Every finding on record at Quitman County Health & Rehab LLC

Based on observation, record review, resident and staff interview, and facility policy review, the facility failed to ensure a resident was transported safely and that appropriate safety devices were used to prevent an accident for one (1) of two (2) resident reviewed for accidents, Resident #11. Resident #11 was transported in a wheelchair that was not secured with a wheelchair restraint/securement system, resulting in the resident rolling backward out of the van when the lift gate was lowered, striking his head on the ramp and sustaining a laceration on his arm and head that required emergency-room evaluation.Findings Include:Review of the facility policy titled Safety and Supervision of Residents revealed Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Record review of Emergency Physician Record dated 7/13/26 revealed Chief Complaint: Fall under context: Presents to emergency department (ED) with complaint of (c/o) headache (HA) and left (LT) elbow injury that started after being dropped in his wheelchair (w/c) during a transfer. Under Clinical Impression: Head contusion and left arm contusion. Under Subjective/Objective Assessment: Patient sent from the nursing home with c/o fall from w/c with head injury and skin tear to left elbow and small laceration to posterior head .During an interview on 7/28/2026 at 1:42 PM, Resident #11 revealed he fell out of the van upon returning from dialysis. He stated his wheelchair was backed up to the lift gate and Certified Nursing Assistant (CNA) #1 lowered the gate and began walking toward the front of the van. Resident #11 stated, I rolled out backward; I hit my head hard on the ramp and got a cut on my arm. He further stated he was taken to the emergency room and did not return to the facility until approximately 9:30 PM later that night.During an interview on 7/28/2026 at 1:50 PM, the Administrator revealed she had reviewed camera footage of the incident and observed CNA #1 turn her back after lowering the lift gate, at which time Resident #11 fell backward out of the van. During an interview and observation on 7/28/2026 at 3:05 PM, CNA #1 revealed she was transportation staff and recalled transporting Resident #11 after his dialysis appointment. She stated she had already picked up another resident whose wheelchair was secured in the van and decided to also pick up Resident #11 because she knew he was finishing dialysis and did not want him to wait. She revealed, I'm going to be honest with you, even if it gets me in trouble, and further stated, he was wedged against the gate lift in the back of the van, and his wheelchair was not secured with a safety buckle. CNA #1 revealed she didn't think he could go anywhere because he was wedged in but apparently when she put the lift gate down, he rolled out because he was not secured. An observation of the transportation van revealed a minivan with two bucket seats and two safety harness buckles on the floor in between the seats. No wheelchair securement buckle was observed for a second wheelchair.During an interview on 7/29/2026 at 8:28 AM, the Housekeeping Supervisor revealed he was responsible for the upkeep of the facility vehicles. He confirmed the transportation van was designed to transport one wheelchair, although additional securement could be installed for a second wheelchair. He confirmed Resident #11 was not properly secured during transport and stated, I can see how when CNA #1 let the gate down and then turned her back it would be easy for the resident to come out.Record review of the admission Record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses that included Chronic Kidney Disease, Stage 4, and Hemiplegia, unspecified affecting left nondominant side. Record review of Resident #11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of May 6, 2026 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident is cognitively intact.

Based on record review, policy review, and interview, the facility failed to ensure its Quality Assessment and Assurance (QAA) Committee met at least quarterly for two (2) of four (4) quarters reviewed.Findings include:Review of facility policy titled Quality Assurance and Performance Improvement (QAPI) - Role of the QAPI Coordinator undated revealed, Duties and responsibilities to the QAPI Program includes.2. Meeting with the QAPI Committee monthly to review assessment tools, data reports, and QAPI activities carried out by departments, services, or committees.Review of facility's Quality Assurance and Performance Improvement (QAPI) Meeting Signature Pages revealed a meeting was held on 1/20/2026 and 6/19/2026.During an interview on 7/30/2026 at 2:00 PM, the Administrator confirmed the committee met only on 01/20/2026 and 06/19/2026 and that no other QAA Committee meetings were held or scheduled over the past 12 months. She stated, That's all I have. It's all I could find. She further confirmed that she was aware the meetings should be held at least quarterly and that they had failed to do that.

Based on facility policy review, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected a resident's Pre-admission Screening and Resident Review (PASRR) status for one (1) of 14 residents reviewed for resident assessments. Resident #20.Findings include:Review of facility policy titled Resident Assessment Instrument revised 9/2010 revealed, .3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning.Record review of Resident #20's Level II PASRR, completed 10/7/2025, revealed the State's PASRR determination indicated Resident #20 met the criteria for having a serious mental illness as defined by PASRR. The Level II PASRR identified an Axis I primary diagnosis of schizophrenia.Record review of Resident #20's Comprehensive admission MDS assessment with an Assessment Reference Date (ARD) of 10/16/2025, revealed Section A1500, PASRR, was coded 0, indicating the resident was not considered by the State Level II PASRR process to have serious mental illness, intellectual disability, or a related condition.Record review of Resident #20's Significant Change in Status MDS assessment with an ARD of 11/14/2025, revealed Section A1500 was again coded 0, indicating the resident was not considered by the State Level II PASRR process to have serious mental illness, intellectual disability, or a related condition.During an interview on 7/29/2026 at 1:45 PM, the Nurse Consultant confirmed Section A1500 was inaccurately coded on both MDS assessments. She stated accurate assessments were important to ensure the assessments reflected residents' needs and that residents received the care and services they required.Record review of the admission Record indicated Resident #20 was admitted to the facility on [DATE] with medical diagnoses that included (Idiopathic) Normal Pressure Hydrocephalus and Schizoaffective Disorder. Review of the MDS, with an ARD of 11/14/2025, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 9, indicating Resident #20 had moderate cognitive impairment.

Based on record review and staff interview, the facility failed to coordinate Resident #20's assessments with the State Level II Pre-admission Screening and Resident Review (PASRR) process. The facility failed to incorporate the PASRR recommendations for psychiatric medication evaluation and monitoring, individual therapy, and psychosocial rehabilitation for one (1) of 14 residents sampled. Resident #20Findings include:Review of a statement on facility letterhead dated 7/30/26 and signed by the Administrator revealed, We do not have a policy on Behavior Health/Mental Health.Review of Level II PASRR completed on 10/7/2025 revealed the Department of Mental Health sent a PASRR notice of nursing facility approval stating Resident #20 was appropriate for nursing home level of care. The notice indicated Resident #20 met criteria for having a diagnosis of mental illness as defined by PASRR, with an Axis I primary: Schizophrenia. The notice goes on to report that Resident #20 would benefit from the specialized services of: Medication evaluation and monitoring by a psychiatrist to evaluate response to psychotropic medications on target symptoms and modify orders, for management of his mental illness; Individual therapy services to develop coping skills to better manage his symptoms of delusions, paranoia, agitation, and refusing care; and to provide an appropriate outlet to express his feelings and emotions; Psychosocial rehabilitation to support and restore community functioning and well-being to promote recovery in the community and to incorporate independent community living due to a discharge anticipated. Recommendations for Placement Needs Specialized Services: Psychosocial Rehabilitation Medication Evaluation and Monitoring Individual Therapy.Record review of a Social Services note dated 11/11/25, documented, Referral emailed to (Proper name of company providing psychiatric services).During an interview on 7/29/26 at 3:45 PM, the Registered Nurse (RN) Nurse Consultant stated that the facility contacted (Proper Name) Health Services, the company used by the facility to provide psychiatric services, and they had no record that Resident #20 had received a psychiatric evaluation or treatment from them. The clinical record similarly contained no evidence that a psychiatric provider evaluated or treated Resident #20 following his 10/9/25 admission.Record review of Resident #20's Psychotropic Evaluation dated 7/21/26, revealed, .Resident is feeling or appearing down, depressed or hopeless >/= (less than or equal to) two weeks.Resident will cry at times but usually easily redirected. Usually happy when out of his room. Family and/or staff believe that depression is consistently contributing to impaired quality of life.Review of the admission Record indicated Resident #20 was admitted to the facility on [DATE] with medical diagnoses that included (Idiopathic) Normal Pressure Hydrocephalus and Schizoaffective Disorder. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/14/2025, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 9, indicating Resident #20 had moderate cognitive impairment.

Based on observation, record review, and staff interview, the facility failed to notify the State Mental Health Authority of a significant change in a resident's mental condition following inpatient psychiatric admissions for one (1) of two (2) Preadmission Screening and Resident Review (PASRR) reviewed, Resident #45. Findings Include:The facility provided a statement on letterhead that read, We do not have a policy on PASSR (pre-admission screening and resident review) change in status request.An observation of Resident #45 on 7/30/26 at 1:04 PM revealed he was sitting in his wheelchair outside his room. The resident was alert to name and displayed facial frowning and a blunt affect.Record review of the admission Record revealed the facility admitted Resident #45 on 9/30/24 with medical diagnoses that included Schizoaffective Disorder, Catatonic Schizophrenia, Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder.Record review of Resident #45's Pre-admission Screening and Resident Review, completed upon admission to the facility, revealed under Level II Outcome Comments, dated 10/3/24, Due to a (suspected or confirmed) level II diagnosis of an Intellectual Disability, an onsite Level II will be initiated. A level II will not be initiated for a serious mental illness (SMI) due to the individual's current orientation and medical condition.Record review of the Department of Mental Health determination letter, dated 10/3/24, revealed, (Resident #45) was referred to the Department of Mental Health for an Intellectual Developmental Disabilities (IDD) level II. (Resident #45) is sixty-one years old, has numerous medical conditions: Anxiety Disorder, Major Depressive Disorder and Catatonic Schizophrenia. Resident #45 is a high risk for institutionalization, extensive medical and personal care needs and may need daily services and supports, he is approved for nursing home placement.Record review of Resident #45's progress notes dated 10/25/25 through 7/30/26 revealed recurring anxiety, paranoia, hallucinations, verbal aggression, threatening statements, physical aggression, resistance to redirection, attention-seeking behaviors, and episodes of intentionally lowering himself to the floor:On 11/11/25, the resident sat in the lobby and called out to staff members as they walked past. He either did not respond when staff spoke to him or stated that he was scared. The resident fidgeted with his hands and displayed pronounced facial grimacing.On 11/13/25, the resident began trembling while walking in the hallway and threw himself toward a nurse. The nurse lowered him to the floor. The resident then got up independently and denied pain or injury.On 11/14/25, the resident appeared anxious, stated that no one wanted to care for him, walked with a shuffling gait, and threw himself onto several employees throughout the day. Staff documented no improvement in his symptoms following an increase in Clonazepam.On 11/18/25, the resident stood in the hallway and refused to move forward or backward. He stated that staff and other residents were trying to kill him, wrung his hands, displayed pronounced facial grimacing, and exhibited periods of catatonia. He denied suicidal or homicidal thoughts but stated that he was afraid of everyone. The resident refused his medication because he was afraid of staff. Later, he grabbed toward a nurse's arm and stated, You could at least help me. The nurse practitioner was notified and ordered a psychiatric consultation. The resident was transferred to Proper name of inpatient behavior facility on 11/18/25 and returned to the facility on [DATE] with an increase in Risperdal to 4 milligrams twice daily.Record review of the proper name of the inpatient Geri-psych facility's History of Present Illness, dated 11/19/25, revealed, Pt (patient) reportedly has been refusing med. Thinks staff/resident there are trying to kill him. Wringing his hands and has deep grimace on face. Threatening other residents.On 12/17/25, the resident was observed crying in bed, fidgeting with his hands, making crying sounds, and displaying pronounced facial grimacing. The resident stated that he did not know what to do and did not know why no one liked him.On 3/3/26, the resident was observed grimacing, whining, fidgeting, and making multiple physical complaints.Record review of Resident #45's Psych Progress Note, dated 3/4/26, revealed, Pleasant and cooperative with assessment. Sleep and appetite Good. Mood okay. Denies negative mood s/sx (signs and symptoms). Pt (patient) is compliant with medications. Staff does not report any behavioral concerns. Further review revealed, Seems to be stable.On 3/5/26, the resident walked throughout the hallway repeatedly stating that no one was paying attention to him and that staff were trying to kill him. Later that morning, the resident stated that no one liked him, people wanted to hurt him, and everyone wanted him to die. He yelled in the hallway, stopped in the middle of the hallway and would not move. The nurse practitioner was notified and ordered a psychiatric consultation. The resident was transferred to Proper name of inpatient behavior facility on 3/5/26 and returned to the facility on 3/17/26.Record review of Resident #45's proper name of inpatient Geri-psych facility History of Present Illness, dated 3/6/26, revealed, He is unsure why he is here. He admits to seeing things. Stuff happening in front of me that ain't there. Also admits to feeling depressed lately. I go off the deep end and get angry sometimes. I can be outside and hear something that ain't there. Not voices, I just hear certain things. I get scared at nighttime.Record review of Resident #45's Nurse Practitioner (NP) Nursing Home Visit, dated 3/24/26, revealed, The patient was seen today. He returned from Geri Psyche on 3/17/26. They increased his Seroquel at night from 600 to 800 mg (milligrams). They decreased his Klonopin to 0.5 mg (milligrams) bid (twice daily).On 3/31/26, the resident experienced an episode of anxiety during which he cried and breathed rapidly.On 4/1/26, the resident stood and urinated on the bedroom floor while staff attempted to redirect him to sit down due to his risk of falling.On 4/2/26, the resident was observed sitting in his doorway, grimacing, wringing his hands, and speaking in a child-like manner.On 4/6/26, the resident hollered at staff, attempted to make himself vomit, stated he could not walk, and remained noncompliant after staff provided him with a wheelchair.On 4/10/26, the resident propelled his wheelchair into the medication cart, hollered at the nurse, and continued the behavior despite redirection. Later that day, the resident hollered from his room and made statements about someone shooting the wrong person and staff not caring about him.On 5/22/26, the resident threatened a staff member by stating, You're stupid. I will knock you out. He then entered the hallway among staff and other residents and stated, All ya'll stupid I'm about to knock somebody out. Another resident reported hearing him state, I'm going to hit that sorry a** b***h. The physician was notified, and the resident was transferred to Proper name of inpatient psychiatric facility on 5/22/26. He returned to the facility on 5/30/26 with a medication change.Record review of Resident #45's proper name of inpatient Geri-psych facility Discharge Summary Report, dated 5/30/26, revealed, He has been showing symptoms of delusion, agitation, and physical aggression. Symptoms were unable to be treated on an outpatient basis which required this Geri-psych admission.On 6/13/26, the resident was observed lying stiff in bed with his arms extended and legs stiff. After getting out of bed, he accused a nurse aide of hitting him, although the nurse documented directly observing that the nurse aide did not hit him. Later that morning, the resident stood in the hallway, began rocking, and lowered himself to the floor. He remained on the floor for several minutes before getting up independently and sitting in a wheelchair. The physician was notified, and staff attempted to locate psychiatric placement.On 7/5/26, the resident stood in the middle of the hallway with his hands clenched into fists and accused a nurse aide of attempting to hit him. He moved to his room after staff redirected him.On 7/7/26, the resident became verbally argumentative and aggressive toward other residents. He grabbed a nurse aide's arm as the nurse aide walked past him. Staff separated the resident from others; however, he continued making inappropriate and confrontational comments despite redirection.On 7/13/26, the resident intentionally lowered himself to the floor, rolled on the floor, and then got up independently without assistance.On 7/15/26, the psychiatric nurse practitioner reported the resident stated he was experiencing hallucinations at night that caused him to feel afraid. The physician was notified, and the resident's Risperdal was increased from 2 milligrams twice daily to 4 milligrams twice daily.Record review of Resident #45's Psych Progress Note, dated 7/15/26, revealed, Resident #45 is sitting in chair in the hallway and declines to go elsewhere for privacy. Pt (patient) is aggravated. He is rambling and speaking in incomplete thoughts, doesn't give direct answers to questions, Staff reports patient had episode of inappropriate behaviors. Pt reports AVH (auditory and visual hallucinations). It's really scared me. I don't know what it is.Overall, the record showed recurring behavioral symptoms from 11/11/25 through 7/15/26, including three transfers for inpatient behavioral-health treatment, continued threatening or aggressive behavior following his returns, repeated accusations that staff intended to harm him, hallucinations, paranoia, and medication adjustments.An interview with Social Services (SS) on 7/30/26 at 1:04 PM revealed Resident #45 displayed frequent behaviors and was routinely seen by psychiatric services at the facility. She confirmed the resident had multiple psychiatric stays and medication adjustments during the past year. SS stated she did not submit a significant change in status to the mental health authority following any of the resident's three inpatient Geri-psych stays. She stated that she did not know she was required to submit the information and stated, I am learning as I go.An interview with the Administrator (ADM) on 7/30/26 at 2:21 PM revealed she was not aware that the facility was required to submit a change in status to the mental health authority when a resident with a mental illness or intellectual disability experienced a significant change. She stated that the corporate nurse informed her of the requirement several months earlier. She confirmed SS was responsible for submitting the information to the mental health authority and stated, She did not know to do it either; she found out the same time I did we were supposed to be doing those. The ADM confirmed the submission was required to ensure Resident #45 received all required services in the appropriate setting.Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/4/26, revealed under Section C a Brief Interview for Mental Status (BIMS) summary score of 10, which indicated Resident #45 was moderately cognitively impaired.

Based on record review, interview, and facility policy review, the facility failed to ensure a prescribed medication was available for timely administration and failed to implement its medication-acquisition process when the medication was unavailable for one (1) of five (5) residents reviewed for medication availability. Resident #20 Findings include:Review of facility policy titled Adverse Consequences and Medication Errors undated revealed, Policy statement: The interdisciplinary team monitors medication usage to prevent and detect medication-related problems. 2. The staff and practitioner strive to minimize adverse consequences by: a. Following relevant clinical guidelines for use, dose, administration of the medication . Record review of Resident #20's May 2026 Medication Administration Record (MAR) revealed an order for Haldol Decanoate 100 mg/mL (milligrams/milliliter), inject 150 mg intramuscularly on the 14th of each month for schizoaffective disorder. On 05/14/2026 at 4:58 PM, nursing documented, MEDICATION NOT IN FACILITY. Further review revealed the scheduled 05/14/2026 dose was never administered. The medical record contained no documented evidence that nursing contacted the pharmacy to obtain the medication, notified the prescribing practitioner of the unavailable and omitted dose, or obtained instructions for administering or rescheduling the missed injection.During an interview on 7/30/2026 at 1:58 PM, the Administrator confirmed Resident #20 did not receive the Haldol Decanoate injection scheduled for 05/14/2026. The Administrator confirmed the medical record contained no evidence that the nurse contacted the pharmacy to obtain the medication or notified the prescribing practitioner that the medication was unavailable and the dose had been omitted. She stated, The nurse should have contacted the pharmacy and notified the physician.Record review of the admission Record indicated Resident #20 was admitted to the facility on [DATE] with medical diagnoses that included (Idiopathic) Normal Pressure Hydrocephalus and Schizoaffective Disorder. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/14/2025, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 9, indicating Resident #20 had moderate cognitive impairment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication error rate was five (5) percent (%) or less for two (2) of 27 medication opportunities. Medication error rate of 7.41%Findings include:The facility provided a document titled Procedure Guideline for Ensuring the Six Rights of Medication Administration, which revealed under, 2. To prevent medication errors, keep in mind the six rights of medication administration each time you prepare to administer a drug; right medication, right dose, right patient, right route, right time, and right documentation. The document further revealed under, 5. Observe the six rights of medication administration: A. right medication: (1) Check the medication label against the MAR (medication administration record) three times:Record review of room [ROOM NUMBER]-B MAR revealed an order dated 7/18/25, Aspirin Oral Tablet 325 MG (milligrams) give 1 (one) tablet via (by) gastrostomy tube (G-tube) one time a day for Cerebrovascular Accident (CVA).During an observation of a medication pass with Licensed Practical Nurse (LPN) #2 on 7/29/26 at 6:21 AM, she removed one acetaminophen (Tylenol) 325-milligram tablet from the medication bottle and crushed it for administration to room [ROOM NUMBER]-B instead of preparing the ordered Aspirin 325-milligram tablet. After entering the resident's room, but before administering the medication, LPN #2 was stopped and informed that she had prepared Tylenol instead of Aspirin. LPN #2 confirmed she had made an error and stated she was nervous and did not read the medication label as she was supposed to. LPN #2 stated that giving Tylenol instead of aspirin would not provide the intended effect for stroke and clot prevention.Record review of room [ROOM NUMBER]-B MAR revealed an order dated 10/18/25, Thiamine HCL (hydrochloride) Oral Tablet 250 MG give 1 tablet by mouth one time a day for alcohol abuse.During a medication pass observation with LPN #1 on 7/29/26 at 8:30 AM, she prepared and administered one 100-milligram thiamine tablet to room [ROOM NUMBER]-B instead of the ordered 250-milligram dose.During an interview on 7/29/26 at 9:30 AM, LPN #1 confirmed she had made an error. After reviewing the physician's order, LPN #1 stated she should have administered two and one-half tablets to equal the ordered 250-milligram dose. LPN #1 stated the resident received thiamine for alcoholism and confirmed that failure to receive the correct dose could result in a low thiamine level and nutritional deficits.During an interview on 7/29/26 at 10:27 AM, the Interim Director of Nursing stated she expected nurses to check the medication and dosage against the order on the MAR three times before administration to prevent medication errors.Record review of the admission Record revealed the facility admitted room [ROOM NUMBER]-B on 10/17/25 with medical diagnoses that included Metabolic Encephalopathy and Alcohol Abuse.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/1/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 14, which indicated room [ROOM NUMBER]-B was cognitively intact.Record review of the admission Record revealed the facility admitted room [ROOM NUMBER]-B on 7/29/21 with medical diagnoses that included Cerebral Infarction, Vascular Dementia, and Gastrostomy Status.Record review of the MDS with an ARD of 5/27/26 revealed under section C, a BIMS summary score of 4, which indicated room [ROOM NUMBER]-B was severely cognitively impaired.

Based on observation, staff and resident interview, record review and facility policy review the facility failed to implement an Activity of Daily Living (ADL) care plan related to removal of facial hair (Resident #3) and nail care (Resident #44) for two (2) of 13 sampled residents. Findings Included: Record review of the facility policy, Care Plans, Comprehensive Person-Centered with revision date of March 2022 revealed, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Resident #3 Record review of Resident #3's Care Plan with a problem onset date of 04/19/2022 revealed .requires assistance with ADLs (Activities of Daily Living) . Approaches . Total assistance x 1 staff for all ADLs (Bed Mobility, Transfers, Locomotion, Dressing, Eating, Toileting, Hygiene, Bathing) . On 08/26/24 at 12:14 PM, an observation of Resident #3 revealed her sitting in her geri chair in the hall and she had scattered white facial hairs above her lip and two white chin hairs which were approximately one (1) inch long. On 08/27/24 at 8:45 AM, an observation of Resident #3 revealed her lying in her bed asleep and she had scattered white facial hairs above her upper lip and two chin hairs which were approximately one (1) inch long. On 08/27/24 at 10:27 AM, an interview with Certified Nursing Assistant (CNA)#1 revealed that Resident #1's scheduled shower days were Monday, Wednesday, and Friday and the CNAs were supposed to take care of facial hair during that time. CNA #1 confirmed that Resident #3 had white facial hair to her upper lip and chin and that her facial hair had not been shaved during her bath the day before. Record review of Resident #3's Admission Record revealed an admitted [DATE] with diagnoses that included Huntington's Disease, Dementia, and Heart Failure. Record review of Resident 3's MDS with an Assessment Reference Date (ARD) of 07/31/2024, Section C revealed a Brief Interview for Mental Status (BIMS) should not be conducted because the resident was rarely or never understood. Section GG - Functional Abilities and Goals revealed Resident #3 was dependent in maintaining personal hygiene. Resident #44 Record review of Resident #44's Care Plan with a problem onset undated, revealed .is at risk for impaired function/Daily ADL abilities and requires assistance to complete Activities of Daily Living (ADLs) .Approaches .Inspect nails daily, clean and cut as needed . An observation on 08/26/24 at 12:17 PM, revealed Resident #44 sitting up in his wheelchair in his room and his fingernails were long, jagged and had a brown substance underneath them. His fingernails were approximately one-half (1/2) to three-fourths (3/4) inch long. Resident #44 revealed that they had not cut his nails in a while and stated, Sometimes I scratch myself. He also confirmed that the staff did not check his nails every day. On 08/27/24 at 10:24 AM, an interview with CNA #1 revealed that they were supposed to provide for resident needs such as nail care and shaving facial hair during their bath or shower time. She confirmed that Resident #44 had long, jagged nails with a brown substance underneath and that his nails should have been addressed yesterday during his shower time. CNA #1 revealed that not doing nail care could cause the resident to scratch himself, it could cause skin tears and possible infection. CNA #1 revealed Resident #44 should have gotten his shower yesterday on the evening shift on 08/26/24 and she agreed that Resident #44 had not received nail care and stated that it did not look like his nails had been cleaned or clipped. On 08/27/24 at 10:30 AM, an observation and interview with Registered Nurse (RN) Supervisor, confirmed that Resident #44's fingernails were long and jagged. She also confirmed the brown substance under his nails. The RN Supervisor revealed that personal hygiene included nail care, grooming, and facial hair and the CNAs were supposed take care of these needs during their baths or showers. The RN Supervisor revealed that long, jagged, and dirty fingernails could cause skin tears, abrasions, and she agreed that it could cause infection if nails were not cared for properly. She also agreed that Resident #44's nails were not clipped nor cleaned during his shower he received the day before and stated, I will get someone on this now. On 08/27/24 at 10:40 AM, an interview with Administrator (ADM) revealed that personal hygiene included mouth care, nail care, and shaving facial hair on men and ladies. She revealed that during resident showers, it was the CNAs responsibility to check the fingernails and to take care of facial hair. She revealed that the CNAs were supposed to check the residents from head to toe while they had them in the shower and take care of any concerns which included fingernails and facial hair. She revealed that they were also supposed to report any other concerns to the nurse. The ADM confirmed Resident #3 and Resident #44's ADL Care Plan was not followed related to nail care and removal of facial hair. On 08/27/24 at 2:52 PM, an interview with Minimum Data Set (MDS) Coordinator revealed that the purpose of the comprehensive care plan was to ensure continuity of care for the residents. She confirmed that Resident #3's ADL care plan was not implemented related to her personal hygiene needs which included removal of facial hair. She also agreed that Resident #44's Care Plan was not followed when the staff failed to clean and clip his fingernails. Record review of Resident #44's Admission Record revealed an initial admitted [DATE] with diagnoses that included Cerebral Infarction, Dysphagia and Chronic Systolic Heart Failure. Record review of Resident #44's Physician Orders revealed an order with start date of 07/01/2024, to inspect nails daily, clean, and cut as needed. Record review of Resident #44's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/26/2024. Section C - Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) Score of 07 which indicated Resident #44 had severe cognitive deficits. Section GG- Functional Abilities and Goals revealed that he was dependent on staff to maintain personal hygiene.

Based on staff and resident interviews, record reviews, and facility policy review the facility failed to verify the documented advance directives signed by the Resident Representative (RR) were the preferences of a cognitively intact resident for one (1) of 16 Advance Directives reviewed. Resident #148. Findings Included: Review of the facility policy, titled Advanced Directives, revealed .Policy Interpretation and Implementation 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate and advance directive if he or she chooses to do so .4. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above, even if his or her legal representative has already been given the information . Record review of the Order Summary Report with active orders as of [DATE] revealed an order dated [DATE] Code Status; DNR (Do Not Resuscitate) EFF(effective) 081424. An additional order dated ,d+[DATE] revealed DNR. Record review of a Nurse Note dated [DATE] at 6:19 PM revealed .States that she is not a DNR . Record review of the Resident/Representative Consent for Cardiopulmonary Resuscitation (CPR) form, dated [DATE], indicated the RR, rather than the resident herself, had signed the document upon admission. The form contained a statement that read, I understand that CPR constitutes an extraordinary measure and SHOULD NOT be done on this resident . Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #148 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. During an interview on [DATE] at 11:30 AM, Social Services stated that the Resident/Representative Consent for CPR was signed by the resident's representative at the time of admission and not by the resident. She admitted that she did not discuss CPR with Resident #148 upon admission. Considering Resident #148's BIMS score of 15, which demonstrates cognitive intactness, she agreed that she should have followed up with the resident directly to verify her preferences regarding CPR. In an interview with Resident #148 on [DATE] at 12:10 PM, the resident confirmed that no one had discussed CPR with her or asked for her wishes regarding resuscitation. She expressed that depending on the circumstances, she might want CPR performed. A review of the Admission Record revealed that Resident #148 was admitted to the facility on [DATE] with diagnoses that included Unspecified dementia.

Based on observation, staff and resident interview, record review and facility policy review the facility failed to provide Activity of Daily Living (ADL) care related to removal of facial hair (Resident #3) and nail care (Resident #44) for two (2) of 13 sampled residents. Findings Included: Record review of the facility policy titled Activities of Daily Living (ADL)s with revision date of March 2018, revealed Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Resident #3 An observation on 08/26/24 at 12:14 PM, revealed Resident #3 sitting in her geri chair in the hall and she had scattered white facial hairs above her upper lip and two white chin hairs that were approximately one (1) inch long. An observation on 08/27/24 at 8:45 AM, revealed Resident #3 lying in her room asleep. She had scattered white facial hairs above her upper lip and two chin hairs that were approximately 1 inch long. During an interview on 08/27/24 at 10:27 AM, Certified Nursing Assistant (CNA) #1 revealed that Resident #3's scheduled shower days were Mondays, Wednesdays, and Fridays. She confirmed that Resident #3 had white facial hair on her upper lip and chin and she revealed that her facial hair should have been shaved during her bath the day before. CNA #1 confirmed that her facial hair had not been taken care of. Record review of Resident #3's Admission Record revealed that she admitted to the facility on [DATE] with diagnoses that included Huntington's Disease, Dementia, and Heart Failure. Record review of Resident 3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/31/2024, Section C revealed a Brief Interview for Mental Status (BIMS) should not be conducted because the resident was rarely or never understood. Section GG - Functional Abilities and Goals revealed Resident #3 was dependent in maintaining personal hygiene. Resident #44 During an observation on 08/26/24 at 12:17 PM, revealed Resident #44 sitting up in his wheelchair in his room and his fingernails were long, jagged and had a brown substance underneath them. His fingernails were approximately one-half to three-fourths inch long. Resident #44 revealed that they had not cut his nails in a while and stated, Sometimes I scratch myself. He also confirmed that the staff did not check his nails every day. During an interview on 08/27/24 at 10:24 AM, CNA #1 revealed that they were supposed to provide for the resident's needs such as nail care and shaving facial hair during their bath or shower time. She confirmed Resident #44 had long, jagged nails with brown substance underneath and that his nails should have been addressed yesterday during his shower time. CNA #1 revealed that by not doing nail care could cause the resident to scratch himself, it could cause skin tears and possible infection. CNA #1 revealed that Resident #44 should have gotten his shower yesterday on the evening shift on 08/26/24 and stated that it did not look like his nails had been cleaned or clipped. On 08/27/24 at 10:30 AM, during an observation and interview with the Registered Nurse (RN) Supervisor, confirmed that Resident #44's fingernails were long, jagged and had brown substance underneath. The RN Supervisor revealed that personal hygiene included nail care, grooming, and facial hair and that the CNAs were supposed take care of these needs during their baths or showers. The RN Supervisor revealed that long, jagged, and dirty fingernails could cause skin tears, abrasions, and she agreed that it could cause infection if nails were not cared for properly. She also agreed that Resident #44's nails were not clipped nor cleaned during his shower he received the day before and stated, I will get someone on this now. During an interview on 08/27/24 at 10:40 AM, the Administrator (ADM) revealed that personal hygiene included nail care and shaving facial hair on men and ladies. She revealed that during resident showers, it was the CNAs responsibility to check the residents from head to toe and to take care of any issues that included fingernails and facial hair. Record review of Resident #44's Admission Record revealed an initial admitted [DATE] with diagnoses that included Cerebral Infarction, Dysphagia, and Chronic Systolic Heart Failure. Record review of Resident #44's Physician Orders revealed an order with start date of 07/01/2024, to inspect nails daily, clean, and cut as needed. Record review of Resident #44's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/26/2024. Section C - Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) Score of 07 which indicated Resident #44 had severe cognitive deficits. Section GG- Functional Abilities and Goals revealed that he was dependent on staff to maintain personal hygiene.

Based on record review, staff interview and facility policy review the facility failed to ensure kitchen sanitation was maintained in a manner that meets professional standards for 44 of 49 residents whose meals are prepared in the kitchen. Findings include: Review of the facility policy titled Machine Warewashing, with a revision date of 6/14, revealed, .Procedure .3. The dishmachine operator documents the machine temperature and concentration of the sanitizing solution for warewashing after each meal on the Dishmachine Temperature/Chemical Log . Review of the facility policy titled, Manual Warewashing, with a revision date of 10/17, revealed, .Procedure . 6. The concentration of the sanitizing solution is checked with an appropriate test kit when the sink is filled .9. The employee using the three compartment sink documents temperature and concentration. A record review of the July Dish Machine and Pot/Pan Sink form revealed that there was no documentation of temperatures or chemical sanitation levels for the low temperature dish machine or the pot/pan sink from 7/1/23 through 7/10/23. During an interview with the Dietary Manager on 7/11/23 at 9:15 AM, she confirmed there were no documented temperatures or chemical sanitation levels for the low temperature dish machine or pot/pan sink from 7/1/23 through 7/10/23. She stated that she was off during that time and did not realize it was not done. The Dietary Manager stated that the tray aids and cooks were responsible for checking and documenting the temperatures and chemical sanitation levels; and that the cooks were responsible for making sure that it was completed when she was out. She verified that the temperatures and chemical sanitation levels should have been checked and documented. During an interview with Tray Aide #1 and Tray Aide #2 on 7/11/23 at 1:20 PM, they both confirmed that they did not check temperature or chemical sanitation levels for the dish machine or pot/pan sink while the Dietary Manager was out. During an interview with the cook on 7/11/23 at 1:22 PM, revealed he had checked some of the temperatures and chemical sanitation levels for the dish machine and pot/pan sink, but he did not document them. He stated that he should have documented the temperatures and chemical sanitation levels. The cook stated that if the temperatures and chemical sanitation levels for the dish machine and pot/pan sink are not checked then you cannot be sure the dishes are clean, and this can lead to foodborne illness for the residents. During an interview with the Administrator on 7/11/23 at 3:30 PM, she confirmed that the kitchen staff should have documented temperature and chemical sanitation levels for the dish machine and pot/pan sink. The Administrator stated that failure to ensure temperatures and chemical sanitation levels are adequately maintained could lead to resident illness.

Based on observation, staff interview, record review and facility policy review the facility failed to discard out of date Influenza vaccines and failed to secure injectable Lorazepam in a locked secured box in the refrigerator for (1) one of (1) one medication storage room. Findings include: Review of the facility policy titled, Storage of Medications with a revised date of April 2007, revealed, Policy Statement The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .Policy Interpretation and Implementation .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secured location . An observation on 07/12/23 at 03:50 PM, with Licensed Practical Nurse (LPN) #2 revealed 10 Fluzone single dose vaccines with an expiration date of 5/20/23, 11 single dose flu vaccines with an expiration date of 5/11/22, one (1) multidose five (5) milliliter (ml) vial out of date on 1/27/22, and four (4) five (5) ml vials of Flu vaccine out of date on 6/30/23. The observation also revealed nine (9) vials of Lorazepam 2mg(milligram)/ml (millimeter) in a locked drawer in the medication room in plastic box sealed with a zip tie. The Lorazepam vial label revealed to refrigerate. The vials were not refrigerated. The refrigerator did not have a secured lock box inside for the storage of control medications requiring refrigeration. LPN #2 confirmed these findings. An interview, concerning the out-of-date flu vaccines, on 7/12/23 at 3:53 PM with LPN #2 revealed if out of date medications are used, they may not be giving the most effective dose to the resident. LPN #2 confirmed the Lorazepam vials indicated to refrigerate. She stated they have always kept them in this locked drawer. An interview on 7/12/23 at 4:10 PM, with the Administrator (ADM) revealed Ativan (Lorazepam)should be in the refrigerator to maintain its potency. She confirmed the vials are labeled to refrigerate. The ADM confirmed the vials were in a plastic container with other medications sealed with a zip tie and in a locked drawer in the medication room that could easily be taken. She stated the Lorazepam should be in a locked box secured inside the refrigerator. She confirmed the refrigerator did not have a secured box, but they would get one. An interview on 07/13/23 at 10:20 AM, with the Director of Nursing (DON) confirmed the flu vaccines were out of date and should have been removed from the refrigerator. She stated that the Lorazepam should be in the refrigerator in a secured locked box. An interview on 07/13/23 at 10:29 AM, with Licensed Practical Nurse (LPN) #3 concerning flu vaccines revealed that she was responsible for them and should have discarded them. She stated that none of the out-of-date vaccines had been given to a resident. A telephone interview on 7/13/23 at 12:58 PM, with the facility Consultant Pharmacist revealed he was in the facility during the survey. He confirmed they probably should have caught the out-of-date flu vaccine in the refrigerator. He stated the resident could be at risk for not receiving an effective dose if an out-of-date vaccine was given. The Consultant Pharmacist stated that ideally Lorazepam should be stored in the refrigerator and the facility should have a secured lock box in the refrigerator. Review of the inpatient influenza vaccination record revealed the last influenza vaccine given was on 2/3/23 from a vial with an expiration date of 6/30/23.

Based on observation, staff interview, record review and facility policy review the facility failed to implement the care plan for impaired respiratory function for (1) one of 16 resident care plans reviewed. Resident #10 Findings include: A review of the facility policy titled, Care plans, Comprehensive Person-Centered, revised December 2016 revealed, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Policy Interpretation and Implementation . 8. The comprehensive, person-centered care plan will: b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . An observation of Resident #10 on 7/11/23 at 11:39 AM, revealed resident receiving oxygen (O2) via nasal canula and the O2 tubing and humidifier bottle with no date. A record review of the care plan for Resident #10 with a problem onset date of 3/22/22, revealed (Proper name of Resident #10) is at risk for impaired respiratory function r/t (related to) Chronic Pulmonary Edema .Approaches .Change O2 tubing and Aquapack Q (every) Monday . During an observation and interview with Licensed Practical Nurse (LPN)#1 on 7/12/23 at 8:30 AM, she confirmed there was not a date on the oxygen tubing or humidifier bottle and revealed it should be changed weekly. LPN #1 then confirmed she was uncertain of the last time the tubing and humidifier bottle was changed because there was no label or date of when it was last changed. An interview and record review of the comprehensive care plan with the Director of Nursing (DON) on 7/12/23 at 9:00 AM, confirmed staff were not following Resident #10's plan of care for oxygen therapy and revealed the purpose of the care plan is to direct the staff of the resident's specific care needed. Record review of the Face Sheet revealed that the facility admitted Resident #10 to the facility on [DATE] with diagnoses of Persistent Vegetative State and Chronic Pulmonary Edema.

Based on observation, staff interview, and record review the facility failed to sign out controlled medications prior to administration to a resident for (1) one of (6) six residents reviewed during medication pass. Resident #29. Findings include: An observation, on 7/12/23 at 9:20 AM revealed Licensed Practical Nurse (LPN) #1 set up medications for Resident #29. The medications included Lacosamide, Xanax, and Norco. LPN #1 did not sign out the controlled medications prior to administering them. An interview on 7/12/23 at 9:25 AM, with LPN #1 revealed that she really did not know when she was supposed to sign them (controlled medications) out. She stated that she does it after she gives them in case the resident does not take it. An interview on 07/13/23 at 08:30 AM, with the Director of Nursing (DON) revealed that all controlled medications should be signed out when the nurse punches it out. If the nurse waits to sign out controlled medications, she could forget to do it and the count would be wrong or could lead to drug diversion. Record review of the July 2023 Physician Orders for Resident #29 dated revealed orders for Xanax 0.5 mg tablet 1 (one) PO (by mouth) BID (two (2) times a day) for anxiety, Lacosamide 150 mg tablet 1 PO BID for convulsions, and Norco 7.5-325 tablet 1 PO BID for pain. Record review of the facility Face Sheet for Resident #29 revealed an admitted [DATE] with diagnosis that included Chronic Obstructive Pulmonary Disease, Heart Failure, generalized Anxiety Disorder, and Unspecified Convulsions.

Based on observation, staff interview, record review, and facility policy review the facility failed to label and date oxygen tubing and a humidifier bottle (Aquapack) for (1) one of (7) seven residents receiving oxygen therapy. Resident #10. Findings include: A review of the facility policy titled, Oxygen Administration, with a revised date of October 2022, revealed Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration .Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure .6. Label oxygen supplies (tubing, mask. Etc.) with date and initial. Supplies should be changed at least weekly while in use . On 7/11/23 at 11:39 AM, an observation of Resident #10 revealed the resident was receiving oxygen (O2) per nasal canula and the oxygen tubing and humidifier bottle were not dated. An observation of Resident #10's O2 tubing and humidifier bottle with Licensed Practical Nurse (LPN) #1 on 7/12/23 at 8:30 AM, confirmed there was not a date on the oxygen tubing or humidifier bottle. State Agency asked how often should the O2 tubing, and humidifier bottle should be changed, and LPN #1 revealed weekly on Mondays. LPN #1 stated she was uncertain of the last time the tubing and humidifier bottle was changed because there was label or date of when it was last changed. LPN #1 confirmed when the tubing is changed it should be dated and revealed concerns from not changing the tubing and humidifier bottle as ordered is dust build up on tubing, increased risk for infection, and giving the resident non humidified oxygen causing sores or dry nostrils. An interview with the Director of Nursing (DON) on 7/12/23 at 9:00 AM, revealed that oxygen tubing and humidifier bottle should be changed weekly and initialed and dated. The DON confirmed if the tubing and humidifier bottle was not dated there was no way to be certain of when it was last changed and confirmed concerns of not changing the tubing as ordered is increased risk of infections. A record review of Resident #10's Physician Orders for July 2023, revealed an order dated 1/24/19 for O2 at 3 L/MIN (liters per minute) continuously Chronic Pulmonary Edema and an order dated 4/24/23, Change O2 tubing and AquaPack Q (every) Monday. Record review of the Face Sheet revealed the facility admitted Resident #10 to the facility on [DATE] with diagnoses including Persistent Vegetative State and Chronic Pulmonary Edema.

Based on observations, staff interviews, and facility policy review the facility failed to perform hand hygiene upon removing gloves, failed to dispose of a pill after it fell on the medication cart, and failed to use a barrier when administering eye drops for (2) two of (6) six residents reviewed during medication pass. Resident #15 and #29. Findings include: Review of the facility policy titled, Handwashing/Hand Hygiene, revised 2015, revealed, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: .m. After removing gloves . Review of the facility policy titled, Installation of Eye Drops, undated, revealed, Purpose The purpose of this procedure is to provide guidelines for installation of eye drops to treat medical conditions, eye infections and dry eyes. After the eye drops are administered, the steps in the procedure include remove gloves and discard into designated container. Wash and dry your hands thoroughly. Clean your equipment and return it to its designated area. An observation during medication pass on 7/12/23 at 8:30 AM, with Licensed Practical Nurse (LPN) #1, revealed during the administration of the Artificial Tears eye drops LPN #1 placed the eye drop box and the eye drop bottle top on the overbed table without a barrier and without disinfecting the table. LPN #1 donned gloves to administer the eye drops. She removed her gloves after administering the eye drops and did not wash her hands before administering the remainder of the residents' medications. LPN #1 exited the resident room and placed the contaminated eye drops in the medication cart drawer. An observation on 7/12/23 at 8:40 AM, with LPN #1 revealed LPN #1 dropped a Folic Acid 1 milligram tablet on the top of the medication cart and picked it up and administered it to Resident #29. An interview on 7/12/23 at 1:30 PM, with LPN #1 confirmed that she did drop a pill on the top of the medication cart during medication pass. She stated that she should have discarded it and got another one because of contamination. She stated that she thought about it but went ahead and put it in the cup. LPN #1 confirmed she should have used a barrier for the eye drops to prevent contamination and placing them in the medication cart drawer contaminated the drawer. She stated that she realized she should have washed her hands after taking her gloves off and before giving the resident the rest of her medication. She stated that she should wash her hands anytime she removes her gloves. An interview on 07/13/23 at 08:30 AM, with the Director of Nursing (DON) revealed staff should wash their hands anytime gloves are removed to prevent contamination and spread of infection. Barriers should be used to prevent the spread of infection or wipe the table with a purple top (disinfectant) wipe because you don't know what is on the tables in resident's rooms. The DON stated that if a medication is dropped on the top of the cart, it should be disposed of and if it was picked up without the nurse having on gloves and put into the medication cup, the whole cup of medications was contaminated.

Based on observation, staff interview, facility policy review, and record review, the facility failed to perform medication administration in a manner to prevent the likelihood of the spread of infection, as evidenced by failure to disinfect a plastic tray barrier and stethoscope, and to perform hand hygiene appropriately between residents during medication administration observations for three (3) of six (6) residents observed during medication administration. Findings include: Record review of the facility policy titled Administering Medications revised December 2012 revealed Medications shall be administered in a safe .manner . 22. Staff shall follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Record review of the facility policy titled Administering Medications through an Enteral Tube revised March 2015 revealed .Steps in the Procedure 1. Wash your hands .34. Wash your hands . Record review of the facilities Infection Control Guidelines for All Nursing Procedures revised May 2021 revealed . General Guidelines 3. Employees must wash their hands using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents d. After removing gloves 4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION(S)] or [MEDICATION(S)] for all the following situations: a. Before and after direct contact with residents; . d. Before preparing or handling medications; . g. After contact with a resident's intact skin; . i. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident j. After removing gloves. On 09/20/21 at 4:30 PM, an observation of Licensed Practical Nurse (LPN) #1 administering medications to the Unsampled Resident A revealed LPN #1 did not wash her hands or use hand sanitizer before preparing medications. LPN #1 removed a plastic tray from the drawer of the medication cart and placed it on top of the medication cart. LPN #1 prepared the medications, placed the medications on the plastic tray and entered the resident's room. LPN #1 placed the plastic tray on the counter by the sink and then placed it on the bedside table without prior sanitation to either area. LPN #1 brought in a box containing a stethoscope. LPN #1 placed the box on the bed of the resident, she opened the box and removed the stethoscope. The Percutaneous Endoscopic Gastrostomy (PEG) tube placement was checked with the stethoscope by placing the stethoscope on the resident's abdomen. The stethoscope was replaced in the box and was not cleaned prior to checking placement or after returning the stethoscope to the box. The plastic tray that contained the medications and the stethoscope box were returned to the medication cart and placed on top of the medication cart. The stethoscope box and plastic tray were then placed in the medication cart drawer without being cleaned and sanitized. LPN #1 did not wash her hands or use hand sanitizer prior to entering the resident's room, after administering the medications, before exiting room or returning to the medication cart. On 09/20/21 at 4:50 PM an observation of LPN #1 administering medications to Unsampled Resident B revealed LPN #1 did not wash her hands or use hand sanitizer before preparing the medications. LPN #1 then entered the resident's room and administered the medications to the resident. LPN #1 did not wash her hands or use hand sanitizer after the medications were administered, before exiting room or returning to the medication cart. On 09/20/21 at 4:55 PM an observation of LPN #1 administering a medication to a resident while she was in the dining room revealed LPN #1 did not wash her hands or use hand sanitizer before preparing the medications. LPN #1 entered the dining room and administered the medication to the resident. LPN #1 did not wash her hands or use hand sanitizer after the medication was administered, before exiting the dining room or returning to the medication cart. 09/20/21 at 5:00 PM an interview with LPN #1 confirmed she did not clean the plastic tray or stethoscope after administering PEG medications to Unsampled Resident A. The interview also confirmed that she did not wash her hands or use hand sanitizer after administering the PEG medications for Unsampled Resident A, before or after administering by mouth (PO) medications to Unsampled Resident B and before or after administering PO meds to the resident in the dining room. LPN #1 confirmed that she should have cleaned the plastic tray and stethoscope box prior to using it and she should have sanitized the plastic tray and stethoscope box after the medication administration prior to placing it back in the medication cart. LPN #1 confirmed that she should have washed her hands or used hand sanitizer prior to entering and exiting the resident rooms and that her failure to do this could spread infection and germs and LPN #1 confirmed that she has had in-services related to infection control and stated, I was just nervous. 09/20/21 at 5:25 PM, an interview with the Director of Nursing (DON) confirmed that plastic barrier trays used during medication administration should be cleaned and disinfected before and after use, stethoscopes should be cleaned and disinfected before and after use and hand hygiene should be done by staff before and after direct contact with residents. Record review of LPN #1's COVID-19 Orientation/Infection Control dated 9/14/21 and signed and checked off by LPN #1 and the DON revealed guidance 1. Oriented to infection control procedure. 2. Proper hand hygiene performed. 3. Standard precautions orientation. 4. Location of PPE (Personal Protective Equipment) .

Based on observation, interview, and policy review, the facility failed to dispose of loose medications in the medication cart drawers; dispose of expired vials of insulin in medication carts; and dispose of one opened and undated vial of insulin and one expired vial of [MEDICATION NAME] serum in the medication refrigerator according to the facility's policies. The expired and undated insulins had the potential to affect three (3) of 10 residents, Residents #14, #23, and #41, who received insulin injections; the expired [MEDICATION NAME] serum had the potential to affect staff and 47 residents who may have required a [MEDICATION NAME] test; and the loose medications had the potential to affect the 47 of 47 residents who received medications. Findings include: Review of the facility's Medication Carts policy, dated [DATE], indicated, Before end of each shift the med cart is to be wiped with disinfectant wipe, all liquid medication bottles should be cleaned with disinfectant wipe and any loose pills in the med cart are to be discarded in the sharps container. The facility's policy for expired vials of medications indicated, To minimize contamination, facility staff should date the label of any multi-use vial when the vial is first accessed and access the vial in a dedicated medication preparation area: If a multi-dose vial has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days . One (1) of the two (2) medication carts utilized contained loose pills in one of the drawers. The medication cart also contained four vials of expired insulins prescribed for three different residents. The refrigerator in the medication room used for storing medications contained an opened and undated vial of insulin and an expired, used vial of [MEDICATION NAME] used for residents and staff. 1. On [DATE] at 8:50 AM, Licensed Practical Nurse (LPN) #66 was observed passing medications from a medication cart. Observation of one of the drawers revealed six unidentified pills of different shapes and colors lying loose on the bottom of the drawer. On [DATE] at 9:00 AM, LPN #66 was asked who was responsible for cleaning out the medication carts. LPN #66 stated the night nurse should have cleaned out the cart before her shift ended last night. LPN #66 stated the pills should not be lying loose in the cart. On [DATE] at 9:05 AM, the acting Director of Nursing (DON) was asked who was responsible for making sure there were no loose pills in the medication carts. The DON said every shift should clean the carts at the end of their shifts. The DON said there should be no loose pills in the medication carts. 2. On [DATE] at 8:50 AM, LPN #66 was observed passing medications from one (1) of the two (2) medication carts being utilized. During the medication pass observation, four (4) opened and expired insulin vials for three (3) residents (Residents #14, #41, and #23) were observed in one the drawers of the medication cart. A vial of [MEDICATION NAME] for Resident #14 was dated as opened on [DATE]. A vial of Humalog insulin for Resident #41 was dated as opened on [DATE]. A vial of [MEDICATION NAME] for Resident #41 was dated as opened on [DATE]. A vial of [MEDICATION NAME] regular insulin for Resident #23 was dated as opened on [DATE]. On [DATE] at 9:05 AM, the acting DON was asked when the insulin should be checked for an expiration date and disposed of if expired. She said the nurse normally checked the open date on the vial before they administered it. She explained if the insulin was expired (28 days after being opened) it should be disposed of and re-ordered if necessary. 3. On [DATE] at 9:05 AM, the Medication Room was inspected with the acting DON. In the refrigerator the following medications were observed: a vial of [MEDICATION NAME]had been opened and used but did not have a date as to when it had been opened; and an opened and used [MEDICATION NAME] vial dated as opened on [DATE]. At that time, the acting DON was asked who was responsible for putting a date on a multi-use vial of medication when they first opened it for use. The acting DON stated the nurse who initially utilized the vial was responsible for dating the multi-use vials. The acting DON was asked why the opened, expired and used [MEDICATION NAME] multi-use vial remained for use in the refrigerator. The acting DON responded the nurse who normally administered the [MEDICATION NAME] test had a family emergency and had to leave, forgetting to dispose of the vial. The acting DON confirmed the [MEDICATION NAME] vial and the [MEDICATION NAME]needed to be disposed of.

Based on observation, interview, and record review, the facility failed to properly assess the use of lap belts as a potential accident hazard for two (2) of 18 residents reviewed, Residents #33 and #42. Findings include: Review of the facility's Hazardous Areas, Devices and Equipment policy, revised 07/2017, indicated, .Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous .Data from Accident and Incident Reports will be used as part of the hazard's assessment and analysis, including trends in accident types, areas in the facility, associations with particular staff or shifts and equipment used . The facility's Falls and Fall Risk, Managing policy, with a revision date of December, 2007, indicated, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . Review of the facility's policy for Restraints, revised (MONTH) (YEAR), revealed restraints shall be used in such a way as not to cause physical injury to the resident and to insure the least possible discomfort to the resident. A resident placed in a restraint will be observed every 30 minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. Restrained individuals shall be reviewed regularly, (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. The facility did not assess the use of lap belts as a possible contributing factor for falls experienced by Resident #33 and Resident #42, nor did the facility consistently refer the residents to therapy for screening as directed by facility policy following a fall. Resident #33 Review of the clinical record revealed the physician ordered the use of a self-releasing seat belt for Resident #33 on 08/16/16. A Fall Assessment, dated 03/21/18, identified Resident #33 as a high fall risk. Specifically, this document noted the resident had a history of [REDACTED]. A Fall Assessment was completed on 06/09/18 and 09/05/18, and noted the same information. Review of the Departmental Notes, dated 11/13/18, revealed Resident #33 was found seated in her wheelchair with her seat belt on and located behind another resident who was in a wheelchair. The entry noted Resident #33 was found with her wheelchair flipped forward and was caught by the back of the other resident's wheelchair. The seat belt had to be released by staff after this incident. There were no injuries sustained by Resident #33. A Resident Incident Report, dated 11/13/18, noted the above information. There was no information in this document that indicated the facility assessed whether the self-releasing belt was a potential accident hazard, or if the lap belt remained the best option for the resident. The report did document this was an unwitnessed event. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/20/19, noted Resident #33 was unable to complete the Brief Interview for Mental Status (BIMS) evaluation due to the resident being rarely/never understood. The resident was assessed by staff to be moderately cognitively impaired. Resident #33 required the assistance of two staff members for bed mobility and transfers. The resident used a trunk restraint daily while out of bed. A care plan, dated as initiated 02/26/19, identified Resident #33 required assistance with activities of daily living. One of the approaches identified was to check the self-releasing seat belt every two hours and to release and exercise the resident. Another care plan issue, dated as initiated 02/26/19, noted Resident #33 was at risk for falls. An approach identified a self-releasing seat belt would be attached to the wheelchair due to decreased safety awareness. Another approach identified Resident #33 should be screened per PT (Physical Therapy) and OT (Occupational Therapy) after falls and PRN ( as needed). There was no evidence to show that this seat belt device was assessed as a potential accident hazard. On 04/02/19 at 10:31 AM, Resident #33 was observed in a wheelchair with a self-releasing lap belt secured about her waist. An interview was attempted with Resident #33. The resident could not be understood at this time. In an interview, on 04/03/19 at 12:02 PM, the acting Director of Nursing (DON) stated therapy staff were to screen for the use of lap belts and make recommendations. Review of the Face Sheet revealed Resident #33 was admitted to the facility, on 08/03/16, with [DIAGNOSES REDACTED]. Resident #42 Review of the Physician Orders, dated 06/26/17, revealed an alarmed self-releasing seat belt for Resident #42 was ordered due to a decrease in safety awareness and [MEDICAL CONDITION]. The Departmental Notes, dated 02/10/19, noted Resident #42's alarm from her self-releasing lap belt was heard. The staff member found the resident at the foot of her bed on the floor. She sustained no injuries. A referral was made, on 02/10/19, to therapy to evaluate Resident #42 from her recent fall. There was no mention of the self-releasing lap belt and whether this might be considered a risk for harm for the resident or not. The evaluation did not state if the lap belt was still considered the best option for safety for the resident or not. The quarterly MDS assessment, with an ARD of 02/27/19, noted Resident #42 was unable to complete the BIMS evaluation due to the resident being rarely/never understood. Staff assessed the resident was moderately cognitively impaired. The resident required limited assistance of two staff members for bed mobility and extensive assistance for transfers of two staff members. The resident used a trunk restraint daily while out of bed. A Care Plan, dated as initiated on 03/05/19, identified Resident #42 was considered high risk for falls. Identified approaches included the resident was to have an alarmed self-releasing seat belt due to decreased safety awareness and [MEDICAL CONDITION]. There was no mention the resident had the behavior of attempting to stand by herself while in the wheelchair. Review of the Departmental Notes, dated 03/16/19, revealed Resident #42 had an unwitnessed fall. Resident #42 was found on the ground, scooting towards her bed from the bathroom, and her shirt was covered with urine. The resident sustained [REDACTED]. In an interview, on 04/03/19 at 12:51 PM, Licensed Practical Nurse (LPN) #66 stated Resident #42 would attempt to stand up on her own from her wheelchair. LPN #66 confirmed the resident used a self-releasing lap belt. In an interview on, 04/03/19 at 1:59 PM, Certified Nursing Assistant (CNA) #22 confirmed Resident #42 would attempt to stand when sitting in her wheelchair even with her lap belt attached. CNA #22 stated she reminds the resident to sit back down. In an interview, on 04/03/19 at 2:54 PM, the MDS Coordinator stated Resident #42 was at high risk for falls. She said the resident had a history of [REDACTED]. A telephone interview was conducted with the Director of Rehabilitation (DR) on 04/04/19 at 9:15 AM. The DR said Resident #42 was safer with a lap belt on than without. The DR confirmed the resident was considered high risk for falls. The DR said if a resident had a fall, therapy would assess them to see if they need therapy or not. The DR was unable to explain why this had not occurred for Resident #42. Review of the Face Sheet revealed Resident #42 was admitted to the facility, on 11/11/16, with [DIAGNOSES REDACTED].

Based on observation, interviews and record review, the facility failed to ensure that two (2) of five (5) residents reviewed for unnecessary medications had adequate indications for use of an antipsychotic medication, [MEDICATION NAME]. Neither resident received a gradual dose reduction (GDR), nor did the physician provide a clinical rationale for the continued use of the medication for Resident #17 and Resident #32. Findings include: Review of the facility's Antipsychotic Medication Use policy, dated as revised (MONTH) (YEAR), noted Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review .residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective .The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications .Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use .or re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks (at the initial MDS assessment) to consider whether or not the medication can be reduced, tapered, or discontinued. Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medication. [DIAGNOSES REDACTED].or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. Review of the Food and Drug Administration Medication Guide revealed, .[MEDICATION NAME] may cause serious side effects, including: 1. risk of death in the elderly with dementia. Medicines like [MEDICATION NAME] can increase the risk of death in elderly people who have memory loss (dementia). [MEDICATION NAME] is not for treating [MEDICAL CONDITION] in the elderly with dementia. The facility failed to ensure Resident #17 and Resident #32 received [MEDICATION NAME] (an antipsychotic medication) at the lowest possible dosage for the shortest period by failing to attempt GDRs and failing to clearly identify the indications for continued use of the medication. The physician failed to assess the residents and provide a medical rationale regarding the continued use of the [MEDICATION NAME]. Resident #17 A physician's orders [REDACTED].#17 at 9:00 PM daily. A review of Resident #17's Behavior/Intervention Monthly Flow Record, from 10/01/18 through 03/30/19, revealed staff monitored for aggressive behaviors, hallucinations, delusions, and [MEDICAL CONDITION] related to the use of [MEDICATION NAME]. None of the behaviors were noted for this period. The electronic Medication Administration Records (MARs) were reviewed from 10/01/18 through 03/30/19. Each month indicated the [MEDICATION NAME] was ordered to treat Resident #17's [MEDICAL CONDITION]. A physician's note, dated 11/15/18, indicated Resident #17's behaviors were well controlled on current medications of [MEDICATION NAME] 50 mg to be administered at 9:00 PM daily, [MEDICATION NAME] (an antidepressant) 200 mg daily, and [MEDICATION NAME] (to treat mild to moderate dementia) 10 mg daily. The Physician's Note continued by stating the resident had a history of [REDACTED]. Resident #17's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/15/19, indicated the resident had a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated moderately impaired cognition. Resident #17 had [DIAGNOSES REDACTED]. Resident #17 did not experience delusions or hallucinations, and was not a danger to self or to others. A care plan, dated as initiated 01/22/19, identified Resident #17 was taking [MEDICATION NAME] for [MEDICAL CONDITION] with behaviors with auditory and visual hallucinations. Review of the Psychologist's Physician Notes, dated 01/30/19, identified a one on one session was held with Resident #17. It was noted the resident had no current issues. Review of the Psychologist's Physician Notes, dated 02/20/19, identified a one on one session was held with Resident #17. It was noted the resident had no suicidal or homicidal ideations and the resident was not plagued with perceptual disturbances. Review of the Psychologist's Physician Notes, dated 03/20/19, identified a one on one session was held with Resident #17. It was noted the resident had no suicidal or homicidal ideations. The Departmental Notes, from 10/02/18 to 04/03/19, revealed Resident #17 exhibited no behaviors such as aggression to self or to others, delusions, or hallucinations. In an interview, on 04/04/19 at 9:55 AM, Certified Nursing Assistant (CNA) #12 stated Resident #17 did not yell out constantly, but would yell during showers. CNA #12 stated the resident did not make up stories that were not true, and did not see things that were not there. She said she had worked with the resident for the past two years. In an interview, on 04/04/19 at 10:00 AM, Licensed Practical Nurse (LPN) #64 said that she has worked with Resident #17 since (MONTH) (YEAR). LPN #64 said the resident did not yell out constantly, did not hit out, did not make up stories, did not see things that were not there, and no one was afraid of the resident. Both the Administrator and the acting Director of Nursing (DON) were interviewed on 04/04/19 at 11:10 AM. The Administrator said Resident #17 was not a threat to others, and generally there were no concerns with Resident #17's behaviors. In an interview, conducted by telephone on 04/04/19 at 1:09 PM, the Medical Director (MD) stated residents are prescribed an antipsychotic who have mental health disorders, and residents who lash out and can hurt themselves or others. He said that he relies on what the nurses tell him when he makes his routine visits, since the staff know about the resident. The MD said they could do better on the residents who have no behaviors and looking at a GDR. He was unable to explain why a GDR had not been attempted for Resident #17 in the 11 months since the [MEDICATION NAME] was initiated despite an absence of behaviors or indicators for the continued use of the medication. Review of the Face Sheet revealed Resident #17 was admitted by the facility, on 06/07/17, with a [DIAGNOSES REDACTED]. Resident #32 The Pharmacist Consultation Report Clinical Comments and Suggestions, dated 10/04/18, indicated, [MEDICATION NAME] 25 mg q (every) HS (hour of sleep) for dementia. Consider reducing to [MEDICATION NAME] 12.5 mg q HS. The physician responded by marking the box that indicated no action was necessary at the time, and direction that the resident was to continue the same dose. Review of the quarterly MDS with an ARD of 12/05/18; the 30-day MDS with an ARD of 01/27/19; and the 14-day MDS with an ARD of 02/18/19 all revealed Resident #32 exhibited no behaviors, hallucinations or delusions during the look-back periods. A Physician's Progress Note, dated 02/13/19 at 8:50 AM, indicated the resident expressed feelings of sadness, but denied experiencing any crying spells. It was noted that the resident napped frequently. A review of the (MONTH) 2019 Behavior/Intervention Monthly Flow Record revealed Resident #32 had cried on five nights. The staff noted they responded each time by providing redirection and one on one. There were no outcomes documented. A review of the (MONTH) 2019 Behavior/Intervention Monthly Flow Record revealed on 13 nights the resident had experienced disordered thinking, although this was not clearly defined. The staff documented they responded each time by providing redirection and one on one. A Physician's Progress Note, dated 03/27/19 at 10:10 AM, revealed the resident had regressed overall and was sleeping excessively. In an interview, on 04/03/19 at 1:39 PM, the acting DON was asked to review the (MONTH) (YEAR) pharmacy consultant's report. She said she would speak to the physician about trying a GDR for Resident #32 as no clinical rationale for the refusal to a dose reduction had been provided. In an interview, on 04/04/19 at 9:10 AM, Registered Nurse (RN) #68 stated she had spoken to the physician about the lack of a GDR since the resident's admission in (MONTH) (YEAR). RN #68 said the physician told her to write the order to decrease the [MEDICATION NAME], and to monitor the resident. In an interview, on 04/04/19 at 10:25 AM, the acting DON explained Resident #32 used to call out or cry but that Resident #32 was quieter now. The acting DON further explained Resident #32 used to talk loudly at night which was disruptive to Resident #32's roommate. In an interview, on 04/04/19 at 10:30 AM, CNA #71 said she had provided care for Resident #32 on day shift for the previous six months. CNA #71 said the resident had always complained of care, and being moved around. CNA #71 said Resident #32 would lightly slap the staff's hands when she didn't want something done. On 04/04/19 at 12:50 PM, the Pharmacy Consultant was interviewed by telephone regarding antipsychotic medications and the physician's response to GDR requests. The Pharmacist stated he reviewed progress notes and physician's orders [REDACTED].#32, however that was all he could do. In a telephone interview, on 04/04/19 at 1:09 PM, the Physician was unable to explain why no GDR had been attempted for Resident #32. Review of the admission physician's orders [REDACTED].#32 was admitted by the facility with [DIAGNOSES REDACTED]. These orders also indicated Resident #32 was admitted with an order for [REDACTED].