Every finding on record at Pruitthealth - Old Capitol

Based on observations, and staff interviews, the facility failed to ensure that one of two residents (R) (R1) was provided privacy during wound care treatment. Specifically, the facility failed to ensure R1's full privacy was provided by ensuring the privacy curtain was fully engaged when conducting wound care treatments. The failure had the potential to result in loss of dignity, and compromised resident rights.Findings include:Record review for R1 revealed resident was admitted to the facility on [DATE] with the diagnoses of but not limited to Pressure ulcer of sacral region, stage 3, Pressure ulcer of other site, stage 3 Note: L foot second digit, Peripheral vascular disease, unspecified, Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease.Review of the physicians' orders located in the electronic medical record (EMR) revealed a treatment order for the sacrum: cleanse with normal saline, pat dry, apply Dakins 0.25% (percent) moistened gauze to the wound bed, pack lightly using gauze, and cover with Optifoam dressing once a day from 7:00 a.m. to 7:00 p.m. Cleanse with normal saline, pat dry, apply Dakins 0.25% moistened gauze to the wound bed, pack lightly using gauze, and cover with Optifoam dressing PRN (as needed) if soiled or dislodged, PRN 1, PRN 2, PRN 3.Review of the care plan for R1 revealed R1 was at risk for further skin breakdown due to history of skin breakdown, incontinence, and impaired mobility. Resident prefers to lie on her back while in bed and will refuse repositioning at times. 3/22/24 unstageable sacral wound - healed 6/13/2024; 10/23/2024, Pressure ulcer to sacrum healed 11/26/2024. 1/1/2025: Ingrown R inner great toe (healed); 3/17/2026: sacral wound. 5/26/2026: Noted to refuse to be turned and repositioned. 7/4/2026 Wound L foot 2nd toe.During wound care observation on 07/28/2026 at 3:31 PM, provided by Licensed Practical Nurse (LPN) AA, revealed that R1 was located in the A bed by the door. Certified Nursing Assistant (CNA) BB pulled the privacy curtain between the A and B beds but failed to pull the privacy curtain around R1, leaving her exposed to the doorway. LPN AA and CNA BB positioned R1 on her left side with her backside facing the door. LPN AA pulled R1's gown away from her backside, exposing her backside and bottom. LPN AA cleaned the sacral area and provided wound care per order. LPN AA stated she forgot the foam dressing. She removed her gloves, sanitized her hands, opened the door, and exited the room, leaving R1 exposed. LPN AA returned and continued treatment. CNA BB removed the soiled brief and stated she did not have another brief and needed to go get one. CNA BB exited the room, again leaving R1's backside and bottom exposed.In an interview on 07/28/2026 at 4:05 PM with LPN AA, she confirmed and acknowledged that full privacy was not provided for R1 during the wound dressing change.In an interview on 07/28/2026 at 4:07 PM with CNA BB, she confirmed and acknowledged that full privacy was not provided for R1 during the wound dressing change. An interview on 08/06/2026 at 11:40 am with the Director of Health Services (DHS) revealed that she expected full privacy and privacy curtains to be pulled during wound care and Activities of daily living (ADL) care.

Based on observations, resident and staff interviews, and record review, the facility failed to provide scheduled showers for three of 20 sampled residents (R) (R15, R16, and R18) dependent on staff for activities of daily living (ADLs). This deficient practice had the potential to result in decreased hygiene and discomfort for residents who relied on staff assistance for bathing. Findings include:1. R15 was admitted to the facility on [DATE] with the following but not limited to diagnoses: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, acute bronchitis, unspecified, end stage renal disease, visuospatial deficit and spatial neglect following cerebral infarction, chronic combined systolic (congestive) and diastolic (congestive) heart failure, dependence on renal dialysis, and muscle weakness (generalized).Review of R15's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident had intact cognition. Section G - Shower/bathe self-indicated the resident was dependent on staff for bathing.During an interview with R15 on 08/04/2026 at 9:30 AM, R15 stated that she had not received a shower in weeks. She reported that although she had a shower in her bathroom, staff did not provide her with a shower.Review of Point of Care History Sheets revealed that R15 received two showers in six months.2. R16 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Muscle weakness (generalized), End-stage renal disease, acute respiratory failure with hypoxia, dependence on renal dialysis, chronic systolic (congestive) heart failure, and primary osteoarthritis, right shoulder.Review of R16's Quarterly MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. Section G on the MDS is titled Functional Status and revealed that Shower/bathe self-indicated the resident was dependent on staff for bathing.During an interview with R16 on 08/04/2026 at 9:15 AM, R16 stated that she had not received a shower in three weeks. She reported that staff had been providing her with bed baths instead. R16 stated that her showers were scheduled for Monday, Wednesday, and Friday.Review of Point of Care History Sheets revealed that R16 received ten showers in six months.3. Review of R18's electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Other polyosteoarthritis; epilepsy, unspecified, not intractable, without status epilepticus; chronic kidney disease, unspecified; other reduced mobility; restless leg syndrome; difficulty in walking, not elsewhere classified; pain in the left knee; pain in the right knee; pain in the right shoulder; and muscle weakness (generalized). Review of R18's MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. Section G on the MDS is titled Functional Status revealed Shower/bathe self-indicated the resident was dependent on staff for bathing.R18 stated that she did not know when she last had a shower. She reported that she was supposed to receive a shower three times a week but stated that this did not occur.Review of Point of Care History Sheets revealed that R18 did not receive any showers in six months.An interview on 08/04/2026 at 10:11 AM with Certified Nursing Assistant (CNA) FF revealed that she documented in the tablet when a resident refused care. She stated that she documented whether the resident received a bed bath or a shower, and that she reported refusals to the nurse. CNA FF stated that residents were scheduled to receive showers three times a week, either Monday, Wednesday, Friday or Tuesday, Thursday, Saturday.An interview on 08/05/2026 at 10:50 AM with CNA EE revealed they rotated halls monthly. She stated that residents were supposed to receive showers three times a week. She stated that if a resident refused, she notified the nurse.An interview on 08/05/2026 at 3:05 PM with CNA GG revealed that she documented in the shower book when she provided a shower. She stated that residents were scheduled to receive showers three times a week. CNA GG reported that she was planning to provide R15 a shower later that day.An interview on 08/06/2026 at 11:40 AM with the Director of Health Services (DHS) revealed that she expected CNAs to offer resident showers and, if a resident refused, the nurse to speak with the resident and pass the information to the next shift. The DHS stated that going forward she would provide more oversight.An interview on 08/06/2026 at 11:58 AM with Licensed Practical Nurse (LPN) DD revealed that she stated that CNAs were supposed to notify the nurse if a resident refused a shower and confirmed that this was not occurring. She reviewed the shower book and stated that there was no documentation of residents refusing showers, and that refusals were not being reported.An interview on 08/06/2026 at 12:00 PM with the Administrator confirmed and verified that the shower sheets in the shower books on both the east and west wings were not filled out to reflect resident refusals of showers.

Based on observations, record review, and resident and staff interviews, the facility failed to ensure that residents received activities that met resident-centered and personal preferences for dependent care residents for three of 20 sampled residents{R} (R15, R16, and R18). This deficient practice had the potential to result in social isolation and failure to support each resident's right to meaningful, individualized activities.Findings Include:1. R15 was admitted to the facility on [DATE] with the following but not limited to diagnoses: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, acute bronchitis, unspecified, end stage renal disease, visuospatial deficit and spatial neglect following cerebral infarction, chronic combined systolic (congestive) and diastolic (congestive) heart failure, dependence on renal dialysis, and muscle weakness (generalized).R15's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that R15 was assessed with a Brief Interview for Mental Status (BIMS) of 13 indicating the resident had intact cognition.Review of R15 care plan dated 03/27/2019 revealed R15 likes to watch T.V. family visits, bingo and conversing. She receives 1:1 activities as tolerated.Observation on 07/28/2026 at 11:35AM, R15 was observed lying in bed in her room with eyes open.Interview and observation on 08/04/2026 at 9:30 AM, R15 stated that she was not offered activities in her room. She stated that when she comes back from dialysis on Mondays, Wednesdays, and Fridays she is put to bed. She stated that the activity director does not do activities in her room.2. R16 was admitted to the facility on [DATE] with the following but not limited to diagnoses: Muscle weakness (generalized), End stage renal disease, acute respiratory failure with hypoxia, dependence on renal dialysis, chronic systolic (congestive) heart failure, and primary osteoarthritis, right shoulder.R16's Quarterly Minimum Data Set, dated [DATE] revealed that R16 was assessed with a Brief Interview for Mental Status (BIMS) of 16 indicating the resident had intact cognition.Review of R16 care plan last reviewed 06/16/2026 revealed R16 like puzzles, sodoku, t.v., stickery and conversing. She frequently orders crafts and other things in mail(medications, cream/pills, electronic devices, et cetera.Observation on 07/28/2026 at 11:35 R15 was observed lying in bed in her room her with eyes open.Interview and observation on 08/04/2026 at 9:25 AM, R16 stated that she go to dialysis on Monday, Wednesdays, and Fridays. She stated that is the only time she is out of bed. R16 stated that she would love to play bingo but they have it on the days that she goes to dialysis. She stated that she get back from dialysis in enough time to go to bingo but they put her back in bed and tells her that they are not taking her to bingo because she may have to use the bathroom and they would have to bring her down to her room and change her and they are not going to do that. R16 stated that she does not receive any activities in her room. She stated that the activity director does not come to her room and provide her with any activities.Review of progress notes for the last year revealed there were no documentations from activities for 1:1 room visits.3. R18 was admitted to the facility on [DATE] with the following but not limited to diagnoses: Other polyosteoarthtitis, epilepsy, unspecifies, not intractable, without status epilepticus, chronic kidney disease, unspecified, other reduced mobility, restless leg syndrome, difficulty in walking, not elsewhere classified, pain in left knee, pain in right knee, pain in right shoulder, and muscle weakness (generalized).R18's Quarterly MDS dated [DATE] revealed that R18 was assessed with a Brief Interview for Mental Status (BIMS) of 15 indicating the resident had intact cognition.Review of R18 care plan dated 06/2025 revealed R18 likes outdoors, tv. bingo and conversing. She prefers at times to stay in room at times.Observation on 08/04/2026 at 10:16 AM, R18 was observed lying in bed in her room.Observations during survey dates revealed bingo in the dining room between 2:00 - 3:00 pm on 7/27/2026, 7/29/2026, 8/3/2026, 8/5/2026. R15, R16, R18 were observed in the dining room participating in bingo.Interview and observation on 08/4/2026 at 10:16 AM, R18 stated that they do not get her out of bed and she wants to play bingo. R18 stated that the activity director does not come in her room and do activities with her. Interview on 08/06/2026 at 10:40 AM with the Activities Director (AD) revealed she did 1:1 with R20 on 7/28/2026. Review of activities charting report for 7/28/2026 revealed a note one-on-one 7:46 am, there was not an activity listed or length of activity. AD stated that she does not remember who she did 1:1 with, she stated that she does not have a set schedule when she do 1:1, sometimes she see them down the hall, she stated that she's on the hall constantly. AD stated that she go to the store every other Thursday. She stated that for the residents that go to dialysis on m w f and miss bingo she was going to-do it in the evening or on Tuesdays but she is getting ready to start a butter bean auction on Tuesdays and Thursdays. AD stated they had a volunteer hospice person to come in and do an activity with the residents and she told them about butter bean auction. AD stated that the residents want to do butter bean auction. AD stated that some of the residents be back in time for bingo but they go to their room because they are tired. She stated that the ones that don't get to go to bingo because they are at dialysis, some of them do crocheting, She stated that R16's family send her stuff through the mail so she can crochet, AD stated that R15 has a phone and she can call and listen to her religion, she stated she is not sure if they are having bible study on the phone, but she also watches tv. She stated that when it was COVID she went to the rooms in sections and sometimes R15 would play bingo and sometimes she would not. AD stated the last time she went room to room and do bingo was way back in 2020 or 2021. She stated that since COVID she has not done bingo in sections like. AD stated that she does not have an activity log report of residents that received 1:1 activities. She stated that she tries to do the front M W F, back Tu- Thursdays and finish up on Friday.Interview with Certified Nursing Assistant (CNA) GG on 08/05/2026 at 3:05 PM, CNA GG stated that she has never seen activities do 1:1 with residents.Interview with the Administrator on 08/06/2026 at 10:49 AM, the Administrator stated his expectation is for residents that are in their rooms, he expects the activity director to find out what their interest / hobbies are and build from there. He stated that her documentation does not reflect what she does because he sees her down the hall throughout the day.

Based on observations, staff interviews, and review of the facility's policies titled Labeling, Dating, and Storage, the facility failed to ensure that food was properly labeled and stored. This deficient practice had the potential to place the 88 residents receiving nutrition and hydration from the kitchen at increased risk of foodborne illness.Findings include: Review of the facility policy titled Labeling, Dating, and Storage, dated 11/11/2022, revealed the Policy Statement stated, It is the policy of [Company Name] for all partners who assist in handling, preparing, serving, and storing food and beverage items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety. The Procedure section stated 1. Food and beverage items will have an identifying label as well as a received date and opened date, as applicable: for items prepared onsite, a 'use by' date will also be indicated. 2. Foods will be stored in their original or approved container and, if opened, shall be wrapped tightly with film, foil, etc. 3. Bulk food dispensing utensils (scoops) shall be stored: a. In a clean, protected location, if the scoops are used only with a food that is not a time/temperature controlled for safety food. 4. Food and beverage items will be discarded according to guidance from a government agency such as the USDA [United States Department of Agriculture] and FDA [Food and Drug Administration]; an example of approved guidance is attached to this policy. Observations during a tour of the kitchen, on 9/19/2025 from 8:15 am through 9:30 am, with the Dietary Manager (DM) revealed:Observation of the walk-in freezer: One bag of diced pepper, opened and undated. One bag of waffles, opened and undated. Observation of the walk-in cooler revealed One half of a block of butter, unlabeled and undated. Two bags of shredded cheese, opened and unlabeled. One bag of cooked chicken fajita in a small, tall plastic container with a discard date of 9/13/2025.Observation of a large floor bin containing dry rice revealed that the lid was not secured, exposing the rice to the environment. The Dietary Manager closed the lid and stated that the rice was exposed to the environment and that she would discard the rice.In an interview on 9/19/2025 at 9:45 am, the DM reported that her expectations were for the staff to monitor for food labeling per each shift and discard expired food items. She stated that the dietary staff had received training on food labeling and dating, and she planned to re-educate them.

Based on observation, resident and staff interviews, record review, and review of the facility policy titled Self-Administration of Medication by Patients/Residents, the facility failed to ensure one of 34 sampled residents (R) (R43) was assessed for medication self-administration before allowing medications at the bedside. This deficient practice had the potential to place R43 at increased risk of medical complications related to medication use. Findings include:A review of the facility policy titled Self-Administration of Medication by Patients/Residents, reviewed 1/6/22025, revealed the Procedure section included, . 3. If the Licensed nurse determines the patient/resident or family member to be capable of self-administration of medications, the attending physician must write an order to that effect that includes the specific medications based off of the Self-Administration Medication Observation. Review of the clinical record for R43 revealed diagnoses including, but not limited to, vascular dementia, hemiplegia, and hemiparesis following cerebral infarction affecting the left non-dominant side. Review of the Quarterly Minimum Data Set (MDS) assessment for R43, dated 8/25/2025, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident is cognitively intact. Section GG revealed R43 had upper and lower extremity impairments on one side.Review of the physician orders for R43 revealed no order for self-administered medications.Record review of the care plan for R43 revealed no care plan for self-administering medication. Observation on 9/19/2025 at 10:28 am revealed a clear plastic medication cup containing one blue capsule and one yellow capsule, and an eight-ounce cup containing an orange liquid. In an interview on 9/19/2025 at 10:30 am, R43 revealed he took his own medications.In a concurrent interview and observation on 9/19/2025 at 10:37 am, in R43's room, the Director of Nursing (DON) and Administrator confirmed that R43 stated that he consumed medication by bedside, unsupervised. The DON and Administrator confirmed that R43 was not assessed to self-administer medication. In an interview on 9/19/2025, at 10:43 am, Licensed Practical Nurse (LPN) CC stated that she was the nurse who provided medication to R43, but was uncertain whether the resident had taken the medication prior to her leaving the room. She stated she placed the medication by the bedside and thought she observed the resident reaching for it in an attempt to ingest it. LPN CC verified that the medication consisted of one capsule of gabapentin, one capsule of potassium chloride, and a liquid combination of multivitamins and valproic acid.

Based on observations, staff interviews, record review, and review of the facility policy titled Infection Prevention-Hand Hygiene, the facility failed to ensure infection control practices were followed during wound care for one of four residents (R) (R8) with wounds. This deficient practice had the potential to place R8 at increased risk for infection due to cross-contamination. Findings include:Review of the facility policy titled Infection Prevention-Hand Hygiene, revised October 2024, revealed the Procedures section included, D. Indications Requiring Hand Wash or Hand Rub: 1. Before and after contact with the resident. 2. Before donning gloves, including sterile gloves. 7. Immediately after removal of personal protective equipment (e.g., gloves, gown, facemasks).Observation on 9/20/2025 at 1:05 pm revealed Licensed Practical Nurse (LPN) AA provided wound care for R8. Observation during the wound care revealed that the LPN changed gloves between each step of the wound care, and did not perform hand hygiene between glove changes during the wound care or between dirty and clean tasks. In an interview on 9/20/2025 at 1:35 pm, LPN AA acknowledged not sanitizing or washing her hands after glove changes. LPN AA further stated she had received education on hand hygiene.In an interview on 9/21/2025 at 9:15 am, the Director of Nursing (DON) stated that her expectation was that the nurse follow infection prevention and hand hygiene during wound care.

Based on interviews, record review, and a review of the facility policy titled Facility Assessment Tool, the facility failed to provide education for all nursing staff to possess the competencies and skill sets necessary to ensure residents were free of medication errors as well as ensure these competencies and skill sets were monitored on an ongoing basis. As a result, one of 26 residents (Resident (R) 50) out of a total sample of 83 residents was hospitalized after a nurse administered a benzodiazepine (an antianxiety drug that can cause sedation), which was not ordered by the physician, to the resident. The facility's failure to provide education for all nursing staff to possess the competencies and skill sets necessary to ensure residents were free of medication errors as well as ensure these competencies and skill sets were monitored on an ongoing basis presented a likelihood of serious harm, injury, impairment, or death due to the significant medication error for R50. Immediate Jeopardy was identified on 5/22/2024 in the area of S483.35 Nursing Services F726 at a scope and severity (S/S) of J. The Administrator and Director of Health Services (DHS) were informed on 5/23/2024 at 9:13 am that the Immediate Jeopardy existed related to the failure to ensure nursing staff were educated on the facility's medication administration policy, competency assessments were conducted on medication administration, and monitoring was completed to ensure nursing staff were properly administering medications according to the policy. The Immediate Jeopardy began on 3/29/2024, the date R50 was administered the benzodiazepine and was admitted to the hospital. Cross reference F760-J: Residents are free of Significant Medication Errors Findings include: A review of R50's undated Face Sheet, located in the Electronic Medical Record (EMR) under the Face Sheet tab, revealed R50 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's disease with dyskinesia and chronic diastolic (congestive) heart failure. A review of R50's Nursing Progress Notes, dated 3/29/2024 and located under the Progress Notes tab of the EMR, revealed, . Resting in bed respiration even and unlabored difficult to arouse requiring chest stimulation to respond skin w/d [warm/dry] to touch verbal response with slow sluggish speech. A review of R50's Hospital Discharge Summary, dated 3/31/2024 and located in the EMR under the Resident Documents tab, revealed . [R50] was admitted on [DATE] from local nursing home due to altered mental status. Patient had been unresponsive with pinpoint pupils given intranasal Narcan and became more responsive temporarily, then unresponsive upon arrival to the ED [emergency department]. Urine drug screen did show benzodiazepines . A review of R14's (R50's roommate) Physician's Orders, dated 7/7/2021 and located under the Orders tab of the EMR, revealed an order for alprazolam (a benzodiazepine) 0.5 milligrams (MG) tablet one tablet by mouth two times a day at 9:00 am and 9:00 pm for anxiety. During an interview on 5/23/2024 at 6:04 pm, the former Clinical Competency Coordinator (CCC) confirmed her role included providing education for all nursing staff to possess the competencies and skill sets necessary to provide nursing care and to monitor the competencies and skill sets on an ongoing basis. The CCC stated nursing staff completed training, competency assessments were conducted upon hire, and annual training included a skills fair and medication administration questionnaire on the computer. The CCC acknowledged she had not conducted medication administration observations of the nursing staff until after the incident occurred when R50 received the wrong medication which was reported to the facility by R50's family member. The CCC indicated after she identified that Licensed Practical Nurse (LPN) 1 was not administering medications per the policy, all nursing staff were educated on how to properly administer medications from 4/2/2024 to 4/5/2024. During an interview on 5/23/2024 at 8:01 pm, the Administrator stated she expected the CCC to provide nursing staff training on medication administration per the policy, identify medication administration errors, and work with the DHS to correct those errors. During an interview on 5/24/2024 at 9:39 am, the DHS confirmed the CCC was training nursing staff on medication administration at the skills fair, and nursing staff were completing a medication administration test on the computer annually. The DHS stated medication administration observations of the nursing staff were not completed on an ongoing basis until after R50's medication error. During an interview on 5/24/2024 at 11:46 am, LPN1 confirmed she prepared R14's medications, placed them in a cup, prepared R50's medications, and then placed them in a cup without labeling the cups at the medication cart. LPN1 stated she placed R50's medications on a tray, held R14's cup of medications in her right hand, and then took them to their shared room and administered them to the residents. LPN1 also stated that she had been administering the residents' medications this way for approximately one year because the residents had more medications to administer, and it was convenient to use the tray to pass them. LPN1 indicated she received training on medication administration at the annual skills fair, completed a medication administration test on the computer, and a medication administration observation was conducted in April 2024 by the CCC. A review of the facility-provided document titled, Facility Assessment Tool, dated April 2024, revealed . 2. Staff training and competency-Annual competencies and based on guest acuity. Utilize [NAME] and Relias for training. Head to toe assessments during orientation . A review of the facility-provided position description titled, RN - Clinical Competency Coordinator, revealed . Key Responsibilities . 5. Implement and oversees the healthcare centers orientation program for new partners and recommends progression to permanent employment or extension of the orientation probationary periods, as well as baseline, annual, and on-going clinical competency evaluation of nursing partners . 29. Completes initial competency assessment of clinical staff upon hire, annually and as needed . 3l. Conducts competency assessments to determine partner learning needs based on patient conditions and acuity . 37283

Based on resident and staff interviews, record review, and a review of the facility policy titled Medication Administration: Oral Medications, the facility failed to ensure residents were free from significant medication errors for one of 26 sampled residents (Resident (R) 50) out of 83 total residents. R50 received a benzodiazepine (an antianxiety drug that can cause sedation), that was not ordered by the physician and contributed to her hospitalization . The facility's failure to ensure residents were free from significant medication errors presented a likelihood of serious harm, injury, impairment, or death to a resident. Immediate Jeopardy was identified on 5/22/2024 in the area of S483.45 Pharmacy Services F760 at a scope and severity (S/S) of J. The Administrator and Director of Health Services (DHS) were informed on 5/22/2024 at 2:50 pm that the Immediate Jeopardy (IJ) existed related to the failure to ensure residents were free from significant medication errors for one resident. The Immediate Jeopardy was determined to exist on 3/29/2024, the date R50 received the benzodiazepine and was admitted to the hospital. The facility failed to provide a Removal Plan, and the IJ at F760 was ongoing at the time of the survey exit on 5/23/2024. Findings include: A review of R50's undated Face Sheet, located in the Electronic Medical Record (EMR) under the Face Sheet tab, revealed R50 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, Parkinson's disease, major depressive disorder, hypertensive heart disease, and type two diabetes. R50 had no known drug allergies. R50 was hospitalized from 3/29/2024 to 3/31/2024. A review of R50's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/7/2024 and located in the EMR under the MDS 3.0 Assessments tab, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating R50 was moderately cognitively impaired. It was recorded that R50 received insulin injections, diuretics, and antiplatelets in the preceding seven days. A review of R50's Physician's Orders, located in the EMR under the Orders tab, revealed no orders for benzodiazepines. A review of R50's MARs, dated March 2024, revealed that R50 was administered her ordered medications on 3/29/2024 at 9:00 am. These ordered medications did not include benzodiazepines. A review of R50's Nursing Progress Notes, dated 3/29/2024 and located under the Progress Notes tab of the EMR, revealed, . Resting in bed respiration even and unlabored difficult to arouse requiring chest stimulation to respond skin w/d [warm/dry] to touch verbal response with slow sluggish speech. V/S [vital signs] 142/52-46-22-97.1-94%. BS [blood sugar] 236 after meal 11:30 am 151 insulin given as ordered. [R50's physician] updated on status, order to send to Emergency Department (ER) . A review of R50's Hospital Discharge Summary, dated 3/31/2024 and located in the EMR under the Resident Documents tab, revealed, . [R50] was admitted on [DATE] from local nursing home due to altered mental status. Patient had been unresponsive with pinpoint pupils given intranasal Narcan and became more responsive temporarily, then unresponsive upon arrival to the ED [emergency department]. R50 was given additional doses of Narcan and Romazicon (drug used to treat drowsiness caused by sedatives) and is now alert and oriented this morning. She does not remember the events that led up to last night. Urine drug screen did show benzodiazepines . A review of R14's (R50's roommate) Physician's Orders, dated 7/7/2021 and located under the Orders tab of the EMR, revealed an order for alprazolam (a benzodiazepine) 0.5 milligrams (MG) tablet one tablet by mouth two times a day at 9:00 am and 9:00 pm for anxiety. A review of the facility's investigative documents revealed the following nursing staff statements written on 4/4/2024: Licensed Practical Nurse (LPN) 1: On 3/29/2024 at 1:00 pm, LPN1 was notified by Certified Nursing Assistant (CNA) 1 that R50 did not eat lunch, so she checked on her and found that she was responsive but lethargic. At 4:45 pm, R50 was difficult to arouse when checking her blood sugar. LPN1 contacted R50's physician and received orders to send R50 to the hospital ED for evaluation and treatment. LPN1 stated the only medications that she gave R50 were the medications ordered by R50's physician. CNA1: On 3/29/2024, R50 was kind of drowsy and fatigued. She would respond with a moan but would go back to sleep. She reported this to LPN1. LPN1 assessed R50 then other nurses entered R50's room. CNA2: On 3/29/2024, she witnessed R50 acting strangely. When she called R50's name, she moaned but did not open her eyes. LPN1 was already informed so she asked her to get another nurse. The nurses assessed R50. During an interview on 5/20/2024 at 9:53 am, R50 stated she remembered that she was given a medication by the nurse that made her sleepy, and then she woke up in the hospital the next day. During an interview on 5/21/2024 at 8:22 pm, the Pharmacy Consultant stated he was contacted by the Director of Health Services (DHS) on 4/4/2024 regarding benzodiazepines showing up in R50's urinalysis and determined after review of R50's medication orders that none of them would show a false positive result for benzodiazepines. The Pharmacy Consultant also stated the medication error was reported to him and that R50's roommate and residents across the hallway were ordered benzodiazepines. During an interview on 5/23/2024 at 6:04 pm, the Clinical Competency Coordinator (CCC) acknowledged that upon investigation of R50 receiving the wrong medication, she observed LPN1 preparing medications for more than one resident at a time at the medication cart, placing all the medications on a tray, taking the medications into the room for more than one resident, and administering medications to both residents on the same trip into the room. The CCC stated this medication administration practice created a potential for residents to receive medications meant for another resident. During an interview on 5/24/2024 at 8:17 am, the Medical Director (MD) confirmed he was notified of the medication administration error that occurred on 3/29/2024 for R50 by the Director of Health Services (DHS). The MD stated that when residents received the wrong medications, it could result in serious harm or death. During an interview on 5/24/2024 at 9:39 am, the DHS stated that R50's family member reported the medication error to the facility when it was discovered during the hospitalization . The DHS also stated that the CCC identified the medication administration error during a medication administration observation of LPN1 on 4/2/2024. The DHS confirmed she had observed LPN1 using a tray to pass medications last year, and LPN1 told her that she only used it to carry inhalers and insulin pens, so she did not stop the practice. The DHS confirmed the medication administration practice used by LPN1 could have caused serious injury or death to R50. During an interview on 5/24/2024 at 11:46 am, LPN1 confirmed she prepared R14's medications, placed them in a cup, prepared R50's medications, and then placed them in a cup without labeling the cups at the medication cart. LPN1 stated she placed R50's medications on a tray, held R14's cup in her right hand, and then took them to their shared room and administered them to the residents. LPN1 stated that she had been administering the residents' medications in this manner for approximately one year because the residents had more medications to administer, and it was convenient to use the tray to pass them. LPN1 indicated the CCC provided medication administration training at the annual skills fair and performed a medication administration observation in April 2024. A review of the facility's policy titled, Medication Administration: Oral Medications, revised 12/10/2021 and provided by the facility, revealed, Policy: It is the policy of the facility that oral medications are administered in an organized and safe manner . Special considerations: . Only one patient/resident's medication at a time should be prepared for administration. Procedure & Key Points: 1. Bring a medication cart in the vicinity of the patient/resident's room. Verify that the patient/resident is in the room . 5. Read and compare the medications with the MAR [Medication Administration Record] and EMAR [Electronic Medication Administration Record]. 6. Place the medication into a souffle cup . 10. Identify patient/resident before administering medication . 37283

Based on interviews, facility policy reviews, and job description reviews, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to avoid significant medication errors during nursing medication administration. The facility failed to provide continued, effective oversight of the nursing staff's medication administration practices. This failure affected one of 26 residents out of 83 total residents (Resident (R) 50) when R50 received a benzodiazepine (an antianxiety drug that can cause sedation), which was not ordered by the physician and contributed to R50 hospitalization . The failure of the facility to provide continued, effective oversight of nursing staff's medication administration practices presented a likelihood of serious harm, injury, impairment, or death due to the significant medication error for R50. Immediate Jeopardy was identified on 5/22/2024 in the area of S483.70 Administration F835 at a scope and severity (S/S) of J. The Administrator and Director of Health Services (DHS) were informed on 5/23/2024 at 9:13 am that the Immediate Jeopardy existed related to the failure to provide continued, effective oversight of nursing staff's medication administration practices. The Immediate Jeopardy (IJ) was determined to exist on 3/29/2024, the date R50 received the benzodiazepine and was admitted to the hospital. The facility failed to provide a Removal Plan, and the IJ at F835 was ongoing at the time of the survey exit on 5/23/2024. Cross reference F760-J: Residents are free of Significant Medication Errors Findings include: During an interview on 5/23/2024 at 6:04 pm, the former Clinical Competency Coordinator (CCC) confirmed her role included providing education for all nursing staff to possess the competencies and skill sets necessary to provide nursing care and to monitor the competencies and skill sets on an ongoing basis. The CCC also stated nursing staff completed training, competency assessments were conducted upon hire, and annual training included a skills fair and medication administration questionnaire on the computer. The CCC acknowledged she had not conducted medication administration audits of the nursing staff until R50's family member reported R50 had received the wrong medication, which contributed to R50 hospitalization from [DATE] to 3/31/2024. The CCC indicated the medication administration audits revealed Licensed Practical Nurse (LPN) 1 was not administering medications per the medication administration policy. During an interview on 5/23/2024 at 8:01 pm, the Administrator stated she was responsible for the overall management of the facility and expected the CCC to provide nursing staff training on medication administration per the policy, identify medication administration errors, conduct ongoing medication administration audits, and collaborate with the DHS to correct any identified errors. The Administrator also stated she was notified by R50's family member on 4/1/2024 that the hospital staff told her that the resident received the wrong medication on 3/29/2024, and it contributed to her hospital admission. The Administrator indicated that upon investigation of the incident, the CCC identified through medication administration observations that LPN1 was preparing the medications at the same time and then passing them to the residents in their rooms at the same time. During an interview on 5/24/2024 at 9:39 am, the DHS confirmed the CCC provided training to the nursing staff on medication administration at the annual skills fair, and nursing staff completed a medication administration test on the computer annually. The DHS stated the investigation of the incident for R50 revealed medication administration audits had not been conducted on a continuous basis to monitor the nursing staff's knowledge and performance of the task. A review of the facility-provided job description titled, Director of Health Services, revealed, . Job Purpose: Plans, organizes, develops and directs the overall operation of our Nursing Services Department in accordance with current federal, state, and local regulations governing our nursing center, and as may be directed by the Administrator and the Medical Director, to provide appropriate care . A review of the facility-provided position description titled, RN [Registered Nurse] - Clinical Competency Coordinator, revealed, . Key Responsibilities . 5. Implement and oversees the healthcare centers orientation program for new partners and recommends progression to permanent employment or extension of the orientation probationary periods, as well as baseline, annual, and on-going clinical competency evaluation of nursing partners . 29. Completes initial competency assessment of clinical staff upon hire, annually and as needed . 3l. Conducts competency assessments to determine partner learning needs based on patient conditions and acuity . A review of the facility's policy titled, Medication Administration: Oral Medications, revised 12/10/2021 and provided by the facility, revealed Policy: It is the policy of the facility that oral medications are administered in an organized and safe manner . Special considerations: . 8. Only one patient/resident's medication at a time should be prepared for administration. Procedure & Key Points: 1. Bring medication cart in the vicinity of the patient/resident's room. Verify that the patient/resident is in the room . 5. Read and compare the medications with the MAR and EMAR. 6. Place the medication into a souffle cup . 10. Identify patient/resident before administering medication . 37283

Based on resident and staff interviews, review of Resident Council Minutes, and review of the facility policy titled, Patient/Resident Council, the facility failed to ensure a response was provided to the members of the resident council when concerns were identified related to transportation accommodations for outings. During the resident council meeting four residents (R) (R30, R36, R54, and R78) had complaints of transportation not being provided for outings and had not received a response. Findings include: Review of documentation provided by the facility titled Patient/Resident Council Minutes/Report Form, from 8/29/2022 to 4/22/2024, included Old Business/Resolutions [store name] trip is on hold due to [transportation company name] does not have van available at this time. Vans is in shop & [sic] also have wrecked vans. Ongoing trip to [store name] pending a van for transportation. During a Resident Council Meeting held on 5/21/2024 at 10:30 am, R30, the Resident Council President stated that residents wanted to take trips, they want a van for transportation, and the Activities Director keeps telling them They're working on it. R30 reported this had been going on for over a year. R36, R54, and R78 confirmed the group had been requesting to go on outings to [store name] and to go out to eat. Additionally, they were told that if they did a van rental, it would cost 20 dollars per person, but have not been given the opportunity to go, and no response had been provided. During an interview on 5/22/2024 at 2:20 pm, the Director of Nursing (DON) stated that the facility did not have their own transportation vehicle, but the facility had a contract with a transportation company to provide transportation for medical appointments, but no transportation was available for outings. The DON was aware that the Resident Council members wanted to go on outings but was unaware if a response had been provided to the residents. During an interview on 5/22/2024 at 4:13 pm, the Social Services Director (SSD) confirmed the Resident Council concern regarding outings had been raised during morning meetings. The facility had discussed borrowing a van from another sister facility, but a response had not been provided that she was aware of. During an interview on 5/22/2024 at 4:35 pm, the Activities Director (AD) confirmed that the Resident Council group members had been asking for transportation for outings to [store name] for quite some time. Additionally, prior to COVID-19 the facility contracted with [transportation company name] for transportation for outings, then once COVID-19 happened, the outings stopped. AD stated that she had spoken with a supervisor at [transportation company name] who told her that there were new rules and no drivers. The facility had also reached out to other sister facilities to borrow a van but were told the vans were already booked and unavailable. Her practice had been to notify the Administrator of the transportation requests, the Administrator signs off on all Resident Council meeting minutes, but no resolution/response had been made. During an interview on 5/23/2024 at 8:21 am, the Administrator stated that she was aware that one resident wanted to go to [store name], but the facility did not provide transportation for outings. In the past, the facility had contacted [transportation company name] and was unable to get an agreement for the transportation company to take the residents on outings. The Administrator confirmed that this information was not conveyed to the residents. During an interview on 5/23/2024 at 2:00 pm, the Ombudsman stated that she had been to several Resident Council meetings and was aware that the residents had voiced requests for transportation for outings. She had advocated on behalf of the residents to the [Coalition group name], but no resolution had been provided to the residents that she was aware of. A review of the facility policy titled Patient/Resident Council, revised 10/20/2017, stated A Patient/Resident Council will be developed and supported by the administration. 2. Issues raised/discussed, and recommendations made by the Patient/Resident Council will be communicated to the healthcare center administration, considered in center planning, and responded to promptly. 3. The Recreation Services Director or Social Services Director will assist in the coordination of the council meetings as requested by the group President and provide assistance as needed in documentation of minutes and serving as liaison with the healthcare center administration in responding to issues that result from group meetings .10. Issues, concerns, ideas, or complaints of the Council will be transferred to the Patient/Resident Council/Family Council Department Response Form by the staff liaison person and given to the Administrator for distribution and response by the appropriate department. The response/action will be documented on this form, returned to the Administrator for review and signature and returned to the Council staff liaison for communication back to the Council Presiding Officer and presentation at the next council meeting. The department response form will be attached to the minutes of the meeting in which the issues was brought up .

Based on observations, staff interviews, and review of the facility policy titled Controlled Substances for Healthcare Centers, the facility failed to ensure that controlled medications (drugs that can cause physical and mental dependence and have restrictions on how they can be filled and refilled) were stored separately from other medications and were stored under a double-lock system in two of two medication storage room refrigerators. Findings include: Observation on 5/21/2024 at 9:18 am of the East Wing medication room, which was located behind the nurses' station, with Licensed Practical Nurse (LPN) 1 revealed the locked refrigerator in the medication storage room contained the following medications: 1. One Novolog insulin aspart flexpen for Resident (R)13. 2. One Levemir insulin flexpen for R22. 3. One Levemir insulin flexpen for R37. 4. One Novolog insulin flexpen and two Lantus Solostar insulin pen for R41. 5. Three Novolog insulin aspart flexpens for R31. 6. Four Novolog insulin aspart flexpens and one injection of Aranesp (a drug used to treat anemia) for R61. 7. Two injections of Risperdal (drug used to treat schizophrenia) Const for R8. 8. One bottle of Lorazepam Intensol Oral Concentrate (Schedule IV controlled medication) for R71. 9. One bottle of Lorazepam Intensol Oral Concentrate for R77. The controlled medications were not stored separately from any other medications and were not stored using a double-lock system. Observation on 5/21/2024 at 9:28 am of the [NAME] Wing medication room, which was located behind the nurse's station, with LPN2 revealed the locked refrigerator in the medication storage room contained the following medications: 1. One Novolog insulin aspart flexpen for R12. 2. One Fiasp insulin flextouch pen and one box of Lokelma (a drug used to treat high potassium levels) containing 14 packets for R25. 3. One box of Dupixent (a drug used to treat eczema) containing two pens for R42. 4. One box of Veltassa (a drug used to treat high potassium levels) containing 12 packets for R58. 5. One bottle of lorazepam (a drug used to treat anxiety) oral concentrate (Schedule IV controlled medication), for R1. The controlled medications were not stored separately from any other medications and were not stored using a double-lock system. During an interview on 5/21/2024 at 9:44 am, the Director of Health Services (DHS) acknowledged she was not aware that the controlled medications had to be stored separately from all other medications. The DHS stated the Pharmacy Consultant audited their medication rooms monthly and found no errors. During an interview on 5/21/2024 at 10:38 am, the Pharmacy Consultant confirmed the controlled medication policy stated controlled medications, Schedule II through V medications, were stored from other medications, but he had not seen them. The Pharmacy Consultant acknowledged he audited the medication rooms monthly but ensured the controlled medications were stored separately had not been completed because the task was not listed on the audit tool. A review of the facility's policy titled Controlled Substances for Healthcare Centers, revised 4/28/2021, revealed, . Storage: Controlled substances in Schedules II, III, IV, and V are stored under double lock in a locked cabinet or safe designated for that purpose and separate from all other medications .

Based on observations, staff interviews, and review of the facility policy titled Labeling, Dating, and Storage, the facility failed to ensure food items were securely closed, labeled, and dated after opening. This had the potential to affect 75 of 83 residents who consumed food from the kitchen. Findings include: 1. During observation and initial kitchen walk-through with the Dietary Manager (DM) on 5/20/2024 beginning at 9:35 am, the following was observed and confirmed by the DM: a. In the dry storage room, there was a one-pound bag of macaroni spiral pasta, open to air, undated and unlabeled. b. In the dry storage room, there was an opened bag of cookies (removed from the original container) that was undated and unlabeled. c. In the walk-in cooler, there were 15 cups of juice in cups that were undated and unlabeled. 2. During a second kitchen walkthrough on 5/21/2024 at 8:48 am with the DM, the following was observed and confirmed by the DM: a. In the walk-in cooler, there was a one-gallon container of ranch dressing that was open, undated, and unlabeled. b. In the walk-in cooler, there was one pound of butter that was open, undated, and unlabeled. During an interview on 5/21/2024 at 10:55 am, the DM stated she expected all foods to be stored properly, including being dated and labeled as required. During an interview on 5/23/2024 at 3:30 pm, the Administrator stated she expected the staff to follow policy, label with appropriate dates, and store food items properly. A review of the facility's undated policy titled Labeling, Dating, and Storage indicated. Food and beverage items will have an identifying label as well as a received date and opened date, as applicable; for items prepared on site, a 'use by' date will also be indicated. Foods will be stored in their original or approved container and, if opened, shall be wrapped tightly with film, foil, etc .

Based on interview, review of facility documentation, and review of facility policy, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure it developed and maintained a program to provide systematic analysis and systemic action aimed at performance improvement. This failure had the potential to affect all 83 residents who currently live in the facility. Findings include: Review of the facility policy titled, [Company Name] Skilled Nursing and Rehabilitation Center Quality Assurance and Performance Improvement (QAPI), dated 02/26/2016, revealed, Policy Statement: The purpose of Quality Assurance and Performance Improvement (QAPI) Program at [Company Name] is to continually take a proactive approach to assure and improve the way we provide care and engage with our patients, partners and other stakeholders so that we may fully realize our vision, mission and commitment to caring pledge. Scope: This policy applies to [Company Name] Skilled Nursing and Rehabilitation Centers (SNRC) and partners as part of the overall QAPI Plan .Procedure: All [Company Name] partners and contracted staff are responsible for the quality of care and services within their respective departments and are expected to participate in the QAPI Program. Each Center must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. It is the expectation of the [Company Name] SNRC QAPI Program that each location will follow the established QAPI process in order to guide and direct the operations of that location . [Company Name] SNRC Standardized QAPI Tools Include: A standard Meeting Minutes template was designed based on the agenda, which will be maintained on the Regional SharePoint site to allow communication with the Regional team . The Quality Management System which is the software program utilized to document Performance Improvement Projects (PIP's) and an overview of the root cause analysis completed. Performance Improvement Projects (PIPs): As part of its QAPI Program, each [Company Name] SNRC develops, implements, and evaluates performance improvement projects. The facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the center must reflect the scope and complexity of the facility's services and available resources. a Performance Improvement projects must include at least annually a project that focuses on high risk, high volume or problem-prone areas for improvement identified through the data collection and analysis based on: Feedback an input from stakeholders; Data/metrics reported monthly from all departments; Adverse event monitoring and investigation/analysis . Documentation of the [Company Name] QAPI Program includes: All performance improvement projects being conducted; The reasons for conducting these projects; Measurable progress achieved during performance improvement projects; Evidence that demonstrates the operation of the center's QAPI Program . An attempt was made to review the meeting minutes and Performance Improvement Projects (PIP) for the previous four quarters. There was no documentation available for review. There was no documentation indicating the facility had been working to identify areas of concern for improvement or to determine the underlying causes of any problems. There was no documentation of current PIPs, or any PIPs having been completed and reviewed by the facility. During the QAPI interview on 05/23/2024 at 5:15 pm, the Administrator stated, There are no sign-in sheets and no meeting minutes to review. We don't have formal minutes of the meetings. We don't have any records of who was there or what we talked about. There are no PIPs in progress or records of any that have been completed.

Based on interview, review of facility documentation, and review of facility policy, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure the required members of the committee attended the quarterly meetings. This failure had the potential to affect all 83 residents who currently live in the facility. Findings include: Review of the facility policy titled, Skilled Nursing and Rehabilitation Center Quality Assurance and Performance Improvement (QAPI), dated 02/26/2016, revealed, Policy Statement: The purpose of Quality Assurance and Performance Improvement (QAPI) Program at [Company Name] is to continually take a proactive approach to assure and improve the way we provide care and engage with our patients, partners and other stakeholders so that we may fully realize our vision, mission and commitment to caring pledge. Scope: This policy applies to [Company Name] Skilled Nursing and Rehabilitation Centers (SNRC) and partners as part of the overall [Company Name] QAPI Plan .Procedure: All [Company Name] partners and contracted staff are responsible for the quality of care and services within their respective departments and are expected to participate in the [Company Name] QAPI Program. Each Center must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. It is the expectation of the [Company Name] SNRC QAPI Program that each location will follow the established QAPI process in order to guide and direct the operations of that location .Communication: The Center Quality Assurance and Assessment (QAA) committee is required to use the established QAPI Meeting Minutes for documenting and communicating QAPI efforts required to the regional committee level. The corporate and regional committees should communicate their efforts to the level below them to ensure all committees are working cohesively. [Company Name] SNRC Standardized QAPI Tools Include: A standard Meeting Minutes template was designed based on the agenda, which will be maintained on the Regional SharePoint site to allow communication with the Regional team. This template also includes a sign in sheet that should be printed and utilized in each center's monthly meeting. An attempt was made to review the sign-in sheets for the previous four quarters. There were no sign-in sheets available for review. There was no documentation indicating who attended any of the meetings or to confirm that the meeting occurred. During the QAPI interview on 05/23/2024 at 5:15 pm, the Administrator stated, The QAPI committee meets at least quarterly but, normally we meet monthly. The Medical Director, Director of Health Services (DHS), myself, the Infection Preventionist (IP), and department heads normally attend the meetings. There are no sign-in sheets and no meeting minutes to review. We don't have formal minutes of the meetings. We don't have any records of who was there or what we talked about.

Based on record review, interviews, and review of the policy titled, Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Mission Statement, the facility failed to ensure a thorough investigation was completed for an injury of unknown origin for one of 26 sampled residents (R) (R#14). Findings include: A review of the policy titled, Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Mission Statement with a review date of 1/8/19 indicated that it is the mission of Pruitthealth and its affiliated providers actively to preserve each patient's right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of patient property. The organization recognizes that every patient has the right be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. A review of the clinical record for R#14 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed R#14 had a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. Section G revealed R#14 required extensive assistance of two persons for bed mobility and dressing/personal hygiene required total dependence of two persons. A review of Progress Note dated 8/28/22 at 10:29 a.m., written by Licensed Practical Nurse (LPN) BB, revealed R#14 reads, during morning care this morning resident noted to have a few skin tears on his right hand on the top and on his right wrist, left hand on top as well. (Physician) notified. Cleansed the areas, dried applied antibacterial ointment, and covered with clean dry dressings. A review of Progress Note dated 8/29/22 at 2:36 a.m. noted (R#14) resident resting in bed. Skin warm and dry to touch. No signs of infection or new areas noted to hand and wrist. Dressing intact clean and dry. Will continue to monitor. Review of progress note dated 8/30/22 at 12:24 a.m. reads - Resident resting in bed. Skin warm and dry to touch. (Respirations) even and non-labored. Dressing remains to both hands with no drainage noted. No new skin tears noted. Will continue to monitor. During an interview and observation on 8/30/22 at 9:32 a.m. with R#14, he was observed to have multiple purple bruises and a band aid to both hands. R#14 stated that he did not know what happened to his hands. During an observation on 8/30/22 at 2:36 p.m., R#14 had a white bandage on the right and left hand. R#14 stated, They put these bandages on my hands while you were gone. During an observation on 8/31/22 at 9:02 a.m. R#14 was lying in bed conversing on his cell phone. Skin tears and bruises observed to both hands. There are two white soiled dressings observed on the bedside table. A review of the electronic mediation record (eMAR) revealed that there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with R#14 on 8/31/22 at 11:02 a.m., R#14 stated that the day before yesterday a big girl and little one came in to change him up and the big one grabbed his hand and caused the bruises and skin tears to both his arms. During an interview on 8/31/22 at 11:06 a.m. with Certified Nursing Assistant, (CNA) AA she stated that she works part time and worked at the facility, Monday (8/29/22), Tuesday (8/30/22) and today this week. She further stated that when she reported to work on 8/29/22, R#14 told her that a girl jumped on him. CNA AA stated that she reported that to the nurse on duty at that time and was told, that the nurses are aware of the situation. CNA AA further stated that R#14 does not and has not ever refused care or been combative with her while giving care. During an interview with LPN BB on 8/31/22 at 11:12 a.m. She stated that two CNAs came to the medication cart and told her that R#14 had open areas to his hands that that the areas were new, and they had not seen the areas before. LPN BB stated that after observing R#14's hands, she determined the areas were fresh and notified the doctor and R#14's wife. LPN BB stated she might not have written an order. LPN BB further stated that R#14 told her that the injuries occurred on the night shift during care that a girl had her hand on his arm, and it opened up. LPN BB stated that R#14 is not all the way there and he makes things up. LPN BB stated that at the beginning of the shift, R#14 was asleep under blankets, and she did not see his arms. LPN BB verified that she did not transcribe a treatment order to the eMAR after speaking with the physician on 8/28/22. During an interview on 8/31/22 at 11:21 a.m. with Registered Nurse (RN) CC, she stated that there was not an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . RN CC stated that due to R#14's low BIMs score, this incident should have been investigated. During an interview with Administrator on 8/31/22 at 11:37 a.m., she stated that she is not aware of anything going on with R#14 hands. She further stated that the staff communicates with her through a phone call or text messages. The Administrator stated that LPN BB may have reach out to the DHS (Director of Health Services) but confirmed that she did not know anything related to R#14 injuries. The Administrator stated that R#14 injuries should have been reported to the state and an investigation should have been conducted; including getting statements from the nurses and the staff that were working at the time of the injuries. During an interview with DHS on 9/1/22 at 9:55 a.m., she stated that she was out on medical leave this week and returned today. She confirmed that she did not have any knowledge of R#14 injuries until today (9/1/22) when the Administrator informed her.

Based on observation, record review, and review of the facility policy titled Stop Orders-Healthcare Centers revealed the facility failed to ensure that a [CONDITION(S)] medications/antianxiety medication was not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of five residents (R) (R#64) reviewed for unnecessary medications. Fundings include: A review of the facility policy titled Stop Orders-Healthcare Centers reviewed 6/22/22 revealed: Policy Statement: It is the policy of the healthcare center to automatically stop medications after the indicated number of days, unless the prescriber specifies a different number of doses or duration of therapy given. Procedure: 1.The following classes of medications are stopped automatically after the indicated number of days, unless the prescriber specifies a different number of doses or duration of therapy to be given. PRN antipsychotic medications-14 days 3.When entering medications covered by the Stop Order Policy on the Medication Administration Record (MAR), the automatic stop date is recorded in the appropriate area on the MAR. A review of R#64's diagnoses revealed (partial list) diabetes mellitus, metabolic [CONDITION(S)], major depressive disorder, dementia with behavioral disturbance, and anxiety disorder. Review of R#64's quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognition: Brief Interview of Mental Status (BIMS) score of three (3) indicating very poor cognitive deficit; Section G-Functional Status: resident required supervision with bed mobility, personal hygiene, toileting, independent with transfers, walking, locomotion dressing, bathing and eating; Section N-Medications: resident received antipsychotic. A review of R#64 Care Plans revealed (partial): At risk for injury related to side effects from antipsychotic medication usage. Behavioral symptoms resident has been noted to wander, refuse care, and be physically and verbally abusive to staff. A review of R#64's Physician orders revealed an order for [MEDICATION(S)] tablet 0.5 milligrams (MG) 1 tablet by mouth (PO) every (Q) six hours PRN for anxiety ordered on 8/29/22 with no stop date indicated. During observations on 8/30/22 through 9/1/22 of R#64 revealed no behaviors or concerns. An interview held on 9/01/22 at 8:51 a.m. with the Director of Nursing (DON) revealed she would expect the [MEDICATION(S)] order to have a stop date. She verified the order did not have a stop date. An interview held on 9/1/22 at 11:14 a.m. with the Administrator revealed residents should have a stop date on antipsychotic medications that are ordered as needed.

Based on observation, record review, and staff interview, the facility failed to disinfect the glucometer per facility policy for four residents (R) observed (R#100, R#18, R#34, R#8) on two of five halls. Findings include: 1. On 9/18/19 at 11:30 a.m., Licensed Practical Nurse (LPN) CC was observed to obtain a hand-held basket containing a glucometer and other supplies, and it was taken to R#100's room. LPN CC was observed to clean the glucometer with an alcohol prep pad only and placed it on a paper towel on top of the resident's bed. After the FSBS was performed, the nurse cleaned the glucometer with a Healthcare Bleach Germicidal Wipe only (the machine was not cleaned with alcohol first). Following this observation, LPN CC stated that she had not used the glucometer on any other residents that day prior to performing the FSBS on R#100 and verified that she did not clean the glucometer with a disinfectant wipe prior to doing his FSBS. LPN CC stated during further interview that she assumed that the nurse on the previous shift had cleaned the glucometer properly with a bleach wipe. 2. On 9/18/19 at 11:47 a.m., LPN CC was observed performing a FSBS measurement for R#18 (this was done immediately following the observation on R#100). After the FSBS was done, the nurse was observed to clean the glucometer with a Germicidal Bleach Wipe only (no alcohol was used first). LPN CC was then observed to continue to another resident's room to do their blood sugar. On 9/18/19 at 1:36 p.m., LPN CC was observed to re-check R#18's blood sugar, as the result obtained earlier at 11:47 a.m. was lower than normal for him. LPN CC was observed to clean the glucometer first with a bleach wipe and allowed to air dry for 25 seconds, before wiping the machine with an alcohol wipe. Without changing her gloves used to clean the machine, LPN CC performed the FSBS on R#18, and then gave him an injection of insulin from a [MEDICATION NAME] (labeled with R#18's name) that she had in the basket containing the FSBS supplies. Continued observation revealed that LPN CC then cleaned the glucometer with a disinfectant wipe with the same pair of gloves on, before placing the machine in a clean plastic cup inside the supply basket. Interview with LPN CC at this time revealed that each hall had their own glucometer and FSBS supplies. During interview with the Infection Control Nurse on 9/19/19 at 10:42 a.m., she stated that none of the residents that got FSBSs had a bloodborne illness. 3. On 9/19/19 at 11:29 a.m., Registered Nurse (RN) DD was observed to take the basket with the FSBS supplies to R#34's room. After cleaning the glucometer with an alcohol prep pad, RN DD was observed to place the glucometer directly on top of the resident's overbed table, with no clean barrier underneath. The nurse then cleaned the glucometer with a bleach wipe and again placed it directly on top of the overbed table. After performing R#34's FSBS, RN DD put the glucometer directly on top of the overbed table, cleaned it with an alcohol wipe, and then placed it in the zippered glucometer pouch before going to the next resident's room. 4. Immediately after doing R#34's FSBS, RN DD took the glucometer supplies to R#8's room at 11:39 a.m. After removing the glucometer from the zippered pouch, RN DD cleaned it with an alcohol wipe, and then placed it directly on top of the resident's overbed table, with no clean barrier underneath. The nurse then cleaned the glucometer with a bleach wipe and again placed it on top of the overbed table. After obtaining R#34's FSBS, RN DD placed the glucometer directly on top of the overbed table, removed her gloves, and wrapped the uncleaned glucometer in a clean glove, put it in the zippered pouch, and exited the resident's room. During interview with RN DD immediately following this observation at 11:47 a.m., she stated that she did not clean the glucometer after doing R#8's FSBS, because she had run out of gloves, and that was why she wrapped the machine in the last clean glove. She verified that she put the glucometer directly on an unclean surface for both R#34 and R#8, and that she should have put a clean paper towel underneath the machine. During interview with the Director of Health Services (DHS) on 9/19/19 at 1:55 p.m., she stated that she would expect for staff to clean the glucometer before and after each use with alcohol and bleach. She further stated that the glucometer should be placed on a clean barrier, and that gloves should be changed after cleaning the glucometer and after performing the FSBS. Review of the facility's Diabetes Monitoring: Blood Glucose Equipment & Supplies policy issued (MONTH) 2012 revealed: Accuchecks/glucometers or other blood sugar monitor devices will be cleaned and disinfected in the following manner before and after each patient/resident use. 1. Wash hands. 2. Put on clean gloves. 3. Clean the outside of the glucometer with [MEDICATION NAME] alcohol wipe . 4. Disinfect the meter with a bleach solution wipe . 5. Remove gloves & wash hands after cleaning glucometer. Review of Skills Competency Checklist Form: Blood Glucose Equipment & Supplies revealed competency checkoffs were done with the nurses on 7/11/19 and 9/11/19 to 9/14/19, with a checkoff form seen for RN DD dated 9/14/19. Further review of the checkoff forms revealed that one was not provided for LPN CC. Review of the steps on the checkoff form revealed that it included to clean the glucometer before and after each patient/resident use, and to clean the outside of glucometer with [MEDICATION NAME] alcohol wipe, then disinfect the meter with a bleach solution wipe, remove gloves and wash hands after cleaning glucometer.

Based on observation, record review, resident and staff interviews, the facility failed to provide evidence that deep tissue injury (DTI) to the heels, that were present on readmission from the hospital on [DATE], were assessed or treated for [REDACTED].#2) reviewed for pressure ulcers. Findings include: Review of R#2's electronic health record (EHR) revealed that he had [DIAGNOSES REDACTED]. Review of R#2's Annual Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 10 (a BIMS score of 8 to 12 indicates moderate cognitive impairment), was independent for bed mobility and transfers, was a pressure ulcer risk, and had no unhealed pressure ulcers. Further review of the MDS listing revealed that R#2 had a Discharge MDS on 8/26/19, and an Entry MDS from an acute hospital on [DATE]. Review of R#2's Cognitive Loss/Dementia care plan revealed that he was usually able to communicate needs and understand others but did have problems communicating words and usually spoke in one word phrases or non-verbal communication. Review of R#2's Pressure Injuries care plan with a problem start date of 6/6/18 revealed that it was updated on 9/17/19 to include that he had actual pressure areas to the bilateral heels s/p (status [REDACTED]. Review of R#2's Braden Scale score dated 9/6/19 revealed that he was moderate risk for pressure ulcer development. Review of a Nurse's Note dated 8/30/19 at 3:30 p.m. revealed that R#2 was readmitted to the facility from the hospital, and had [DIAGNOSES REDACTED]. Skin assessment done per writer. Review of R#2's Admission Observation assessment dated [DATE] at 3:30 p.m. revealed: Redness to sacrum area. Resident's right lateral heel and left heel has discoloration. (deep tissue injury). Review of a 24-Hour Report Form dated 8/30/19 revealed that R#2 was readmitted from the hospital and had discoloration to bilateral heels. Review of a Nurse Practitioner's (NP) Post hospitalization Progress Note dated 9/3/19 at 9:21 a.m. revealed that R#2 was admitted to the hospital from 8/26/19 to 8/30/19 for acute hypoxic [MEDICAL CONDITION], [MEDICAL CONDITIONS], interstitial pneumonia, and [MEDICAL CONDITION], and was found to have right [MEDICAL CONDITION] with mets (metastasis). Patient remains unable to get out of bed/stand/ambulate due to deconditioning and weakness. Right sided weakness post old [MEDICAL CONDITION]-but functional, moving bilateral upper extremities. BLE (bilateral lower extremities) without [MEDICAL CONDITION]. Further review of this progress note revealed no mention of the pressure ulcers to R#2's heels. Review of nursing Progress Notes from the date of readmission to the facility on [DATE] through 9/5/19 revealed that there was no mention of a DTI to his heels, that the physician and/or responsible party (RP) were notified of the wounds, and no mention that his heels were being floated on pillows to relieve pressure, nor any mention that heel protectors had been applied. The first notation in the nursing Progress Notes seen that R#2's heels were floated on pillows was dated 9/6/19 at 2:38 a.m. Review of a SBAR (Situation-Background-Appearance-Review and Notify) Communication Form dated 9/5/19 at 5:41 p.m. revealed that R#2's bilateral heels had purple discoloration, which started on 8/30/19, and had gotten worse since it started. The description of the wounds was a purple blister-like areas to bilateral heels. Further review of the SBAR revealed that R#2's NP was notified on 9/5/19 at 2:00 p.m., and the family was notified that day at 5:41 p.m. Review of the Nursing Notes section on the form revealed that R#2 already had on pressure relief boots, the BLE were floated, and orders were received for wound care. Review of a physician's orders [REDACTED].#2's bilateral heels with NS (normal saline), pat dry, apply [MEDICATION NAME] solution, cover with an ABD (abdominal) pad, wrap with Kerlix every Tuesday, Thursday, and Saturday until healed. Review of another physician's orders [REDACTED].#2 every shift, and to float heels on pillows as tolerated. Review of R#2's Treatments Administration History revealed that the treatment to the heels was not documented as done until Saturday 9/7/19. Review of a NP's Progress Note dated 9/12/19 at 2:25 p.m. revealed that R#2 was having bilateral heel pain, was not able to get out of bed without assistance, and the bilateral heels were purplish in color. Review of the Plan section revealed to reduce the risk for further skin breakdown, continue care for heels, offload both heels when patient in bed, and would add [MEDICATION NAME] three times a day to decrease bilateral heel pain. During interview on 9/17/19 at 10:16 a.m., R#2 indicated by nodding that he had been in the hospital recently and pointed to his feet. Observation at this time revealed that he had bilateral heel protectors on, and dressings to both feet could be seen. When asked if he had sores on his heels, R#2 said yes. During interview with the Licensed Practical Nurse (LPN) Skin Integrity Coordinator (SIC) on 9/17/19 at 3:21 p.m., she stated that she did not know why the physician was not contacted and treatment begun to R#2's heels after he was readmitted from the hospital with the DTIs on 8/30/19. She verified that the first mention that the NP was notified of the wounds was on the 9/5/19 SBAR, and that treatment to the heels were not documented on the treatment record as done until 9/7/19. The SIC stated during continued interview that she did wound assessments and measurements as soon as she was made aware of a new wound and then every Monday thereafter, thought she was notified of R#2's wounds on 9/5/19, but did not remember where the measurements of the wounds were. Review of a computerized Weekly Wound Note dated 9/9/19 revealed that the DTI to the right lateral heel measured 3 by 1.7 cm (centimeters), and the DTI to the left lateral heel measured 2.3 by 5 cm. Observation of wound care performed by the SIC and assisted by Certified Nursing Assistant (CNA) AA on 9/18/19 at 1:51 p.m. revealed that the skin to R#2's right lateral heel was dark purple, and measured by the SIC at 2.6 by 3.0 cm. Further observation revealed the left lateral heel was measured as 3.7 by 5.0 cm, with a dark purple discoloration. During interview with the SIC after the wound care observation, she verified that she could not find any other documentation other than what was in the 8/30/19 Admission Observation note of the resident having a DTI until 9/5/19. During interview with LPN BB on 9/19/19 at 1:41 p.m., she verified that she readmitted R#2 back from the hospital in (MONTH) and did his Admission Observation. She further stated that R#2 had discoloration to both of his heels, but that she did not notify the physician or begin any treatment, other than she floated his heels. LPN BB stated during continued interview that the Treatment Nurse usually came in the day after an admission and did skin assessments on all new admissions and readmissions. She stated that she noted on the 24-Hour Report that R#2 had returned from the hospital, and that he had discoloration to his heels. During interview with the Director of Health Services (DHS) on 9/19/19 at 1:48 p.m., she stated that all Department Heads looked at the 24-Hour Report, and they discussed items on the form in the morning meetings. She stated during continued interview that if a resident had a new wound, the physician and RP should be notified right away, and treatment begun by the charge nurse until the treatment nurse could assess the resident. The DHS stated that R#2 returned from the hospital 8/30/19, which was a Friday, but the Treatment Nurse should check the 24-Hour Report on the following Monday for any new wounds. She further stated that the charge nurses could notify the Treatment Nurse of any skin issues either by notation on the 24-Hour Report, verbally, or by putting a note in the SIC's box, but notification did not have to be done on both the 24-hour report and SIC box. The DHS stated during continued interview that wounds should be assessed during treatments, and documentation including measurements, description, changes in the wound, and interventions made at least weekly. She stated that the Treatment Nurse should do the initial skin assessment and/or readmission skin assessment within 24 hours (or on Monday for a late Friday or weekend admission). On 9/19/19 at 1:55 p.m., the DHS provided Documentation of Wound Observation and Assessment Forms dated 9/5/19 with the of the assessment of R#2's heels which revealed: DTI to left lateral heel, unstageable, 2.2 by 5 cm in size, with intact dry skin and pain. The right lateral heel assessment noted the wound to be an unstageable DTI, measuring 2.8 by 1.7 cm, with intact dry skin and no pain. Review of the narrative description of the wounds on the Documentation of Wound Observation and Assessment Form revealed that the SIC was notified on 9/5/19 of areas to R#2's bilateral heels that were present upon hospital readmission. Further review of the form revealed that she removed a dressing from the bilateral heels, and to the right lateral heel she noted a SDTI (suspected DTI), with deep discoloration to the skin. She noted that the left heel also had a SDTI, and that the area was discolored with approximately 0.1 cm of redness to the surrounding area. Review of the facility's Wound Assessment policy dated 11/11/16 revealed: A thorough wound assessment should consist of objective criteria and measurements that promote accurate, consistent comparisons to determine the extent of the wound and the effectiveness of wound healing.

Based on observation, record review, review of the facility policy titled Care Plans, and staff interview, the facility failed to develop a comprehensive care plan to address antipsychotic and antidepressant medication for one resident (R) (#58) of five residents reviewed for unnecessary medications. Findings include: Review of the clinical record revealed R#58 was readmitted to the facility on [DATE] and has a [DIAGNOSES REDACTED]. Review of the (MONTH) 2019 Physician Orders revealed an order dated 6/27/19 for [MEDICATION NAME] (antidepressant medication) 5 milligrams (mg) daily and an order dated 6/26/19 for aripiprazole (antipsychotic medication) 10 mg daily. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#58 received antipsychotic and antidepressant medication for seven days of the look back period. The care plan for R#58 last revised on 9/12/19 did not address the residents use of [MEDICAL CONDITION] medications. During an interview on 9/19/19 at 10:45 a.m., the Registered Nurse (RN) Case Mix Director confirmed that a care plan to address the use of an antipsychotic and antidepressant medication had not been developed for R#58. RN stated that a care plan for an antipsychotic and antidepressant with interventions to monitor possible side effects should be developed for any resident who receives these medications. She stated that this was an oversight on her part. Observations on 9/17/19 at 1:30 p.m., 9/18/19 at 8:50 a.m., and 9/19/19 at 8:51 a.m. revealed R#58 in her room, sitting on the bed and exhibiting no behaviors. A review of the facility policy titled Care Plans reviewed 10/28/18 documented under Care Plan Review and Update: 1. Comprehensive care plans should be reviewed not less than quarterly according to the OBRA MDS schedule, following the completion of the assessment. Care plan updates/reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay

Based on record review, staff interview and facility policy, the facility failed to notify the physician of an abnormal x-ray result for one resident (R) (R#76). The sample size was 36 residents. Findings Include: Review of the Admission Record dated 6/1/2017 revealed that the resident had the following diagnoses,but not limited to [MEDICAL CONDITIONS], hypertension, diabetes, pneumonia, [MEDICAL CONDITION], dementia, depression, [MEDICAL CONDITIONS] reflux disease, [MEDICAL CONDITIONS], left sided [MEDICAL CONDITION]. Review of the medical record Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated 4/2/2018, revealed that at 12:15 p.m. the resident was observed lying on the floor in his room. The resident was assessed and no visible injuries were noted and that the resident was able to move all of his body parts without any complaints of pain. Further review revealed that at 2:30 p.m. R #76 was complaining of not being able to move his left leg. The nurse attempted to move R #76's leg causing him to yell out in pain. At 3:20 p.m. the facility Nurse Practitioner (NP) was notified and gave the order to obtain an x-ray of the resident's left knee and hip. Review of the mobile X-ray company's report dated 4/2/2018 for R #76 revealed finding that the resident had an acute left intertrochanteric fracture. Joint alignment unremarkable. The word Alert was stamped on the x-ray results. Further review of the document revealed that the facility received the fax on 4/2/2018 at 5:26 p.m. with a handwriten note that stated reviewed with NP 4/5/2018. An interview on 6/05/18 at 4:10p.m. with NP revealed that she was informed of R#76's fall on 4/2/2018 and ordered an x-ray of the left knee and hip. The NP stated that she didn't receive the results of the x-ray until 4/5/18 and gave the order to send R # 76 to the hospital. An interview on 6/5/18 at 4:55 p.m. with the Director of Health Services (DHS) confirmed that the left knee and hip x-ray results for R #76 were faxed and received at the facility on 4/2/18 at 5:26 p.m. The DHS confirmed that the results were not given to the Nurse Practitioner (NP) until 4/5/18. During an interview on 6/7/18 at 8:28 a.m. the DHS stated that the x-ray results were faxed to the physician's office on 4/2/18 and that the charge nurse at the facility had incorrectly read the x-ray results as normal. She stated that it is her expectation staff notify the physician of abnormal test results within two hours of receiving the abnormal test results. The Director of Health Service provided a Lippincott Procedures -SBAR Communication printout on 6-8-2018 at 4:00 p.m. as the facility policy for notification of change to a physician, although it did not contain the facility policy for reporting a notification of change to a resident's physician.