indicated, This is an ALLEGED mishandling by the resident's [family member]. Resident has a dislocated shoulder. During an interview on 7/16/2024 at 4:12 pm, the Director of Health Services (DHS) stated that R2 was admitted to the facility with chronic pain. The DHS stated R2 started to complain of more pain to their shoulder, and on 11/10/2023, the resident's family called and alleged R2 had a displaced shoulder and alleged facility staff caused it. She stated that she called the dialysis provider, who said they had sent the resident to a vascular doctor. She stated that she called the vascular doctor, who reported that the resident's shunt had been displaced, and the shunt needed to be pushed back in. The DHS stated she then contacted NP #17 and got an order for an x-ray. Further interview with the DHS revealed, if she received a complaint of staff being rough, she would report it to the Administrator, suspend the staff member, speak to the resident, complete a head-to-toe assessment, and it should be reported to the state within two hours. The DHS further stated if a resident had an injury and they did not know how the injury occurred, she would report it to the Administrator and report it to the state. The DHS stated that while they were working to identify the cause of R2's arm pain, the resident's family called on 11/10/2023 and alleged the resident had a dislocated shoulder, caused by facility staff. The DHS said that despite discussions with the dialysis provider and vascular doctor, the family member continued to accuse facility staff of causing the injury. The DHS revealed after the family member made the allegation, it should have been reported to the state survey agency within two hours. During an interview on 7/16/2024 at 4:37 pm, the Administrator confirmed R2's family made the allegation on 11/10/2023, but the facility did not submit the initial report to the state survey agency until 11/14/2023. The Administrator stated the allegation should have been reported to the state on 11/10/2023.

Based on observations and staff interviews, the facility failed to properly store and maintain personal care use equipment in a sanitary manner for two shared bathrooms on the 100 Hall for four residents' rooms (Rooms 104, 105, 106, 107); Specifically, the facility failed to properly label and store contoured fracture bedpans, urinals, and specimen collector pan. The facility census was 69. Findings include: Observation on 9/5/2023 at 11:50 a.m. revealed in the shared bathroom located between rooms [ROOM NUMBERS], one urinal stored on the top of commode tank was unlabeled and unbagged. Two contoured bedpans and a fracture bedpan nested together on the floor were unlabeled and not secured in a bag. Observation on 9/5/2023 at 12:03 p.m. revealed in the shared bathroom located between rooms [ROOM NUMBERS], one urinal stored on the top of commode tank was unlabeled and unbagged. One contoured bedpan and one fracture bedpan nested together on the floor were unlabeled and not secured in a bag. Observation on 9/6/2023 at 8:28 a.m. revealed in the shared bathroom between rooms [ROOM NUMBERS], one urinal stored on the bathroom wall handrail was unlabeled and unbagged. Two contoured bedpans and one fracture bedpan nested together on the floor were unlabeled and not secured in a bag. Observation on 9/6/2023 at 8:31 a.m. revealed in the shared bathroom located between rooms [ROOM NUMBERS], one urinal stored on the top of commode tank was unlabeled and unbagged. One contoured bedpan and one fracture bedpan were nested together on the floor unlabeled and not secured in a bag. Interview on 9/6/2023 at 9:15 a.m. with Certified Nursing Assistant (CNA) AA revealed she had received in-service education training on proper cleaning and storing of urine measuring pan, fracture bedpan, wash basins and urinals. She further revealed that after they give a resident their bed bath, they are required to wash the basins out, dry it out, bag it in a storage bag, and place them on the bottom shelf of the resident's nightstand next to their bed. Interview on 9/6/2023 at 9:35 a.m. with CNA BB revealed she had received in-service education trainings on cleaning and proper storing of urine measuring pan, fracture bedpan, wash basins and urinals. She further revealed that after they give a resident their bed bath, they are required to wash the basins out, dry it out, bag it in a storage bag, and place it on the bottom shelf of the resident's nightstand next to their bed. Interview on 9/6/2023 at 9:51 a.m. with the Director of Nursing (DON) stated that all bedpans, graduated urinal containers, fracture pans, specimen collector pans, and wash basins, should be cleaned, properly labeled, and covered with a bag. Interview on 9/6/2023 at 11:00 a.m. with the DON revealed the facility did not have a policy on bed pans and urinal storage. She further stated the facility conducted an in-service education training immediately to train on labeling and storing multiple elimination containers in a bag with all nursing staff.

Based on observations, record review, staff interviews, and review of the facility's policy titled, Care Plans, the facility failed to develop a person-centered care plan for one of 17 residents (R) (R#59). Specifically, the facility failed to develop a care plan that addressed R#59 indwelling urinary catheter care needs. Findings include: Review of the facility policy titled Care Plans, revised July 27, 2023, subtitled, Care Plan Review and Update revealed: 1. Care plan updates/reviews will be performed within seven days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. 2. Updates to the care plans should be made with any changes in condition at the time the change in condition occurred. Record review for R#59 revealed diagnoses of but not limited to hydronephrosis with renal and ureteral calculous obstruction, chronic kidney disease, stage 4 (severe), and end stage renal disease. Review of Minimum Data Set (MDS) dated [DATE], revealed for Section C (Cognitive Patterns)-a Brief Interview for Mental Status (BIMS) of 06, which indicated severe cognitive impairment. Section G- (Functional Status) -revealed she required extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. Section H (Bladder and Bowel) revealed an indwelling urinary catheter and always incontinent of bowel. Observations of R#59 on 9/5/2023 at 11:00 a.m., 9/6/2023 at 10:40 a.m., and 9/7/2023 at 12:40 p.m. revealed she had an indwelling urinary catheter. Review of R#59's care plans dated 8/8/2023 revealed there was no care plan that addressed her indwelling urinary catheter needs. Interview on 9/7/2023 at 12:40 p.m. with MDS LPN revealed she updated care plans quarterly, she gathers information from nurse's notes, clinical records, and facility activities reports. She also revealed it is the responsibility of the nurse on duty for that resident's room number to update the physician orders and care plan upon residents return from the hospital if necessary. She verified R#59 did not have a care plan for the indwelling urinary catheter. Interview on 9/7/2023 at 1:15 p.m. with Licensed Practical Nurse (LPN) CC revealed nurses are responsible for updating physician orders and care plans as soon as possible when a resident returns from the hospital to the facility. Interview on 9/7/2023 at 1:55 p.m. with the Director of Nursing revealed her expectation is for physician orders and care plans to be updated as soon as possible for all new equipment, behaviors, medications, and orders. She confirmed R#59 did not have a care plan for the indwelling urinary catheter.

Based on observations, record review, interviews, and review of the facility policy titled, [CONDITION(S)] Care-Pre and Post [CONDITION(S)], the facility failed to ensure that pre and post [CONDITION(S)] assessments were conducted for one resident (R) R#39. In addition, the facility failed to ensure ongoing communication between the facility and the [CONDITION(S)] center for R#39. Findings include: Review of the facility policy titled, [CONDITION(S)] Care-Pre and Post [CONDITION(S)], revised May 25, 2018, revealed under Documentation Tools: [CONDITION(S)] Communication Form-maintain [CONDITION(S)] Communication Form in the patient/resident chart. Review of the clinical record for R#39 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment. Section O revealed resident was receiving [CONDITION(S)]. Review of the updated care plan revised 3/1/2022 documented resident is on [CONDITION(S)] three times per week due to [CONDITION(S)]. Interventions to care include coordinate residents' transportation to [CONDITION(S)] center as scheduled, observe for sign and symptoms of fluid retention, and observe shunt for patency. Review of the electronic medical record (EMR) for R#39 revealed missing and incomplete [CONDITION(S)] Communication Form. For the month of January 2022, there was no evidence of communication between the facility and the [CONDITION(S)] center for 11 of 12 scheduled [CONDITION(S)] treatments. The one form available for review for the month of January, was incomplete. For the month of February 2022, there was no evidence of communication between the facility and the [CONDITION(S)] center for four of 12 scheduled [CONDITION(S)] treatments. Three of the eight forms available for review were incomplete. For the month of March 2022, there was no evidence of communication between the facility and the [CONDITION(S)] center for three of the 14 scheduled [CONDITION(S)] treatments. Four of the eight forms available for review were incomplete. Observation and interview on 4/13/2022 at 11:15 a.m. with R#39, stated he had no problems with his [CONDITION(S)] treatments. He stated he takes the [CONDITION(S)] Communication Forms with him to the [CONDITION(S)] center but does not always bring them back. Interview on 4/13/2022 at 11:47 a.m., with Licensed Practical Nurse (LPN) Unit Manager (UM) BB she stated the nurses complete the top section of the [CONDITION(S)] Communication Form and send them to the [CONDITION(S)] clinic with the resident. The form includes the resident's vital signs and an update of the resident's overall condition. The resident should return with the bottom section completed by the clinic which also includes post treatment vital signs and weight, condition of the vascular access/shunt site, any new physician orders, and any occurrence during [CONDITION(S)]. She stated, when the [CONDITION(S)] clinic fails to complete their section, it is the facility nurse's responsibility to call the clinic and obtain the data to complete the form. Once completed, Medical Records scans them into the EMR. Interview on 4/14/22 at 3:03 p.m. with the Director of Health Services (DHS), stated the bottom section of the [CONDITION(S)] Communication Form should be filled out by [CONDITION(S)] clinic before resident leaves the clinic. If the form is returned incomplete, the facility nurses should call the clinic to obtain the information and complete the form before it's scanned into the system. During further interview, she stated she has had many discussions with the clinic about their inconsistency in completing the [CONDITION(S)] Communication Form. She confirmed the facility nurses were not calling the clinic to obtain the missing data per facility policy.

Based on observations, staff interviews, and facility policy titled Medication Administration: Equipment and Supplies, the facility failed to ensure one of three medication carts (the same cart on two separate observations) was locked, attended (by licensed staff) and inaccessible to others. The deficient practice had the potential to allow unauthorized persons, including residents, visitors, and other staff, to access medications. The sample size was 31. Findings include: Review of facility policy titled, Medication Administration: Equipment and Supplies, revised 12/10/2021, documented the policy is that the healthcare center maintains equipment and supplies necessary for the preparation and administration of medications to patients/residents. Procedure 1. The following equipment and supplies are acquired and maintained by the healthcare center for proper storage, preparation, and administration of medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 4/12/2022 from 10:30 a.m. to 10:41 a.m., a medication cart on the 100 Hall, near room [ROOM NUMBER] was unlocked and unattended. A housekeeping employee was cleaning rooms on the 100 Hall and walked past the unlocked medication cart two times. At 10:38 a.m., a cognitively impaired resident in a wheelchair self-propelled past the unlocked cart. Interview on 4/12/2022 at 10:41 a.m. with Licensed Practical Nurse (LPN) AA as she walked to the cart, stated she was responsible for the cart. LPN AA was able to open the drawers without using the keys to unlock the cart and acknowledged that the cart was unlocked. LPN AA stated she did not realize she had left the cart unlocked. She stated that she is aware that the cart should be locked when unattended. Observation on 4/13/2022 at 11:42 a.m. during Medication Administration on the 100 Hall with LPN AA, she gathered supplies from the medication cart to check a resident's blood glucose. The medication cart was parked along the wall by room [ROOM NUMBER]. LPN AA proceeded across the hall into room [ROOM NUMBER], leaving the medication cart unlocked and unattended. The medication cart was not in direct view of the nurse. Interview on 4/13/2022 at 11:46 a.m. with LPN AA, after returning to the medication cart, acknowledged that she had left the medication cart unlocked and unattended. Interview on 4/13/2022 at 12:10 p.m. with the Director of Health Services (DHS), stated the nurses are aware that medication carts should be locked when they are not working on the cart and/or when it is not in the nurse's view.

Based on observations, interviews and record reviews the facility failed to label medications, according to requirements, in three of three medication carts. Findings include: A review of the facility policy, Medication Administration: General Guidelines, dated with effective date of 4/1/1998 and a reviewed and revised date of 4/6/2018 revealed, item 4. medications are administered at the time they are prepared; item 10. indicates medications are administered within 60 minutes before or after scheduled times; item 18. indicates, prior to administration, the information on the Medication Administration Record [REDACTED]. indicates the nurse may not alter the medication label. A review of the facility policy, Medication Storage in the Healthcare Centers, dated 4/1/1998 and a revision date of 9/15/2017 revealed, item 1. the pharmacy dispenses medications in containers that meet legal requirements and transfer from one container to another is done only by a pharmacist. On 1/9/19 at 8:36 a.m., during the medication cart check for the 100-hall with Licensed Practical Nurse (LPN) AA, revealed two unlabeled pills were observed in the cart, in an unlabeled clear plastic medication cup, at the back of drawer number two. The two pills were not in any kind of blister-pack or packaging. One medication was a white capsule and one medication was a small, white round pill. LPN AA reported she did not know where the medications came from nor how long the medications may have been in the cart. LPN AA reported she does not ever pull the drawers out that far to see the back of the drawer. At this time, the Director of Nursing (DON) was summoned and she was shown the unlabeled medications in the cart. The DON reported the medications should have been discarded and not left in the cart. The DON reported the pharmacy had checked the carts the previous day. Observation and interview on 1/9/19 at 9:50 a.m. with LPN BB during routine medication administration of the 200-hall, revealed that while preparing medication for R#65, she stated that she was out of iron pills and had retrieved some from another medication cart. LPN BB showed the surveyor a plastic medication cup with a hand-written label on the front reading iron and 10 tablets were observed in the medication cup. LPN BB then took one pill from the medicine cup and placed it in the resident's medication cup and she proceeded to administer the medication to the resident, as ordered. An interview on 1/9/19 at 10:00 a.m. with the DON regarding the process for a nurse to replace floor stock to a cart when the supply is depleted. She reported the nurse goes to the medication supply room and retrieves a new bottle of medication. She reported if the medication is out, the nurse should let her know so more can be ordered from the pharmacy. An interview on 1/9/19 at 10:10 a.m. with LPN BB and the DON revealed that she got iron tablets from the other nurse on another cart. LPN BB revealed that she took 10 pills out of the stock bottle, from the other medication cart, and placed them in a plastic medication cup. She further revealed that she placed a paper label on the cup that reads Iron. The DON reported that is not the proper process for replacing floor stock to the cart. She reported the nurse should have retrieved the medication from the medication room and if there were none in the medication room, the nurse should borrow the entire bottle from another cart, leaving the pills in the original container and the nurse should let the DON know the medication is out so more can be ordered. An interview on 1/9/19 at 11:13 a.m. with the DON revealed she does not know if they have a policy specific for management and use of floor stock medications. The DON reported the unit manager usually does the ordering for floor stock, but the DON had done it the last time and evidently left off the reorder for the iron. As of survey exit the facility had not produced a policy regarding floor stock medications. Observation and interview on 1/10/19 at 9:00 a.m. with LPN CC for the 300-hall medication cart, revealed that an open vial of [MEDICATION NAME] injectable 2 milligrams (mg) per milliliter (mL) was observed without a label or any patient identification on the vial. The Registered Nurse (RN) Supervisor DD was summoned, and he observed the opened, unlabeled vial and he reported the vial should have been discarded.

Based on record review and staff interviews the facility failed to follow the [MEDICAL TREATMENT] care plan, check and record blood pressure and pulse, monitor the right chest perm-cath and left arm fistula sites before and after [MEDICAL TREATMENT], and communicate with the [MEDICAL TREATMENT] center for one resident (R) 216. According to the facilities Resident Census and Conditions of Residents (CMS Form 672) there are five [MEDICAL TREATMENT] residents. The sample size was 17. Findings are as followed: R #216 is a [AGE] year old female admitted to facility on 12/14/17 with admitting [DIAGNOSES REDACTED]. A record review of R #216's Entry Assessment Minimum Data Set ((MDS) dated [DATE] revealed no Brief Interview for Mental Status or Care Area Assessment. A record review of R#216's Interim Care Plan created on 12/15/17 revealed blood pressure and pulse before and after [MEDICAL TREATMENT] and monitor shut as indicated. A record review of the December 2017 and January 2018 Nurse's Notes(NN) for R#216 revealed missing documentation that supports the facility's nursing staff monitored the right chest perm-cath access for signs of infection or bleeding and monitored the left arm fistula for bruits and thrills and signs of infection and bleeding. A record review of R# 216's December 2017 and January 2018 Medication Administration Records (MAR) revealed missing documentation that supports the facility's nursing staff monitored the right chest perm-cath access for signs of infection or bleeding and monitored the left arm fistula for bruits and thrills and signs of infection and bleeding. A record review of the facility's policy titled [MEDICAL TREATMENT] Care Pre and Post [MEDICAL TREATMENT] last reviewed March 2016 revealed staff are expected to take and record patient/resident blood pressure and pulse before and after [MEDICAL TREATMENT], observe shunt access prior to patient/resident transport to [MEDICAL TREATMENT] and post-[MEDICAL TREATMENT] to palpate for evidence of thrill and auscultate bruit. A record review of the [MEDICAL TREATMENT] communication form revealed missing post-[MEDICAL TREATMENT] center communication off blood pressure and pulse on 12/22/17, 12/27/17, and 12/31/17. An interview with Licensed Practical Nurse LPN/Unit Manager on 1/4/18 at 10:22 a.m. revealed nurses are expected to document on the MAR the bruits/thrills, and the pre- and post-[MEDICAL TREATMENT] blood pressure and pulse. The same interview also revealed the [MEDICAL TREATMENT] Center Communication Forms are not being completed by [MEDICAL TREATMENT] centers after several complaints have to [MEDICAL TREATMENT] staff. LPN/Unit Manager continued to reveal that the MAR were not updated to have pre and post [MEDICAL TREATMENT] blood pressure and pulse and bruits/thrills monitoring. An interview with LPN/Unit Manager on 1/2/18 at 10:42 a.m. revealed she faxed the missing [MEDICAL TREATMENT] Center Communication Forms to the [MEDICAL TREATMENT] clinic to be completed. An interview with the Director of Nursing (DON) on 1/4/18 at 4:16 p.m. revealed nursing staff are expected to document on the MAR and/or nurse's notes the bruits/thrills and pre- and post- blood pressure and pulse. The interview further revealed nursing staff were recently educated on the care of [MEDICAL TREATMENT] residents. An interview with the LPN BB on 1/4/18 at 2:28 p.m. revealed she is new to day shift, and is aware she is supposed to document on MAR the pre- and post- blood pressure, and bruits/thrills. LPN BB further revealed she has not been doing that, only doing the pre [MEDICAL TREATMENT] BP, however was in-serviced today.

Based on interview and record review, the facility failed to timely obtain a Pre -Admission Screening and review (PASSAR) Level ll assessment and coordinate services for one resident, R #37, of 17 residents in the sample. Findings include: R #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review of resident record revealed resident #37 is not receiving any antipsychotic medications however, the resident is being monitored for behaviors. Per Treatment Administration Records (TARs), resident has not exhibited behaviors for 3 months. On 1/2/18 at 11:44 a.m. during record review, the facility was unable to locate any PASSAR information in R#37 medical record. An interview with, Social Services Director (SSD), presented evidence of Department of Medical Assistance-6 Form (DMA-6) dated 11/4/14. On 1/3/18 at 2:16 p.m. an interview with Minimum Data Set (MDS) Coordinator AA, revealed completed PASSAR level I dated 11/6/14. When asked why a Level II had not been completed, especially since the resident has [DIAGNOSES REDACTED]. Review of resident annual MDS dated [DATE] and quarterly MDS dated [DATE] supports a [DIAGNOSES REDACTED]. On 1/4/18 at 8:16 a.m. a 2nd request for completed version on PASSAR level ll was made to SSD and to MDS Coordinator AA. On 1/4/18 at 09:28 a.m. an interview with the SSD, revealed the PASSAR process is a coordinated effort. Per SSD, the Admissions Coordinator handles setting up the reevaluation review if the resident needs another evaluation beyond PASSAR Level l. When asked where was the PASSAR Level ll for this resident, SSD stated the resident was admitted in 2014. They have not been able to locate it. On 1/4/18 at 9:43 a.m. Conversation with the Admission Director (AD), offered a copy of an email sent 1/4/17 at 7:30 a.m. to another entity, requesting a copy of the PASSAR Level ll paper work. Per AD the paperwork would be sent as soon as possible (ASAP). On 1/4/18 at 12:04 p.m. AD offered another email sent to Department of Behavioral Health and Developmental Disabilities (DBHDD) requesting a copy of the resident's assessment as the previous company stated they did not assess the resident and it was DBHDD who completed the assessment. On 1/4/18 at 2:53 p.m. when asked SSD how does the facility know what services to provide the resident and what services are currently being provided since there is no PASSAR Level ll to reference. SSD stated that the resident was referred for services today, 1/4/18, and they will be in to visit resident within 24 hours. When asked to verify, that to date, since admission, the resident has not received any services, SSD validated by stating that is correct she has not been receiving services. SSD went on to state the resident is unable to communicate and has a Brief Interview for Mental Status (BIMS) of 0 making her ineligible to receive services. When asked to produce evidence of that assessment/evaluation, SSD was unable. When asked when was the resident diagnosed with [REDACTED]. When asked if the resident's BIMS was always a 0, SSD stated yes resident's BIMS has been a 0 since admission. Review of resident's MDS offers no score for resident's BIMS which remained consistent through most recent MDS assessment dated [DATE].

Based on observation, record review and interviews, the facility failed to ensure that the privacy curtain was pulled closed for one of 19 sampled residents (R) (R#107), while he waited for assistance with incontinent care. Specifically, R#107 was left exposed, uncovered and wearing a soiled adult brief while two Certified Nursing Assistants (CNA) and a family member were in the room assisting his roommate. The facility's failure resulted in psychological harm for R#107 as evidenced by observing the resident repeatedly looking over his shoulder with a frowned expression on his face and during an interview with R#107 on 12/20/16 at 2:42 p.m. in which the resident expressed that he was embarrassed to have his bottom exposed to strangers. Findings include: Record review for R#107 revealed admission to the facility on [DATE]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of six, indicating severe cognitive impairment. The resident usually understands, misses some part/intent of message but comprehends most conversation. R#107 requires extensive assistance for bed mobility, transfers and toileting. The resident is always incontinent of bowel and has a urinary catheter. Review of the Admission Interim Care Plans Form dated 12/8/16 documented the resident has severe contractures, has urinary catheter related to pressure ulcers in that area, requires assistance with toileting, requires cueing to turn and reposition, and does not resist care. Observation on 12/20/16 at 02:44 p.m. of R#107 revealed the resident lying on his bed (bed B) on his left side with his back turned towards bed A. The privacy curtains for both beds A and B were completely open. R#107 didn't have any pants on and was wearing a soiled brief. A top sheet was pulled half way down to the resident's middle thighs. Two Certified Nursing Assistants (CNA) and a family member were providing assistance to the roommate that was just being admitted to bed A of this shared room. There was a strong odor coming from the adult brief and R#107 repeatedly looked over his shoulder towards bed A with frowned expressions on his face. During an interview on 12/20/16 at 2:42 p.m. with R#107, it was determined that the resident was able to be interviewed despite his BIMS score of six. He was cognitive, intelligent, able to answer questions appropriately, knew of his condition, knew how long he had been in the facility, knew his roommate was just being admitted and knew he was waiting for the CNA to finish with his roommate so that she could change his brief. During the interview R#107 revealed he had a bowel movement and has been waiting for 15 minutes to be changed. R#107 stated the CNAs were aware that he needed to be changed but they were busy with the new resident in bed A. R#107 further revealed he felt embarrassed to have his bottom exposed to strangers. R#107 stated he wasn't able to turn to his right or to cover himself because his mobility was limited. During an interview on 12/20/16 at 2:52 p.m., with CNA BB, that was in the room during the time of observation, she apologized for not getting back to R#107 sooner. CNA BB further stated that she was so caught up with taking care of the newly admitted resident in bed A that she overlooked the fact that she should have covered R#107 and close the privacy curtain. CNA BB stated that she was trying to finish with the new resident in bed A and his wife as soon as possible to go take care of the needs of R#107. Observation on 12/20/16 at 2:54 p.m. revealed CNA BB pulled the privacy curtain around the bed of R#107, provided incontinent care, and later covered him with the top sheet and a blanket. Review of the Inservice Report Sign-In Sheet Form dated 3/31/16 revealed the Title of Inservice as Staff Expectations. The Summary of Inservice included Resident Rights and Choices. CNA BB's signature was on the sign-in Sheet. Review of the Resident's Rights & Abuse In-Service outline documented: Those employed by the nursing home are to care for it's residents in such a manner and in such an environment as will promote maintenance or enhancement of the quality of life of each resident. Dignity is defined as- the state or quality of being worthy of honor and respect. Specific Rights included the right to privacy. The facility was unable to provide a policy related to Resident Rights and/or Dignity. In a post survey interview with the Administrator, during the Quality Assurance process, on 12/30/16 at 11:07 a.m., she stated that she would obtain a facility policy related to Resident Rights and Dignity and forward to the State Agency (SA) via email. In an email from the Administrator on 1/4/17 at 12:32 p.m. she stated What I found on the Dignity issue is that we have no specific policy on Dignity other than what is in the Residents Bill of Rights. In an email on 1/4/17 at 3:03 p.m., the Administrator stated The policy for dignity and resident's rights is covered in the resident guide that is given to all of our residents upon admission. A post survey interview on 12/30/16 at 12:55 p.m., the DON revealed that when a resident is exposed in a soiled brief and a roommate is being newly admitted to the facility, she expects for the curtain to be pulled to provide privacy for each resident. The DON stated that she can only explain that maybe the curtain was left open in order to have more room for the new admission. DON informed that no policy is available related to privacy, but residents can file a grievance if and when they feel that their rights have been violated. Review of the Guest Services Guide, provided in the email from the Administrator on 1/4/17 at 3:03 p.m., revealed a section titled Educating & Promoting Patient/Resident Rights with an issue date of January 2002 which documented: Policy: It is the(NAME)Corporation companies' policy that the individual rights of patients/residents will be protected and safeguarded by all partners. Procedure- Areas of Risk:(NAME)Corporation companies' will establish specific procedures with regard to identified areas of risk that impact patient/resident rights which included, but not limited to, Privacy and Confidentiality.

Based on observation, record review and interviews, the facility failed to ensure the temperature, of the low temperature dishwasher, was at least 120 degrees Fahrenheit (F) in accordance with the manufacturer's recommendations for proper sanitation, during a wash/rinse cycle. The facility's failure to maintain the proper temperature required for sanitation, increased the risk of potential foodborne illness of 63 residents that received an oral diet. The facility census was 67. Findings include: Review of the undated guideline printed from the Ecolab website, in which the facility uses as practice, titled By Ruth L. Petran PhD- Vice President, Food, Safety & Public Health documented: In every restaurant, one ingredient cannot be overlooked: Clean dishes and utensils. It can expose your customers to dangerous foodborne illness. Best practices to warewashing, the following basics are recommended: Check the gauges and compare their readings with the minimum temperatures, chemical concentrations and pressure measurements listed on the data plate. Low-temperature, or chemical sanitizing machines, also show minimum rinse and wash temperatures- typically 120 degress F for both, on the data plate. Observation of the low temperature dishwasher in the kitchen on 12/19/16 at 11:00 a.m. revealed the temperature thermostat on the front bottom. The temperature read 90 degrees F during the wash cycle of several dishes and utensils. Further observation revealed a sticker on the front of the temperature dial that stated the minimum temperature setting should be at least 120 degrees F. The Dietary Manager (DM) was called to observe the dishwasher temperature at this time. The Dietary Aide (DA) ran the dishwasher through four (4) cycles, however, the maximum temperature reached each time was 90 degrees F. The sanitizer was at 150 parts per million (ppm). The DM confirmed the temperature did not go above 90 degrees F and stated at the time of the observation that this was not an acceptable temperature and that the dishes would need to be re-washed. During further interview on 12/19/16 at 11:29 a.m. with the DM he stated this was the first time the temperature was cold during the wash cycle, especially after all these attempts. The DM said there will be another wash cycle after lunch and he would be more than happy to re-run the cycle because by then the water should have reheated to the correct temperature. The DM said he was going to report this to the Maintenance Director so he could fix the water heating problem. Review of the Dishmachine Temperature Log Form for December 2016 revealed the dishwasher temperature and sanitation was recorded each day at 120 degrees F and sanitizer at 50 ppm. A subsequent observation of the low temperature dishwasher on 12/19/16 at 12:45 p.m. with the DM revealed the maximum temperature during the wash and rinse cycle slowly reached 100 -110 degrees F after four attempted cycles over a 30 minute time frame. During interview at this time with the DM, he stated the staff would wait another 30 minutes to rerun the cycle so the water could be hot enough. Observation on 12/19/16 at 1:45 p.m. of the dishwasher during the wash cycle revealed the temperature reached 120 degrees F. An interview on 12/20/16 at 11:14 a.m. with the Maintenance Director revealed that on 12/19/16, the kitchen staff notified him that the dishwasher temperature was low. The Maintenance Director stated that today the dishwasher temperature was still too low at 110 degrees F. He said that the water for the three compartment sink could not be in use at the same time the dishwasher is in use. He stated there is not enough hot water in the water tank to run hot water for both simultaneously. The kitchen staff is not supposed to run the dishwasher if the sinks are being filled. The Maintenance Director further revealed that the wash cycle is supposed to run at 125-130 degrees F per manufacture's recommendation and that the water heater is set to a maximum of 150 degrees F. The dishwasher uses 2.7 gallons of water. The kitchen runs out of hot water once every four (4) to six (6) weeks because staff keeps it running for too long while filling up the three compartment sink. The Maintenance Director said when that happens, it usually takes around 15-20 minutes before the water heats back up and staff knows to notify him when that happens. During an observation on 12/20/16 at 11:32 a.m., the three compartment sink was being filled with hot water at the same time the low temperature dishwasher was in use. The temperature of the dishwasher did not go above 100 degrees F during all four wash cycles observed. Interview on 12/20/16 at 11:34 a.m. with Maintenance Director revealed that because the three compartment sink is filling up with hot water, the water in the dishwater will not heat up. The Maintenance Director confirmed the temperature did not reach above 100 degrees F. An interview on 12/22/16 at 8:19 a.m., with the DA CC revealed she has been working at the facility since March 2016 and is not aware of any issues going on with the dishwasher temperature. DA CC further stated when she runs a wash cycle (dishwasher) she does not pay attention to what's happening with the three compartment sink and is not aware of how it might affect the dishwasher temperature.

Based on interview and record review, the facility failed to notify the physician of elevated blood sugars greater than 400, for one resident (R) (R#21) out of 19 sampled residents. Refer F309 Findings include: Record review for R#21 revealed a Physician order [REDACTED]. Per the prescribed sliding scale for insulin, administer 9 units of insulin for blood gluscose of 400-439. Review of the Medication Administration Record (MAR) for R#21 documented the following blood sugar results with no explanation or evidence of physician notification documented on the front or back of the MAR: August 19, 2016, 11:00 a.m. blood sugar 453, 0 units insulin administered August 22, 2016, 11:00 a.m. blood sugar 420 August 25, 2016, 11:00 a.m. blood sugar 475, 9 units insulin administered August 29, 2016, 11:00 a.m. blood sugar 449, 9 units insulin administered September 15, 2016, 9:00 p.m. blood sugar 417 September 16, 2016, 9:00 p.m. blood sugar 405 September 19, 2016, 9:00 p.m. blood sugar 402 September 22, 2016, 9:00 p.m. blood sugar 435 September 23, 2016, 11:00 a.m. blood sugar 550, 9 units insulin administered. Review of the Nurses Notes from August, 2016 through September, 2016 revealed no documentation of physician notification for elevated blood glucose on August 19, 22, 25, 29 or September 15, 16, 19, 22, 23 of 2016. Additionally, there was no evidence/documentation that insulin had been administered August 19, 2016, nor was there evidence/documentation of a physician order [REDACTED]. Further review of the MAR and Nurses Notes for August and September, 2016 did not indicate any adverse outcome to R#21 related to the above elevated blood sugars or insulin coverage. Interview with the Licensed Practical Nurse (LPN) AA on 12/22/2016 at 2:48 p.m. revealed that if a resident's blood sugar is out of parameters she would notify the physician and document that information in the nurses notes, on the 24 hour report and would document the ordered coverage of insulin on the MAR next to the sliding scale. Additionally, a note would be documented on the back of the MAR explaining the circumstances. During an interview on 12/22/16 at 2:25 p.m., the Director of Nursing (DON), she confirmed that there was no documentation in the clinical record or on the MAR for R#21 that would indicate the physician had been notified of the above out of parameter blood sugars. Additionally, the DON confirmed there was no evidence/documentation that orders had been obtained for the insulin administered in August and September 2016 for the blood sugars over 449. The DON stated that the nurses usually fax a notification form to the physicians office and he returns the fax with an order; however, no such documentation was available. The DON further stated that she was unable to make contact with the nurse that should have documented these findings. The facility was not able to provide a policy related to physician notification/change of condition. A post survey interview, during the QA process, on 12/30/16 at 11:07 a.m. with the Administrator revealed the facility does not have a specific policy related to physician notification/change of condition.

Based on interview and record review, the facility failed to follow physician orders [REDACTED].#21). Findings include: Review of the policy titled Medication Administration: Insulin Sliding Scales revised on 6/18/15 documented to check the prescriber's order and to calculate the correct amount of insulin to be administered using scale ordered by the physician. Record review for R#21 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. Active [DIAGNOSES REDACTED]. Record review for R#21 revealed the following Physician order [REDACTED]. Record Results. Administer sliding scale subcutaneously. For blood sugar greater than 250: 251-279 = 4 units 280-319 = 5 units 320-359 = 6 units 360-399 = 7 units 400-439 = 9 units For blood sugar less than 60 or greater than 400, notify the medical doctor (MD). The Medication Administration Record (MAR) documented: August 19, 2016, 11:00 a.m. blood sugar 453, 0 units insulin administered August 25, 2016, 11:00 a.m. blood sugar 475, 9 units insulin administered August 29, 2016, 11:00 a.m. blood sugar 449, 9 units insulin administered September 23, 2016, 11:00 a.m. blood sugar 550, 9 units insulin administered Review of the Physician order [REDACTED]. Further review of the MAR and Nurses Notes for August and September, 2016 did not indicate any adverse outcome to R#21 related to the above elevated blood sugars or insulin coverage. Interview with Licensed Practical Nurse (LPN) AA on 12/22/2016 at 2:48 p.m. revealed that the protocol for administering sliding scale insulin is to check the blood sugar and administer insulin per the sliding scale. LPN AA confirmed that if the blood sugar was over 400, she would notify the physician. She stated that if the blood sugar was out of the parameter for the sliding scale, she would notify the physician to obtain a new one time order for insulin dosage. LPN AA stated that a new order must be written even if the physician states to give 9 units for blood sugars over 439. Further, she would document that information in the nurse's notes, on the 24 hour report and would document the ordered amount of insulin on the MAR next to the sliding scale. A note would be documented on the back of the MAR explaining the circumstances. During an interview on 12/22/16 at 2:25 p.m., the Director of Nursing (DON), she confirmed that no documentation was available to indicate that the physician was notified or that an order had been obtained for the insulin administered in August and September 2016 for R#21 for the blood sugars over 449. The DON stated that her expectation was that the orders be followed and the physician be notified as indicated. The DON further stated that she was unable to make contact with the nurse responsible for not following the physician's orders [REDACTED].

Based on observation and staff interview the facility failed to properly demonstrate use of the three compartment sink to prevent the potential for food borne illness. Findings include: Observation on 07/01/14 at 11:20 a.m. revealed a dietary worker using the 3 compartment sink to wash the bowl, lid, and blade for the food processor. The dietary worker washed the kitchen equipment in soapy water, rinsed, then dipped the items in the sanitizer solution and put on the rack to dry. The dietary worker did not submerge the kitchen equipment for 1 minute as posted above the 3 compartment sink. Interview on 07/01/14 at 11:25 a.m. with the Dietary Manager revealed that she provided an in-service on the use of the 3 compartment sink a few months ago. Continued interview revealed that she was able to verbalize that kitchen equipment that is cleaned in the 3 compartment sink needs to be submerged for 1 minute in the sanitizer solution. Interview on 07/01/14 at 11:28 a.m. with the dietary worker revealed that she did not know that she needed to submerge kitchen equipment that is sanitized in the 3 compartment sink sanitizer solution.

Based on observation, record review, and staff interview the facility failed to provide a safe smoking environment for six (6) residents (#17, #76, #84, "C", "D" and "E") from a sample of forty-four (44) residents, as evidenced by the use of unsafe ashtrays; lack of a fire extinguisher in close proximity of the smoking area; and unsecured storage of smoking materials. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for those six (6) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of September 20, 2012 until April 5, 2013, at which time a plan was implemented by the facility to remove the immediate jeopardy situation. The facility's Administrator and owner were informed of this Immediate Jeopardy on April 3, 2013 at 7:05 p.m. Findings include: 1. Observations on 4/02/13 beginning at 4:00 p.m. revealed signage posted throughout the facility stating not to give residents smoking materials. Interview with the administrator on 4/2/13 at 4:12 p.m. revealed the facility changed its smoking policy in September, 2012 because a resident was burned on 9/20/12, while smoking without a staff member present and required medical attention. Continued interview revealed that prior to this incident, residents were allowed to keep their own smoking materials if they were deemed as safe smokers. Review of the smoking assessment for resident "B", the resident that was burned, dated 7/18/12 revealed that the resident was assessed as able to see clearly to perform the task, able to light a cigarette, smoke a cigarette and extinguish a cigarette safely. Resident "B" had been assessed as a safe smoker, not requiring supervision to smoke and with a Brief Interview of Mental Status score (BIMS) of 9. Interview with resident "B" on 4/3/13 at 11:59 a.m. revealed she was trying to smoke a cigarette and put the lighter too close to her body, and her blouse caught on fire. She revealed she got burned from her waist up. Observation of the resident's burn scars revealed a scar on her left chin/neck and left breast. Interview with housekeeping staff "AA"on 4/3/13 at 8:45 a.m. revealed that the front porch is the smoking area for residents, and the smoking times are 8:30 a.m.; 10:00 a.m.; 1:30 p.m.; 3:00 p.m.; 6:00 p.m.; 8:00 p.m.; and 10:00 p.m. She revealed residents were able to go out by themselves to smoke until a resident burned herself. Residents' cigarettes and lighters are now kept in a bucket behind the nurse's desk. She gets the bucket and aprons and takes the residents out. All smokers wear an apron. There is an ashtray, but only one resident, #7, is allowed to use it. The other residents put their cigarette butts into a cup of water which she disposes of after the residents have finished smoking. She revealed she did not know where the nearest pull station was. Observation on 4/3/13 at 2:00 p.m. of the designated smoking area revealed the nearest fire extinguishers to the front door were down each hall A, B, and C. Each fire extinguisher was approximately 120 feet from the front door. Continued observation revealed three (3) metal trash cans approximately three (3) feet high with a metal ash tray covering the trash can; there was a plastic bag in each trash can, overlapping the outside of the can by approximately four (4) inches. Interview with the administrator on 4/3/13 at 11:45 a.m. related to safe smoking practices revealed that staff did not periodically go through a resident's room to look for smoking materials but would if there were a reason to suspect that a resident had smoking materials. He was not aware of any residents having cigarettes on their person or in their room since the change in smoking policy in September 2012. Continued interview revealed that the facility did not inventory residents for smoking materials when they return from the hospital or from a leave of absence and the smoking residents were not reminded of the smoking policy when they returned to the facility. The administrator thought smoking assessments were done quarterly. 2. Interview with Certified Nursing Assistant (CNA) "MM" on 04/03/13 at 4:50 p.m., revealed that she supervised smoke breaks frequently and that if a resident caught on fire, she would get something to smother it, such as a sheet or blanket, that she would have get from down one of the halls or she might even take off her own jacket to smother the fire. Continued interview revealed that the first place she would go to get a fire extinguisher would be the Pantry (which was located on the A-hall behind to the Nurse's Station). During observation, she was not able to find an extinguisher in the Pantry at this time, and stated she would go to the Medication Room next to locate a fire extinguisher. The door to this Med Room, located in the back of the Nurse's Station, was observed to be open at this time, but CNA "MM" was unable to locate a fire extinguisher inside. Upon further interview with CNA "MM," she stated there were fire extinguishers on each hall, and that she would probably get the one on the A-hall. During interview with Licensed Practical Nurse "CC" at this time, she stated that the Med Room door was normally kept locked, and the nurses were the only ones with keys to get in the room. Observations on 04/03/13 at 11:35 a.m. and 4:50 p.m., and after the 6:17 p.m. smoke break revealed fire extinguishers were located on the walls between rooms A-7 and A-9; between B-7 and B-9; and between C-4 and C-5. Measurement of the distance from the front door to these fire extinguishers with the Maintenance man on 4/5/13 beginning at 8:45 a.m. revealed that the A and B hall extinguishers were 101 feet from the front door and the C hall extinguisher was 135 feet from the front door. Continued observations revealed that the box containing the smoking materials was on the floor just inside the A-hall side of the nurse's station, with the smoking aprons on top. There were unsecured entrances into the Nurse's Station from the A- and C-halls. On 04/05/13 at 1:05 p.m., the Minimum Data Set Coordinator provided a list of residents in the facility who were independently mobile and able to access the nurse's station where the smoking materials were kept. Review of this list revealed that twenty-eight residents met this criteria; twenty-five of these were identified as cognitively-impaired; and five of these residents were smokers. Observations of residents #7, #17, #38, #52, and #84 on a smoke break on the front porch on 04/03/13 at 6:17 p.m. revealed the break was supervised by the Director of Nurses and CNA "MM." Except for resident #84, the residents were allowed to hold their cigarettes, and the ashes were deposited in the metal ashtray portions of one of three tall cylindrical containers. Plastic trash can liners were observed in the bottom container sections below the ashtrays. As the residents finished smoking, the still-lit cigarette butts were observed to be placed in a plastic glass half-full of water that had been placed on top of the ashtray. 3. Observations on 4/2/13 at 8:00 a.m., 12:00 noon and 4:00 p.m., on 4/3/13 at 9;00 a.m., 11:00 a.m. and 3:00 p.m. at the nurses station revealed a red tackle box with smoking products (cigarettes and lighter) unlocked with four fire proof aprons stack on top of the box in the right corner near the desk. The nurses station had an unsecured entrance on each side. Review of the Smoking Policy and Procedure for Patients, revised September, 2012 revealed that Smoking materials and aprons will be kept at the nurse's desk to be provided to patients at permitted smoking times. A staff member will be assigned to monitor and assist patients as needed with their smoking at permitted smoking times. The immediate and serious threat to resident health and safety was determined to be removed on April 5, 2013, when the facility had completed the following steps: ? A fire extinguisher was installed on the porch which is the designated smoking area. ? The tackle box/smoking box was locked with a key and is now being kept in the medication room. The LPN charge nurses have keys which are kept on the key ring with the keys to the medication cart/room. ? The policy was revised to address the security of smoking materials. ? The facility has two approved closed tall hard plastic ash trays into which cigarette butts are dropped. ? Staff in-services regarding the safety of residents/supervision of smokers was completed 4/4/13 ? All staff not working due to vacation, illness or scheduling will be inserviced regarding resident safety/supervision of smokers on their return to work ? A fire blanket was obtained on 4/4/13. ? Smoking assessments were current and dated ? The facility Administrator has been designated with oversight of this program including quarterly reports to the QAA committee. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on April 5, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had conducted inservice training regarding resident safety/supervision of smokers for all staff who were working at the time the inservice training was conducted on 04/04/2013, however, some staff were not available for inservice at that time due to being on vacation, ill, or not scheduled to work. These remaining staff members who were not working at the time of the inservice training will be inserviced upon their return to work. The QAA committee has not met to monitor the effectiveness of the new interventions put in place to ensure resident safety related to the smoking environment and staff education. Therefore, the non-compliance continues but the scope and severity level was reduced to a "D" level. 4. During observations in the Common Baths on the C-hall on 04/03/13 at 7:30 a.m., the following was noted: a. Common Bath on the laundry room side of the hall: -The grab bar on the right side of the shower stall could be pulled away from the wall due to one of the three brackets securing the bar to the wall had come loose. -The toilet seat was freely moveable approximately three inches from side to side. -The grab bar next to the commode, which appeared to be a towel bar, had one of two screws on one of the brackets come out of the wall, making the bar loose on one side. b. Common Bath on the Medical Records side of the hall: -The grab bar in front of the commode, which appeared to be a towel bar, was bent in the middle. One of four screws securing it to the wall had come loose and it was movable when pulled on. The above concerns were verified during interview with the Director of Nurses on 04/03/13 at 8:00 a.m.