Every finding on record at Rockledge Healthcare & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to maintain a homelike interior in 1 of 28 rooms, on 1 of 2 units, (East Wing, 103). Findings: On 3/31/25 at 11:45 AM, the first drawer of a nightstand was missing in room [ROOM NUMBER]. Subsequent observations on 4/01/25 at 11:33 AM and 4/02/25 at 3:10 PM, the first drawer of the nightstand was still missing. On 4/02/25 at 3:11 PM, Certified Nursing Assistant (CNA) K explained she entered work orders to alert maintenance of needed repairs in resident's rooms. She stated the first drawer of the nightstand in room [ROOM NUMBER], had been broken for awhile and pointed to the top of a dresser where the drawer had been placed. She indicated maintenance was aware of the needed repair. On 4/02/25 at 4:45 PM, the Maintenance Director stated he was responsible for the functionality of everything in the facility. He explained the staff was supposed to enter work orders to let him know when something needed his attention. At 4:59 PM, the Maintenance Director toured room [ROOM NUMBER]. He acknowledged the drawer needed to be fixed and said it was an easy fix. He stated he had not been aware of the issue. Review of the Work Orders for room [ROOM NUMBER] from January to April 2025 did not reveal a report about broken furniture including the drawer repair. On 4/03/25 at 1:57 PM, the Administrator indicated her expectation from staff was to follow up with maintenance when things were not repaired. She stated staff needed to follow the facility process and inform maintenance electronically or verbally of repairs needed in the facility. Review of the facility's Plant Operations Administrative Overview policy issued on February 2021, revealed the General Maintenance Division functions included the installation of pre-assembled cabinetry and minor furniture repairs.

Based on observation, interview, and record review, the facility failed to conduct a medication self-administration assessment to ensure safety for 1 of 1 residents reviewed for self-administration of medications, of a total sample of 51 residents, (#97). Findings: Resident #97 was admitted to the facility on [DATE] with diagnoses including left tibia fracture, muscle weakness, and polyneuropathy. A review of the Minimum Data Set admission assessment with an assessment reference date of 3/05/25 revealed resident #97 had a Brief Interview for Mental Status score of 15 out of 15, which indicated that he was cognitively intact. On 4/02/25 at 10:09 AM, resident #97 was observed lying on his back in bed watching television. His bedside table was next to his bed with various personal items, including a box of Ocusoft Retaine MGD ophthalmic emulsion that contained 28 single doses (0.01 fluid ounces). The resident said he used the eye drops for his eyes. On 4/02/25 at 10:13 AM, the resident's bedside table was observed with primary Registered Nurse (RN) D, who acknowledged the box of single-dose eye drops at resident #97's bedside. Once outside the room RN D reviewed resident #97's physician orders and acknowledged there were no orders for the eye drops resident #97 had in his possession. RN D explained that residents required a physician's order to self administer medications. RN D stated there was no order for eye drops. On 4/02/25 at 11:16 AM, the Director of Nursing stated residents should have a completed self-administration assessment and a physician's order for self administration of the medication prior to resident self-administering medications. A review of the facility's policy and procedure for Self-Administration of Medications dated 4/1/22 revealed, It is the policy of this facility that residents who wish to self-administer their medications may do so if it is determined that they are capable of doing so.

Based on observation, interview, and record review, the facility failed to follow appropriate hand hygiene and personal protective equipment (PPE) practices per infection control standards; and failed to prevent cross contamination when handling trash. Findings: On 4/02/25 at 9:49 AM, Certified Nursing Assistant (CNA) J obtained a pair of gloves from a treatment cart. He donned the gloves without performing hand hygiene and entered a resident's room to assist the wound care nurse. A few minutes later on 4/02/25 at 9:53 AM, CNA J confirmed he was supposed to perform hand hygiene when donning and doffing gloves. He explained he had forgotten to do this but said it was important for sanitation and protection of the residents. On 4/02/25 at 2:58 PM, CNA J was observed at the doorway of room [ROOM NUMBER] holding a clear, plastic bag with trash in his right hand and wearing a personal backpack while talking to a staff member who was inside the room. He then entered room [ROOM NUMBER] and continued talking to the other staff with the bag in his hand. CNA J stepped out of room [ROOM NUMBER] a few minutes later. He explained the bag contained trash he collected from a different room, room [ROOM NUMBER]. He validated he was not supposed to bring trash bag from another room into other resident rooms. On 4/02/25 at 4:35 PM, the Director of Nursing stated she expected staff to perform hand hygiene when donning and doffing gloves. She indicated staff were to discard anything they removed from a resident's room in the soiled utility room and perform hand hygiene before entering another resident's room. She acknowledged entering a resident's room with trash from another room was a problem with cross contamination and was considered a break in infection control process. Review of the facility's policy titled Hand Hygiene dated 4/01/22 read, The facility considers hand hygiene the primary means to prevent the spread of infections.

The facility failed to label drugs and biologicals safely and accurately, in accordance with currently accepted professional principles for 2 of 7 residents observed for medication administration, of a total sample of 51 residents, (#305, and #7). Findings: 1. On 3/31/25 at 5:14 PM, during medication administration observation with Registered Nurse (RN) A on the [NAME] medication cart 2 it was noted that the medication on the Electronic Medication Administration Record (eMAR) indicated Eliquis 5 milligrams (mg) give 1 tablet. The label on the actual medication instructed that 10 mg of Eliquis was to be administered. RN A did not administer the medication and stated he would call the physician to clarify the order. 2. On 4/01/25 at 9:14 AM, during medication administration observation with Licensed Practical Nurse (LPN) B, on the South medication cart 2, there were discrepancies found with the medication label for two of resident #7's medications. The order on the eMAR read Sodium Chloride 1 gram and one tablet to be given. In conflict with the eMAR, the medication label indicated two tablets, one gram each of the Sodium Chloride were to be given. The second medication on the eMAR instructed nurses to give Levetiracetam (an anti-seizure medication) 1500 mg by mouth every 12 hours. However, the actual medication label indicated two 1000 mg tablets were to be given, for a total of 2000 mg of Levetiracetam. LPN B did not explain why the actual medication labels did not match the physician orders in the eMAR. She did not administer the medications and stated she would call the physician to clarify the orders. On 4/03/25 at 9:25 AM, RN C explained whenever an order was changed, she updated the order, reordered the medication, then removed the old blister pack from the cart and placed it in the return bin to the pharmacy. She explained if it was a case of where the actual medication was the same but the dosage changed, for example the new order said to give two tablets, and the old order said to give one; she would put a sticker that noted the order change on the medication label and continue to use the medication from that blister pack until the new medication came in. On 4/03/25 at 9:31 AM, RN D explained if there was a new order or a changed order, she would take the medication out of the cart to the return bin. She would then send a message to the pharmacy about the changed dosage. If she discovered that the label did not match the order, she would take the medication out of the cart. RN D said that sometimes if you could have used the same medication, you could put a sticker on that read note direction change. In a phone interview on 4/03/25 at 11:01 AM, Consultant Pharmacist G said he completed medication cart audits once a month for storage of medications and verified there were no expired medications. However, he explained he did not check the eMAR to the order to verify that the label on the medications had not changed or were correct. He said he completed a monthly review including pharmacy recommendations and was involved in the facility's Quality Assurance and Performance Improvement meeting every month. Consultant Pharmacist G indicated he audited the nurses' documentation and sent a report to the facility monthly. He stated he was unaware of any discrepancies with medication labels from the last audit and acknowledged that incorrect labels could lead to medication errors. On 4/03/25 at 12:07 PM, the Unit Manager (UM) for [NAME] way explained if an order was changed or a medication dosage was updated, she would put the new order in the computer and send it to the pharmacy. She continued that the section for updated orders allowed them to use or not use the medication on hand. The UM explained if the medication was not used, the process was to discontinue the medication, remove it from the cart and place it in the return to pharmacy bin. If they chose to use the medication on hand, the process was to place a sticker which indicated, see direction change and once the new order came in, the old blister pack was removed from the cart. On 4/03/25 at 12:15 PM, the consulting pharmacy customer representative H said via telephone if an order was changed by the physician, the new order was entered, the old one discontinued and the medication removed from the cart. They explained the facility could reuse the medication on hand, if possible, by placing a sticker for the direction change. He stated Consultant Pharmacist G was responsible for medication label to eMAR checks, and acknowledged administration inaccuracies on medication labels could lead to medication errors. On 4/03/25 at 2:34 PM, the Director of Nursing (DON) stated her expectation was that discontinued medications be removed from the medication cart and if using a medication on hand when there were order changes, the sticker for the direction change should be placed on the medication until the new medication was delivered. She confirmed any medication with a label which was different from the order should be removed. The facility's Policy on Medication/Biological Storage Issued 4/01/22 indicated in the procedure section, The Nursing staff shall be responsible for maintaining medication storage .and Drug containers that have missing, incomplete, improper or incorrect labels should be returned to the pharmacy for proper labeling before storing. The facility shall not use discontinued, outdated or deteriorated medications, drugs or biologicals.

Based on observation, interview, and record review, the facility failed to maintain adequate communication with the dialysis center, follow the comprehensive person-centered care plan and ensure post-dialysis assessments were completed for 1 of 2 residents reviewed for dialysis, of a total sample of 51 residents, (#655). Findings: Review of the medical record revealed resident #655 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included end-stage renal disease (ESRD) with dependence on dialysis, and type 2 diabetes. Review of the Minimum Data Set Medicare 5-day assessment with Assessment Reference Date of 3/27/25 revealed resident #655's Brief Interview for Mental Status score was 11 out of 15 which indicated moderately impaired cognition. The assessment showed the resident had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. The assessment revealed resident #655 required hemodialysis. Review of resident #655's care plan for hemodialysis dated 3/24/25 included complete dialysis communication tool on dialysis days and review upon return from dialysis. Monitor for bruit and thrill at shunt site. A shunt is a connection between a vein and artery that helps your body create the flow of blood it needs for dialysis to work (retrieved from https://www.bmc.org on 4/04/25). On 4/01/25 at 9:15 AM, resident #655 stated the staff did not take vital signs or check her dialysis site when she returned from dialysis. Review of the Dialysis Communication Form showed three sections, the first section was to be completed prior to leaving the facility for dialysis, the second section to be completed by the dialysis center and the third section to be completed by the facility post dialysis. Review of current physician orders revealed resident #655 went to dialysis three times per week, Monday, Wednesday and Friday. Review of the Dialysis Communication Forms revealed resident #655 went to dialysis six times between 3/21/25 and 4/02/25. The forms indicated that only one day (3/21/25) were all three sections completed by nurses. On 3/24/25 only the first page was completed, on 3/26/25 only the first and third pages were completed, the form on 3/28/25 was missing, for 3/31/25 and 4/02/25 only the first page was completed. Four of the six forms did not contain a post dialysis assessment. Review of the progress notes for that time period did not reveal any facility contact made with the dialysis center. On 4/03/25 at 11:12 AM, the Unit Manager (UM) for the west wing stated, the process for dialysis was for nurses to complete the first page of the Dialysis Communication Form, the second page should be completed by the dialysis center and the third page is completed by the nurse when the resident returned to the facility. The UM confirmed the forms were not completed for resident #655. She explained that when the dialysis center did not complete the form she would call and request the form to be completed and sent. She stated even when she called the dialysis center, often the completed form did not get sent back. She confirmed the nurse was supposed to ensure the forms were complete. The UM the nurses were educated to complete the form when the resident returned from dialysis. The policy and procedure Hemodialysis dated 4/1/22 described, The facility and the Dialysis Center should maintain regular communication.

Based on observation, interview, and record review, the facility failed to follow the physician's order for oxygen (O2) for 1 of 3 residents reviewed for O2 use, of a total sample of 50 residents, (#8). Findings: Review of resident #8's medical record revealed she was readmitted to the facility on [DATE] with diagnoses including acute respiratory failure, congestive heart failure (CHF), anemia, and shortness of breath. Review of resident #8's significant change in status Minimum Data Set assessment with Assessment Reference Date of 1/15/25 revealed she used O2. Review of resident #8's medical record revealed a physician's order dated 12/30/24 which read, Oxygen at 2 liters/minute (LPM) continuous, via NC (nasal canula) every shift. A care plan for a potential for complications of respiratory distress related to CHF and respiratory failure was initiated on 5/17/23. The interventions included, Administer medications as ordered; observe for effectiveness and for SEs (side effects). Administer O2 as ordered. On 3/31/25 at 11:36 AM, resident #8 was lying in bed with her eyes closed, wearing a NC in her nose. The NC was connected to an O2 concentrator set at 4 LPM. A second observation on 4/01/25 at 11:36 AM, revealed resident #8's O2 concentrator was set at 3.5 LPM and later on 4/01/25 at 3:38 PM, the O2 concentrator was at 4 LPM of O2. On 4/01/25 at 3:47 PM, Licensed Practical Nurse (LPN) L stated she had five residents in her assignment using O2. She explained she checked the concentrator when she gave the medications to those residents. She indicated her assessment included ensuring the tubing was changed once a week, the NC was on the resident properly, and checking the resident's oxygen saturation. She mentioned resident #8 was not ambulatory and was always in bed. She stated the nurses were responsible for ensuring the O2 concentrator was set at the rate ordered by the physician. Later on 4/01/25 at 3:55 PM, LPN L walked into resident #8's room and checked the O2 concentrator. She acknowledged the O2 was set at 4 LPM. On 4/01/25 at 4:00 PM, the Director of Nursing (DON) checked resident #8's physician orders and confirmed the order for O2 was 2 LPM. She went to resident #8's room, confirmed the O2 was set at 3.5 LPM and changed it to 2 LPM. Later on 4/01/25 at 4:08 PM, the DON explained she expected the nurses to check the O2 concentrator at the beginning of their shift and periodically throughout their shift to ensure it was correct. She indicated it was important to follow the physician's orders accurately. Review of the facility's policy titled Oxygen Administration issued on 4/01/22 read, It is the policy of the facility to provide guidelines for safe oxygen administration. The procedure listed O2 was administered as ordered by physician.

Based on interview, and record review, the facility failed to ensure the completion and accuracy of Level I Preadmission Screening and Resident Review (PASARR) documents on admission and/or failed to make referrals for newly evident or possible mental disorders/diagnoses to evaluate the need for specialized services or alternative placement for 4 of 5 residents reviewed for PASARRs, of a total sample of 51 residents, (#49,#79, #23, and #34). Findings: 1. Review of the medical record revealed resident #49 was admitted to the facility on [DATE] from the hospital with diagnoses that included enlarged heart, hypertensive heart disease with heart failure, adjustment disorder with depressed mood, sleep disorder, pain and major depressive disorder. Resident #49's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/18/25 revealed the resident scored 10 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated he had mild cognitive impairment. The assessment revealed resident #49 felt depressed, had no behaviors nor rejection of care, and had no diagnosis of depression nor mood disorder listed as active diagnoses. Resident #49's had a Plan of Care which outlined the potential for adverse side effects related to the use of psychotropic medications, antidepressant for treatment of depression and insomnia. The plan of care also focused on the potential for or actual psychosocial wellbeing issue due to the depression diagnosis. On 4/03/25 at 4:45 PM, a review of resident #49's PASARR Level I Screen for Serious Mental Illness and/or Intellectual Disability or Related Conditions dated 2/07/25, revealed no diagnoses listed in Section A for Mental Illness or Suspected Mental Illness. 2. Resident #79 was initially admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. His diagnoses included metabolic encephalopathy (brain dysfunction), acute and chronic respiratory failure with hypoxia (low oxygen), chronic obstructive pulmonary disease, anxiety disorder, unspecified mood disorder, major depressive disorder, brief psychotic disorder, and primary insomnia. Resident #79's Order Summary Report indicated the resident had an order for Seroquel oral tablet 25 milligrams (mg) to be given three times a day related to brief psychotic disorder and Depakote Sprinkles Oral Capsule Delayed Release 125 mg, four capsules by mouth to be given twice a day related to unspecified mood disorder. Resident #79 had a Plan of Care with the focus for the potential for adverse side effects related to the use of psychotropic medications for the treatment of psychosis. The Care Plan related to resident #79's exhibited behaviors of hallucinations, yelling at staff that they are stepping on the cat, and resident thinks he's going to work. Resident #79's PASARR Level I Screen for Serious Mental Illness and/or Intellectual Disability or Related Conditions dated 12/29/24 revealed no diagnoses listed in Section A for Mental Illness or Suspected Mental Illness. On 4/01/25 at 2:57 PM, the Social Services Director was asked if she was responsible for updating the PASARR forms and said she was not assigned and that she only started working at the facility a few weeks ago but was aware that she will be responsible for them in the future. The Nursing Home Administrator (NHA) said it was the Minimum Data Set (MDS) Coordinator who oversaw PASARR forms. On 4/01/25 at 4:05 PM, the MDS coordinator said that she reviewed the PASARR forms from the admission packet and ensured they were signed. If there was anything that needed to be updated, it would be discussed in their morning clinical meeting and addressed. For example, if it was determined by the psychiatrist that there may be a new diagnosis they will then update the forms. The MDS Coordinator was then asked about resident #79's diagnoses not listed in section A of the PASSARR Level 1 form, and explained he might have another form because he was sent out to the hospital recently and that the Director of Nursing (DON) might be working on it. She was also asked about resident #49 as well and acknowledged that diagnoses were not listed in Section A. On 4/01/25 at 4:22 PM, the DON explained that the process was to look at the forms, ensured they were correct, and updated them in the system if there was a new diagnosis. She continued to explain that she did not have access to update the PASARR forms and would find out from the NHA who was responsible. The DON also mentioned that she had only just started working at the facility for about three weeks. On 4/01/25 at 4:32 PM, the Nursing Home Administrator (NHA)explained they were in a transitional period after the Assistant Director of Nursing (ADON) resigned, and she had been responsible for updating the PASARR forms. She said the ADON had been gone for three weeks and confirmed the forms should have been updated. 40892 3. Review of the medical record revealed resident #23, a [AGE] year-old female, was admitted to the facility from an acute care hospital on 2/27/25 with diagnoses that included multiple rib fractures, severe protein-calorie malnutrition, diabetes, schizophrenia disorder- bipolar type, major depressive disorder, and, post-traumatic stress disorder (PTSD). The MDS Admission assessment with an ARD of 3/06/25 revealed that resident #23 had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated she was cognitively intact. The level I PASARR dated 2/06/25 indicated the finding was based on documented history but did not include the admission diagnoses of anxiety disorder, bipolar disorder, depressive disorder, schizoaffective disorder, and PTSD from 2/27/25. On 4/01/25 at 4:05 PM, the MDS coordinator stated she reviewed the PASARR forms upon admission to ensure their completion. She said the forms were updated as needed. The MDS Coordinator acknowledged that resident #23's PASARR did not include the diagnoses. 4/02/25 at 5:40 PM, the Administrator stated that the Assistant Director of Nursing (ADON) was responsible for PASARRs. When the facility was aware of a new admission, the ADON and Social Service Director collaborated to ensure completion of the PASARR. 4. Review of the medical record revealed resident #34, a [AGE] year-old male, was admitted to the facility from an acute care hospital on 1/29/25 with diagnoses that included Parkinsonism, major depressive disorder, schizophrenia disorder-bipolar type, and brief psychotic disorder. The MDS Admission assessment with an ARD of 2/04/25 revealed that resident #34 had a BIMS score of 14/15, which indicated he was cognitively intact. The level I PASARR dated 1/14/25 indicated finding is based on documented history and medications but did not include admission diagnoses of major depressive disorder, schizophrenia disorder- bipolar type, and brief psychotic disorder from 1/29/25. On 4/01/25 at 4:05 PM, the MDS coordinator stated she reviewed the PASARR forms upon admission for completion. The forms were updated as needed. The MDS Coordinator acknowledged resident #34's PASARR did not include any diagnoses. On 4/1/25 at 4:22 PM, the Director of Nursing, (DON) explained that level I PASARRs were reviewed for completion and accuracy upon admission. The document was updated as needed to reflect the resident's medical record. 04/02/25 at 5:40 PM, the Administrator stated that the ADON was responsible for reviewing PASARRs. The Administrator said when the facility was aware of a new admission, the ADON and Social Service Director collaborated to ensure completion of the PASARR which included reviewing all PASARRs for completion and accuracy. The Facility's Policy issued 4/01/22 indicated the facility will ensure each resident in a nursing facility is screened for a mental disorder or intellectual disability prior to admission.

Based on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected Pre-Admission Screening and Resident Review (PASARR) results for 2 of 5 residents reviewed for PASARR, (#6, #8), and use of insulin for 1 of 1 resident (#97) reviewed for insulin, of a total sample of 50 residents. Findings: 1. Review of resident #6's medical record revealed she was initially admitted to the facility on [DATE] and readmitted from an acute care hospital on 7/25/24. Her diagnoses included schizoaffective disorder- bipolar type, bipolar disorder, major depressive disorder and generalized anxiety disorder. Review of resident #6's annual MDS assessment with Assessment Reference Date (ARD) of 8/14/24 revealed question A1500 on Section A read, Is the resident currently considered by the state level II PASARR process to have serious mental illness (SMI) and/or intellectual disability (ID) or a related condition? The documented answer was No. Review of resident #6's medical record revealed a PASARR Level II Determination Summary Report dated 9/07/23. The section Outcome/Disposition showed Meets the state definition of Serious Mental Illness? Yes. 2. Resident #8 was readmitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type, major depressive disorder and generalized anxiety disorder. Review of resident #8's annual MDS assessment with ARD of 3/31/24 revealed question A1500 on Section A read, Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition? The answered was No. Review of resident #8's significant change in status MDS assessment with ARD of 1/15/25 revealed question A1500 on Section A read, Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition? The answer was No. Review of resident #8's medical record revealed a PASARR Level II Determination Summary Report dated 10/24/2023. The section Outcome/Disposition showed Meets the state definition of Serious Mental Illness? Yes. On 4/03/25 at 12:00 PM, the MDS Lead explained she reviewed that PASARRs were present for all newly admitted residents and paid attention to any yes answers. She indicated the PASARR was important because it determined if the facility was an appropriate setting to meet the needs of residents with SMI or ID. She stated Section A of some MDS assessments had a question about PASARR. She reviewed question A1500 on resident #8's annual MDS with ARD of 3/31/24, and confirmed it was answered No. She indicated that resident #8 met the state definition of SMI and the answer on the MDS assessment should have been yes. She also reviewed the significant change in status for the MDS with ARD of 1/15/25. She stated A1500 was also answered no. She reviewed resident #6's Level 2 determination completed on 9/07/23 and the annual MDS with ARD of 8/14/24 and stated it showed A1500 answered no. The MDS Lead stated accuracy of the assessment was important. Later at 3:00 PM, the MDS Lead confirmed the three MDS assessments were coded incorrectly. The Resident Assessment Instrument (RAI) instructions for A1500 read, Review the PASARR report provided by the State if Level II screening was required . Code , yes: if PASARR Level II screening determined that the resident has a serious mental illness and/or ID/DD (intellectual disability/developmental disability) or related condition, and continue to A1510 . Review of the facility's policy titled MDS Assessments dated 4/01/22 indicated, It will be the policy of this facility to complete MDS assessments in accordance with the RAI manual guidelines. 40892 3. Resident #97 was admitted to the facility on [DATE] with diagnoses including left tibia fracture, muscle weakness, and polyneuropathy. A review of the MDS admission assessment with an ARD of 3/05/25 revealed the resident's use of the high risk medication insulin was incorrectly assessed as yes. A review of the resident's physician orders since admission revealed no orders for insulin injections. On 4/03/25 at 1:19 PM, the MDS coordinator accessed resident #97's MDS and explained she was responsible for completing his MDS assessment. She said she reviewed the medication administration documentation before completing the MDS. She acknowledged the MDS indicated the number of days insulin injections were received during the last seven days or since admission if admission/entry or reentry if less than seven days reflected seven. The MDS coordinator printed the Medication Administration Record (MAR) for February 2025 and March 2025, and confirmed there was no documentation of insulin injections being given. The MDS coordinator stated, The resident did not receive insulin; the MDS was incorrect. Review of the Center for Medicare & Medicaid Services (CMS) RAI Version 3.0 Manual Section N: Medications. The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and or select medications were received by the resident. The facility's policy and procedure, MDS, dated [DATE], read, It will be the policy of this facility to complete MDS assessments in accordance with the RAI manual guidelines.

Based on observation, interview, and record review the facility failed to ensure a safe and sanitary environment in the laundry department to prevent cross-contamination of facility equipment and facility linens. Findings: An observation of the laundry department was conducted with the Housekeeping/Laundry Manager, Regional Housekeeping/Laundry Manager and Administrator In Training. The laundry's soiled linen sorting area had 6 covered bins containing soiled linen, an outdoor leaf blower, a floor cleaning/buffer machine which was plugged into the electrical socket, and battery and battery charger. The Laundry Manager explained it was a soiled room used for sorting the facility's soiled linens prior to washing. The Laundry Manager and Administrator in Training stated the leaf blower, the floor machine and battery charger should not be in the soiled room to prevent cross contamination. On 07/11/23 at approximately 12:50 PM, the laundry area containing the facility's 3 washing machines revealed all 3 washing machines were currently in process of washing soiled laundry. Approximately 4 feet directly across from the washing machines were 2 uncovered soiled laundry bins which were full of soiled linens and 1 uncovered soiled laundry bin which contained residents' soiled resident personal clothing. The Laundry Manager said the laundry staff had been using the washing area to sort the soiled linens and these soiled linens were just waiting to go into the washers. The Laundry Manager explained that when the wash had completed we would bring the large blue cart from the dryer/folding room and empty the clean laundry in to the bin and take it to the dryers for processing. On 07/11/23 at 12:45 PM, the Laundry Aide explained that for efficiency she had completed pre-separation in the room with the washing machines because the other soiled room was full of new soiled bins which had just come to the department. She said she would empty the clean laundry from the washing machines and bring it in the bin to the dryers. We really should not be doing the separation in this room because we are mixing the clean laundry with the dirty laundry. Facility's (Contractor Name) Chapter 2, Linen Operations and Management Policy, not dated, read, . How the Laundry Works . Cross-contamination should be a concern in areas containing clean or soiled linen . Transporting Linen - Soiled Soiled linen mush be kept in a container and covered at all times, this includes soiled utility rooms, sorting areas, and transportation to and from those areas . Separation and Sorting of linen Separation of linen is key to preventing cross-contamination . Soiled and clean linen need to be separated from each other at all times . Sorted soiled linens enters the wash area only after making sure any clean linen is first removed from washers and taken into dryer area . Remember that soiled linen cannot be in the wash area at the same times as clean . Review of the Facility's Infection Prevention and Control Program Policy, dated 11/28/2022, read, Policy: The primary mission is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Procedure: . 5. A system for linen handling to prevent the spread of infection to include handling, storing, processing and transporting linens .

Based on interview, and record review, the facility failed to demonstrate the effectiveness of the performance improvement plan for education of nursing staff and implementation of following physician orders for oxygen for 1 of 3 residents reviewed for oxygen therapy out of a total sample of 44 residents. Findings: Cross reference to F695 On 7/13/23 at 7:40 PM, during an interview with the Executive Director, and Director of Nursing (DON), the Executive Director stated that on 6/26/23, they implemented a Performance Improvement Plan (PIP) to ensure proper oxygen use. He stated education was started on 6/26/23 with nursing staff and had been ongoing along with conducting random audits. A request was made to review the in-service training along with subject matter covered and signature records of nursing staff from 6/26/23. The DON stated education was provided to nursing staff verbally on 6/26/23 and 6/27/23. The DON added that education was provided on a one to one basis with each nurse on all shifts for a total of 8 nurses. She reported there were no sign in sheet, and education was ongoing. The Executive Director stated there was a systematic change and they now have guardian angels to ensure oxygen tubing was labeled with date. He explained nursing was conducting random audits. Review of the facility Performance Improvement Plan revealed, QAA Ad Hoc meeting dated 6/6/23, initiated on 6/28/23 for systemic issue regarding physician orders not being followed for oxygen dosage administration, and oxygen tubing not changed. There was documentation of a second Ad Hoc meeting dated 7/6/23. Further review of the facility's PIP revealed Director of Nursing Services/designee target date 6/26/23 with nursing education ongoing, no ill effects of residents from audits completed on 6/26/23. Quality review of oxygen initiated on 6/26/23 with ongoing monitoring of tubing dated, bagged, changed weekly, oxygen orders entered into computer, oxygen set on correct liters, and physician orders followed (liters on device match the physician orders). Review of audits showed 15 residents audits completed with no resident name or room numbers on the audit. The Executive Director stated they only used medical record numbers on the audits. The audits were dated on 6/26/23 with sections checked for oxygen orders to be entered into the computer, oxygen saturation for shortness of breath as needed, resident care plans in place, visualize oxygen tubing bagged, dated, changed weekly, and as needed. The audit also noted, ensure oxygen is set on correct liter, device match physician order, and physician order for oxygen. The Executive Director provided one partial page of nursing signatures for education in service regarding oxygen dated 7/10/23 with subject matter for oxygen orders to be entered in the computer, oxygen saturation as needed for shortness of breath, oxygen tubing should be bagged, dated, changed weekly, & as needed, ensure the oxygen is set on the correct liter per physician order. Review of the facility employee list showed 25 LPNs and 13 RNs for total of 38 nursing staff. The DON stated she educated 8 nurses which was less than 25% of nursing staff. The Executive Director and DON stated there were no issues with the audits for residents with oxygen. Investigative findings during the week of 7/11/23-7/14/23 identified concerns regarding resident #27's readmission to the facility on [DATE]. The resident received continuous oxygen without a physician's order and the oxygen tubing was not dated. Review of 2023 Quality Assurance and Performance Improvement (QAPI) Plan showed the purpose is to provide excellent quality care and services to the residents. The facility has a performance improvement program which systematically monitors, analyzes, and improves its performance to enhance resident quality of care and quality of life. The QAPI program focuses on systems and processes. It strives to identify gaps within these systems and processes, rather than placing blame on an individual. The plan showed under feedback, data systems, and monitoring that education and training will be offered during regularly scheduled meetings, new hire orientation, performance improvement plan development, and as needed.

Based on observation, interview, and record review, the facility's administration failed to effectively utilize its resources to implement its smoking policy and procedures to provide adequate oversight of 16 smokers and ensure the safety of all residents in the facility. Findings: Cross reference F689. On 7/13/23 at 12:11 PM, the facility's Executive Director and Director of Nursing (DON) discussed the facility's protocols for safe smoking. The Executive Director explained residents who were identified as smokers on admission were evaluated by the nursing department to determine if they were physically and cognitively able to smoke safely. He stated the facility maintained an open smoking porch from 7:00 AM to 8:00 PM daily. The Executive Director stated a staff member was always assigned to the designated smoking area to attend to and monitor the smokers. He explained the assigned staff member was responsible for retrieving smoking materials when residents finished smoking and he/she would place the items in a bag labeled with the resident's name which was kept on the resident's unit. The Executive Director confirmed the staff members who were assigned to the smoking area were educated regarding collecting smoking items as the facility wanted to ensure compliance with the smoking policy. He stated nursing staff were responsible for ensuring the smoking rules were enforced. The Executive Director verified there was no change in the facility's smoking policy in the last 60 to 90 days. On 7/13/23 at approximately 12:17 PM, the survey team informed the Executive Director and DON that facility staff stated there was a change in the smoking policy that occurred less than a month ago. The Executive Director stated he was not aware of any changes. The Executive Director and DON were informed that observations and interviews conducted during the recertification survey revealed residents who smoked kept their cigarettes and lighters on their person and in their rooms, and assigned staff in the the smoking area were not collecting smoking paraphernalia. The DON stated it was concerning that residents with lighters might be in rooms with residents who utilized oxygen. The Executive Director concurred. The Executive Director denied knowledge of the information provided regarding the facility's smokers not adhering to policy and procedures. He said, That's news to me. The Executive Director validated the facility's administration was ultimately responsible for ensuring the safe smoking policy and procedures were implemented. Review of the Facility assessment dated [DATE] revealed the facility would provide person-centered care while identifying hazards and risks for residents. Review of the job description for the Administrator, revised on 1/01/15, revealed he/she was primarily responsible for the day-to-day functions of the facility to assure the highest degree of quality care was provided for residents. The Administrator was responsible for safety in the facility to include ensuring staff, residents and visitors followed established safety regulations such as smoking regulations.

Based on observation, interview, and record review, the facility failed to ensure residents who smoked did not keep lighters or ignition materials on their person for 6 of 7 residents reviewed for smoking and failed to identify an accident hazard of a wet floor for 1 of 1 residents reviewed for accidents, out of a total sample of 44 residents,(#6, #69, #75, #50, #303, #73, #26). Findings: 1. Resident #50 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, atrial fibrillation, anxiety disorder, and type 2 diabetes. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 6/12/23 revealed the resident's cognition was intact, with a Brief Interview for Mental Status (BIMS) score of 14/15. On 7/10/23 at 1:33 PM, resident #50 said, I do smoke and I keep my cigarettes and lighter with me. On 7/11/23 at 12:51 PM, the resident stated she kept her cigarettes and lighter in her room in the drawer of the bedside table. She opened the drawer and a pack of cigarettes with a lighter were noted inside. Review of resident #50's smoking assessment dated [DATE] indicated resident #50 may smoke unsupervised in designated smoking areas. The resident may maintain own smoking material (per facility policy). Resident /resident representative/family have been informed of smoking policies and procedures. Resident #50's smoking care plan reflected the following, focus: Resident has been assessed as able to smoke independently. Resident/responsible party have been informed of the facility smoking policy. Goal: resident will adhere to the smoking policy daily through the next review date. Interventions: maintain smoking materials in designated area. 2. Resident #303 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, chronic respiratory failure, depression, and anxiety. On 7/10/23 at 2:00 PM, resident #303 said, I keep my cigarettes and lighter with me all the time. My nurse took them one time and now I keep them with me. On 7/11/23 at 1:24 PM, resident #303 was seen in the smoking area as she took cigarettes and a lighter out of a bag kept in her walker. Resident #303's smoking care plan reflected the following, focus: Resident has been assessed as able to smoke independently. Resident/responsible party have been informed of the facility smoking policy. Goal: resident will adhere to the smoking policy daily thru the next review date. Interventions: maintain smoking materials in designated area. On 7/12/23 at 05:22 PM, the [NAME] Wing Unit Manager (UM) stated the facility had confiscated so many lighters and vape pens and they end up back in here. The UM said families continued to bring them to the residents. The UM explained families and residents were educated to the smoking policy. In the past we would lock up all the cigarettes and lighters and keep them in a box and hand them out when the residents would come out to smoke but the families still brought cigarettes and lighters and gave them to the residents. Now they allow the residents to keep their cigarettes, but they are supposed to return the lighters when they come inside, but that does not always happen and again the visitors bring them. On 7/13/23 at 12:12 PM, the Administrator stated a resident was identified as a safe smoker if they could light and hold their own cigarette. He noted the smoking porch was open from 7 AM to 8 PM and residents could go out whenever they wanted during that time. The Administrator explained there was always a staff person outside, primarily assigned to the smoking porch. The cigarettes and lighters are collected and put in a bag labeled with the resident's name and are kept on the unit. He indicated the smoking material were collected because they want to be compliant with the smoking policy. It is a struggle to keep residents who smoke from getting extra cigarettes. We monitor the residents and educate the families and residents. He noted the nursing team was ultimately responsible for residents smoking and there had not been any changes to the policy in the past 90 days. Administration is ultimately responsible for making sure the policies are followed. He said there was a guardian angel program and administrative staff were assigned a group of rooms. They do daily room rounds and they look at the rooms for smoking material. Both the Director of Nursing (DON) and the Administrator stated it would be concerning if a resident had a lighter in the room as some roommates had oxygen and confused residents could access the lighters. The DON stated she did rounds on all units. On 7/13/23 at 1:09 PM, Registered Nurse (RN) G stated smoking materials were kept on the East Wing because that is where the residents go to smoke. On 7/13/23 at 1:23 PM, Licensed Practical Nurse (LPN) F stated cigarettes and lighters were kept in a lock box in the medication room. She stated if a resident wanted to smoke, they took the box outside and gave them their cigarettes and lighter if they were a safe smoker. If a resident needed assistance, we give them a cigarette and we light it for them. If they require a smoking blanket, we put it on before they smoke. She noted there was usually someone assigned to the smoking porch but if that staff person was on break, other staff took turns to supervise the residents who smoked. If they have a lighter when they come out to the porch, we are supposed to take it from they when they finished smoking. If they refuse to give it to us, we should notify the DON or Administrator. 35339 3. Review of the medical record revealed resident #69 was admitted to the facility on [DATE], with diagnoses of chronic respiratory failure, congestive heart failure, chronic kidney disease and dependency on supplemental oxygen. Review of the MDS annual assessment with assessment reference date of 10/29/22 showed resident used tobacco products. Further review of MDS quarterly assessment with assessment reference date of 04/26/23 showed the resident's Brief Interview for Mental Status score was 15 which indicated she was cognitively intact, independent with supervision and set up for activities of daily living. A care initiated 10/07/22 and revised on 4/12/23 showed the resident had been assessed as able to smoke independently. Intervention revealed maintain smoking materials in designated area. A careplan focus initiated 10/30/21, revised on 02/13/23 for potential for complications of respiratory distress related to dependence on supplemental oxygen, resident chooses to smoke cigarettes with an intervention dated 10/30/21 to administer oxygen as ordered. Review of the physician order dated 8/11/22 showed oxygen at 3 liters per minute via nasal cannula every shift. Review of smoking evaluation dated 06/14/23 at 2:52 PM, revealed under maintenance of smoking materials resident#69 must request smoking materials from staff. On 07/11/23 at 11:12 AM, resident #69 was noted smoking in close proximity to Certified Nursing Assistant (CNA) P who monitored residents smoking. Resident #69 stated, she had her own cigarettes and lighter. Further observation of the smoking area did not reveal a smoking box or secure container for storage of resident's cigarettes or lighters. On 07/12/23 at 12:28 PM, resident #69 was lying in bed with oxygen infusing via nasal cannula at 3 liters per minute. She stated she had her lighter and cigarettes. She then pointed to a little black pouch on top of the small refrigerator across from the foot of her bed. She gave permission for this surveyor to look inside at the cigarettes and lighter. The pouch contained cigarettes in a green box and a lighter. She stated she kept her cigarettes and lighter with her. 07/12/23 at 10:54 AM, the DON stated a staff member was assigned to supervise the smoking area. She said resident smoking evaluation were completed quarterly, and some residents did not need to be supervised. She stated staff assisted residents with cigarettes and lighters, and no resident should have cigarette lighter with them. She stated she would have to get clarification from the regional nurse if residents could keep cigarettes and emphasized residents could not keep lighters with them. 4. Review of the medical record showed resident #75 was admitted to the facility on [DATE] with diagnoses of diabetes type 2, depressive disorder, hypertension, and nicotine dependence. Review of the MDS admission assessment with assessment reference date of 12/15/22 revealed current tobacco use. The MDS quarterly assessment with assessment reference date of 06/07/23 showed the resident's Brief Interview for Mental Status score of 13 which indicated she was cognitively intact, independent, set up only, of one person for assistance with activities of daily living. Care plan initiated 12/12/22 and revised on 4/12/23 showed focus for resident desires to smoke, has been assessed as able to smoke independently with intervention indicating smoking materials were to be maintained in designated area. Review of smoking evaluation dated 6/14/23 at 2:43 PM, showed resident must request smoking materials from staff located under maintenance of smoking materials. On 07/11/23 at 11:09 AM, resident #75 was in wheelchair at a table outside, smoking. She stated she had her own cigarettes and lighter and staff did not give them to her. 07/12/23 12:06 PM, resident was in the smoking patio. Certified Nursing Assistant (CNA) A stated less than a month ago, the facility stopped doing the smoke box for storage of residents' cigarettes and lighters. He stated yes, now we are passing out the cigarettes and lighters to the residents. 5. Review of the medical record reflected resident #6 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, nicotine dependence, hypertensive heart disease with heart failure, anxiety disorder, and osteoporosis. Review of the MDS admission assessment with assessment reference date of 01/13/23 revealed current tobacco use. The MDS quarterly assessment with assessment reference date of 04/10/23 revealed Brief Interview for Mental Status score of 15 which indicated she was cognitively intact. The assessment noted the resident required extensive to total assistance of one person with activities of daily living. A Care plan initiated 10/7/22 and revised on 7/11/23 revealed resident #6 desired to smoke, had been assessed and was able to smoke independently with intervention dated 6/16/23 to accompany resident to designated smoking area and provide supervision. A smoking evaluation dated 6/14/23 at 2:49 PM, indicated resident #6 must request smoking materials from staff. On 07/11/23 at 11:09 AM, resident #6 was in her wheelchair in the smoking patio, smoking. She stated she had her own smoking material. On 07/13/23 at 12:12 PM, the Administrator stated everyone should be following the smoking policy and there had been no changes in the policy. He stated he was not aware staff had not been collecting cigarettes and lighters from residents after they finished smoking. 36489 6. Review of the medical record revealed resident #73 was originally admitted to the facility on [DATE] with diagnoses including muscular dystrophy, right side paralysis, generalized muscle weakness, and muscle spasms. Review of the MDS Annual assessment with ARD of 4/28/23 revealed resident #73 required limited assistance from one person for transfers and supervision for locomotion off the unit. He used a wheelchair for mobility, was only able to stabilize with staff assistance when he moved from a seated to standing position, and functional limitation in range of motion related to impairment on one side of his upper and lower extremities. The MDS assessment showed resident #73 currently used tobacco. Resident #73 had a care plan for smoking, initiated on 7/11/22, which indicated he was assessed as able to smoke independently and was informed of the facility's smoking policy. The goals were that he would demonstrate safe smoking practices and adhere to the smoking policy. The interventions included maintain smoking materials in the designated area and nursing staff were to redirect the resident if they observed unsafe smoking practices. Review of a Smoking Evaluation form dates 6/14/23 revealed the resident smoked cigarettes and had the cognitive, visual, and physical ability to smoke safely. The document indicated the facility deemed resident #72 as able to smoke unsupervised in the designated smoking area and he could maintain his own smoking material according to the facility's policy. The form showed the resident was informed of smoking policies and procedures. On 7/11/23 at 11:31 AM, resident #72 sat in his wheelchair on the facility's smoking porch. He stated he received education on the smoking policy when he was admitted to the facility. The resident explained his son provided cigarettes and lighters for him and he kept these items in his room. On 7/11/23 at 3:52 PM, resident #72 was in his room and showed a green and white box with cigarettes and a tan-colored lighter in the top drawer of the bedside table. On 7/12/23 at 11:06 AM, the DON explained there was always an assigned staff member on the smoking porch to hand out cigarettes and lighters. She explained the staff member would either give lighters to the residents or assist them to light their cigarettes. The DON verified residents should return lighters to the staff member and not retain lighters after smoking. On 7/12/23 at 1:01 PM, the [NAME] Wing Unit UM stated he was aware some residents had access to lighters. He explained the problem was they got lighters from outside. The UM stated when staff found residents with lighters, they retrieved them and placed them in a bag with the resident's name, which was kept on the East Wing. Review of the facility's policy and procedure for Safe Smoking, issued on 4/01/22, read, Residents that are smokers may not keep lighters/ignition material on their person or in their room unless provided by a nurse to be used during smoking opportunities. Lighters/ignition materials must be maintained at the resident's designated nurse's station or other centralized location specific for this purpose. 7. Review of the medical record revealed resident #26 was admitted to the facility on [DATE] with diagnoses including arthritis of both knees, abnormality of gait and mobility, legal blindness, and a history of falling. Review of the 5-day scheduled assessment for Medicare Part A Stay with ARD of 6/07/23 revealed resident #26 had a Brief Interview for Mental Status score of 14 which indicated he was cognitively intact. He required supervision for walking, extensive assistance for toilet use and personal hygiene, and used a walker and wheelchair for mobility. The MDS assessment indicated the resident was always continent of bowel and bladder. He had one fall with no injury since admission. Resident #26 had a baseline care plan initiated on admission, 5/15/23, for risk for falls. The interventions included checking the environment for trip hazards, encouraging the resident to wear well-fitting, non-slip footwear, and ensuring the CNA care plan or Kardex reflected any special interventions needed to prevent falls, and that those approaches were implemented. The baseline care plan was resolved, and a comprehensive care plan for risk for falls related to generalized weakness, seizures, and legal blindness was initiated on 5/17/23. The goals included minimizing the resident's risk for falls with staff intervention. The interventions directed staff to keep the resident's environment clean and walkways free of clutter, and observe for use of appropriate footwear and assist as needed. On 7/10/23 at 1:18 PM, during tour of the [NAME] Wing, resident #26's bathroom revealed a large puddle of yellow liquid with an odor of urine on the floor to the left of the toilet. On 7/10/23 at 1:31 PM, CNA H was informed of the large puddle of urine on resident #26's bathroom floor. She explained there was a problem with that bathroom as it was shared by four residents in adjoining rooms, one of whom, resident #26's roommate, had dementia and would not use an incontinence brief. CNA H stated the roommate regularly went into the bathroom and urinated everywhere. She stated she had reported the situation to all the nurses she worked with and also informed the [NAME] Wing UM. She recalled during one particular shift she had to clean up urine on the floor three times. CNA H stated on two separate occasions she walked into the bathroom and almost slipped and fell in the urine on the floor. She validated resident #26 had to use that bathroom. On 7/10/23 at 1:40 PM, the [NAME] Wing UM stated residents' rooms and bathrooms were cleaned daily and as needed as any concerns were brought to the attention of staff. The [NAME] Wing UM stated he was aware resident #26's roommate urinated on the floor in the shared bathroom and he acknowledged the situation warranted more frequent monitoring and cleaning of the floor. On 7/11/23 at 11:16 AM, resident #26 stated his roommate made a mess of the bathroom. The resident explained since his roommate was admitted there was often a significant amount of urine on the floor. Resident #26 stated he did not like to walk in the urine it, but his sandals were very hard to put on without assistance so he ended up going to the bathroom without shoes. The resident stated he slipped and fell in urine on the bathroom floor within the last two to three days, and required assistance from staff to get up off the floor. Review of the Situation, Background, Appearance, Review and Notify Communication form dated 7/09/23 revealed resident #26 had a change in condition related to a fall as he was observed on his buttocks on the bathroom floor. The document indicated there was urine on the bathroom floor and to make the situation better, he was encouraged to use the urinal. On 7/12/23 at 12:29 PM, the Assistant Director of Nursing stated she was on call on 7/09/23 and received notification from resident #26's assigned nurse via text message regarding resident #26's fall in urine on the floor. She explained the resident was not injured and she verified staff cleaned up the urine. On 7/12/23 at 1:11 PM, the DON and [NAME] Wing UM stated the facility was not aware there was a fall and accident hazard related to urine on the resident #26's bathroom floor prior to his fall on 7/09/23. The DON reviewed the medical record and stated resident #26's roommate was admitted to the facility on [DATE]. On 7/12/23 at 1:16 PM, CNA H joined the interview and informed the DON and [NAME] Wing UM that over the last two weeks she had informed the nurses assigned to resident #26 and his roommate about the concern regarding urine on the bathroom floor. On 7/13/23 at 9:58 AM, resident #26 was told review of the facility's fall investigation revealed information that conflicted with his statement during an interview on 7/11/23 at 11:16 AM, in which he stated he slipped and fell in urine on the bathroom floor. The resident smiled and stated after he spoke with facility staff yesterday, he recalled that his fall occurred as a result of his knee buckling. The facility's policy and procedure for Falls, issued on 4/01/22, revealed the facility would attempt to prevent falls and injuries related to falls by identifying possible causes that were associated with or directly result in a fall. Review of the undated job description for Concierge revealed duties and responsibilities included keeping floors dry and reporting any hazardous conditions to a nursing supervisor or member of management.

Based on observation, interview and record review, the facility failed to honor the right to make choices about significant aspects of activities of daily living related to preferred method of toileting (#250), and frequency and preferred method of bathing, (#9, #28, #307, #308, #252) for 6 of 8 residents reviewed for choices of a total sample of 44 residents. Findings: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses to include depression, bipolar disorder, sleep apnea. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 2/14/23 revealed the resident's cognition was intact, with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Resident #9 required limited assistance with one person for dressing, personal hygiene, and one-person physical assist for bathing. On 7/10/23 at 1:50 PM, resident # 9 stated she had not had a shower since she moved to this room. She said they brought a towel and wash cloth in for her to wash herself. Review of the medical record revealed the resident transferred to her current room on 6/25/23 and had one shower since the move with no other type of bathing noted. 2. Resident #28 was admitted to the facility on [DATE] with diagnoses of encephalopathy, and history of falls. The resident's modified quarterly MDS assessment with ARD of 5/19/23 revealed the resident was cognitively intact with a BIMS of 15 out of 15. She required limited assistance of one person for bed mobility, transfers, dressing, person hygiene, and one-person physical assist for bathing. On 7/13/23 at 4:41 PM, resident #28 stated she preferred showers but was always given a bed bath. Review of the record revealed resident #28 received a bed bath on 6/30/23, 7/03/23, 7/05/23, and 7/10/23. There was no documentation for showers noted. 3. Resident #307 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, with dependence on dialysis. On 7/11/23 at 2:00 PM, the resident stated she had not been offered a shower since admission, nor was she offered a bed bath. She said, I take myself in the bathroom and wash off. A care plan dated 7/03/23 noted resident #307 had a self-care deficit with dressing, grooming, and bathing related to generalized weakness, and limited endurance. 4. Resident #308 was admitted to the facility on [DATE] with diagnoses of encephalopathy, history of falls, and artificial hip joint. On 7/11/23 at 2:14 PM, resident #308 stated she had her first shower yesterday. She said, I have not been offered a bed bath or shower since admission. I take myself to the bathroom and wash up. The resident said it felt so good to get a shower. A care plan dated 6/30/23 read resident #308 has a self-care deficit with dressing, grooming, and bathing related to generalized weakness. On 7/12/23 at 5:18 PM, the [NAME] Wing Unit Manager stated his expectation was that residents received showers on their shower days. He stated he would also expected the Certified Nursing Assistant (CNA) be truthful about showers. He explained, In the future I will be checking behind the CNA to ensure the showers are done. He noted he spoke to residents daily and none of them told him they were not getting showers. On 7/13/23 at 1:17 PM, CNA J stated when a resident was ready to get up in the morning and it was not their shower day, she would wash them up and get them dressed. She said, if they get around independently, I give them a towel and washcloth so they can wash up. If they need help, they will ask. 36489 4. Review of the medical record revealed resident #250 was admitted to the facility on [DATE] with diagnoses including brain cancer, left side paralysis, and generalized muscle weakness. Review of the Nursing Admission assessment dated [DATE] showed resident #250 was oriented to person, place, time, and situation. The document indicated the resident expressed personal care and lifestyle preferences that the facility would honor as able. The assessment showed resident #250 required assistance from staff for toileting. On 7/10/23 at 5:35 PM, resident #250 explained he was continent of urine and said, I would like to use the urinal instead of a diaper. He stated on admission to the facility, he informed staff he required assistance with placement of the urinal as his left arm was paralyzed. However, resident #250 stated since being in the facility, CNAs informed him he needed to use an incontinence brief and they would change him after he urinated in the brief. On 7/10/23 at 5:47 PM, resident #250 informed the [NAME] Wing Unit Manager (UM) that CNAs had not been offering him a urinal per his request on admission. He reiterated his preference to not urinate in an incontinence brief. The [NAME] Wing UM retrieved the resident's urinal from the bathroom and held it for him to void. He verified the resident urinated readily, and voided approximately 500 milliliters (ml) of urine. For most people, the bladder holds between 500 and 700 ml of urine, but the urge to urinate usually occurs when it fills with 200 to 350 ml of urine (retrieved on 7/20/23 from www.my.clevelandclinic.org/health/body/25010-bladder). On 7/12/23 at 9:28 AM, resident #250 stated despite the discussion with the [NAME] Wing UM on 7/10/23, he still had not received assistance with the urinal as requested. He said, One lady came in yesterday and said she would help me. She must have got pulled off because she never came back. The resident stated when he was in the hospital he used the call light and staff came to his room to assist him with the urinal. The resident said, I have tried that here and it just doesn't happen.I know when I need to go. Sometimes it takes a minute to get started, but I know. Resident #250 emphasized he did not like to urinate in a brief as the bed got wet and it was just not what he was accustomed to doing. On 7/12/23 at 12:44 PM, the [NAME] Wing UM recalled he met with resident #250 on the morning after he was admitted to the facility. He stated the resident expressed a preference to be assisted to use a urinal and he assured him staff would be able to do that. The [NAME] Wing UM acknowledged he was aware this aspect of care was important to the resident. 5. Review of the medical record revealed resident #252 was admitted to the facility on [DATE] with diagnoses including fracture of the sacrum or tailbone, Multiple Sclerosis, Parkinson's Disease, spinal stenosis, generalized muscle weakness, and a history of falls. Review of the Minimum Data Set (MDS) Admission assessment with assessment reference date of 6/30/23 revealed resident #252 had a Brief Interview for Mental Status score of 13 which indicated she was cognitively intact. The document showed the resident required extensive assistance from two staff members for dressing, extensive assistance from one staff member for personal hygiene, and she was totally dependent on one staff member for bathing. Resident #252 had a care plan for self-care deficit with grooming and bathing initiated on 6/30/23. The interventions instructed staff to provide hands on assistance with dressing, grooming, and bathing as needed. Review of the [NAME] Wing shower schedule revealed resident #252 was scheduled for showers during the day shift on Mondays, Wednesdays, and Fridays. On Monday, 7/10/23 at 5:27 PM, resident #252 stated in over two weeks since admission to the facility, she received one shower and one complete bed bath. She said, That's it since I've been here. She stated on admission, she was informed she would be able to have a shower or bed bath on Mondays, Wednesdays, and Fridays. The resident explained the extent of daily care besides those two occasions was just help with changing her incontinence brief and wiping that area. She pointed to a package of disposable wipes on her overbed table and stated she used them to clean her underarms. On 7/11/23 at 11:10 AM, the resident was in bed and confirmed she wore the same T-shirt from the previous afternoon. She said, No shower yet. On 7/12/23 at 1:03 PM, the Director of Nursing stated her expectation was staff would offer either bed baths or showers according to the resident's preference on the scheduled days of the week, and additional baths as needed or requested. Review of the facility's Welcome Guide dated 1/01/23 revealed every resident had the right to self-determination and would be treated in a manner that promoted quality of life and recognized individuality. Review of the facility's policy and procedure for Resident Rights, Dignity, and Visitation Rights, issued on 4/01/22, revealed the facility would assist each resident to exercise his or her rights and provide care that was .consistent with his/her normal life habits, observing the resident's choices whenever able.

Based on interview and record review, the facility failed to conduct a Level 1 Preadmission Screening and Resident Review (PASARR) for 1 of 4 residents reviewed for PASARRs of a total sample of 44 residents, (#26). Findings: Review of the medical record revealed resident #26 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder, epilepsy, recurrent mild depressive disorder, dementia, and traumatic brain injury. Review of the Minimum Data Set (MDS) Admission assessment with assessment reference date of 5/22/23 revealed resident #26 was admitted to the facility from another nursing home or swing bed. The MDS assessment indicated the resident was not evaluated by a Level 2 PASARR and determined to have a serious mental illness and/or mental retardation or a related condition. PASARR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care and that they receive necessary services in the most appropriate setting. PASARR requires that Medicaid-certified nursing facilities conduct a preliminary assessment called a Level 1 screen prior to admission, to determine whether the potential resident might have a serious mental illness or intellectual disability. Those individuals who test positive at Level I are then evaluated in depth with a Level 2 screen to determine appropriate placement and recommended services (retrieved on 7/20/23 from www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/preadmission-screening-and-resident-review/index.html). Review of scanned documents in resident #26's electronic medical record showed no PASARR form. On 7/12/23 at 2:33 PM, the Social Services Director (SSD) was asked if she could assist in locating resident #26's PASARR form in the electronic medical record. She reviewed the scanned documents and validated the PASARR form was not scanned into the medical record. The SSD explained the resident was admitted from another skilled nursing facility and a PASARR form should have been generated by the current facility. The Medical Records staff who shared the SSD's office was asked to check unscanned paperwork for the resident's PASARR form. The Medical Records staff searched through her papers, was not able to find the document, and left the office. On 7/12/23 at 3:34 PM, the SSD provided a PASARR Level 1 form for resident #26. The document listed the name and address of the current facility as the present location of the individual being evaluated. The form indicated the resident had mental illnesses or suspected mental illnesses (depressive disorder and post-traumatic stress disorder) and a related condition (epilepsy). The document read, Incomplete forms will not be accepted. By signing this form below, I attest that I have completed the above Level I PASARR screen for the individual to the best of my knowledge. The PASARR form was signed by Registered Nurse (RN) K and the line designated for the date was incomplete and read, 1. Review of the facility's active staff list revealed RN K was not listed as a current employee. On 7/13/23 at 9:33 AM, the Human Resources staff confirmed RN K no longer worked at the facility. She stated RN K used to be the facility's Assistant Director of Nursing (ADON) and Staff Educator before she was terminated on 1/17/21. On 7/13/23 at 9:37 AM, the Admissions Director explained residents who were admitted from other skilled nursing facilities, home or assisted living facilities (ALFs) would have PASARR forms complete in-house. She stated when resident #26 was admitted from an ALF in May 2023, the facility did not have an ADON, so the Director of Nursing (DON) would have completed the form. The Admissions Director showed an email dated 5/15/23 at 1:46 PM that she sent to all department heads including the Executive Director, the DON, and SSD, with detailed information regarding the resident's transition to long-term care. The email read, He will need a PASARR. The Admissions Director stated when the Medical Records staff informed her yesterday that there was no PASARR form for resident #26, she told her she sent the email to the DON. On 7/13/23 at 10:30 AM, the DON verified resident #26's PASARR Level 1 form was not dated and never uploaded into the electronic medical record. She was asked if she could explain how the document was signed by RN K who was terminated more than two years prior to the resident's admission. The DON stated she had no idea how old the form was or where it came from. On 7/13/23 at 11:08 AM, the SSD stated she found the PASARR form in a box on the [NAME] Wing nurses' station, The facility's policy and procedure for Role of Admissions and Social Services in PASARR, issued on 4/10/22, revealed the facility would ensure each resident was screened for a mental disorder or intellectual disability prior to admission. The policy indicated the PASARR Level 1 form would be scanned into the electronic medical record or maintained in a specified tracking mechanism.

Based on interview and record review, the facility failed to develop and implement a baseline care plan that reflected person-centered care related to assistance with toileting for 1 of 3 residents reviewed for activities of daily living (ADLs), of a total sample of 44 residents, (#250). Findings: Review of the medical record revealed resident #250 was admitted to the facility on [DATE] with diagnoses including brain cancer, left side paralysis, and generalized muscle weakness. Review of the Nursing Admission assessment dated [DATE] showed resident #250 was oriented to person, place, time, and situation. the document indicated the resident expressed personal care and lifestyle preferences that the facility would honor as able. The assessment showed resident #250 required assistance from staff for toileting and did not have a urinary catheter. On 7/10/23 at 5:35 PM, resident #250 explained he was continent of urine and on admission to the facility, he informed staff he required assistance with placement of the urinal as his left arm was paralyzed. Resident #250 stated since being in the facility, Certified Nursing Assistants (CNAs) informed him he needed to use an incontinence brief and they would change him after he urinated in the brief. Review of resident #250's medical record revealed a baseline care plan for assistance with ADLs was initiated on 7/03/23. The goal noted the resident would have his ADL needs met. The interventions instructed nursing staff to assist and provide ADL care and support as needed. The baseline care plan did not include information regarding the resident's request to use a urinal instead of an incontinence brief for voiding. A baseline care plan for expressed personal care and lifestyle preferences was initiated on 7/03/23, but was noted to be resolved, and it had no interventions listed. Review of the CNA care plan or Kardex showed at the time resident #250 was interviewed on 7/10/23, there were no person-centered care instructions regarding use of a urinal for toileting. On 7/12/23 at 12:44 PM, the [NAME] Wing Unit Manager (UM) recalled he met with resident #250 on the morning after he was admitted to the facility. He confirmed the resident expressed a preference to be assisted to use a urinal and he thought he updated the Kardex with that information on the same day. Review of the Kardex with the [NAME] Wing UM and the Director of Nursing (DON) revealed the document now included instructions for a toileting plan that involved prompting the resident every two hours and cuing him with a urinal. The DON was asked to review the baseline nursing care plans for this intervention and she was not able to locate it. On 7/13/23 at 3:36 PM, the Minimum Data Set (MDS) Licensed Practical Nurse (LPN) validated resident #250 never had a person-centered baseline care plan developed for incontinence and/or toileting. She was informed a new intervention regarding use of a urinal was discovered on the CNA Kardex although there was no related baseline care plan. The MDS LPN reviewed the resident's electronic medical record and noted the intervention was added to the Kardex by the Regional Nurse on 7/10/23. The MDS LPN explained if staff placed items on the Kardex without entering an order, progress note, other documentation, or verbally communicating with her, she would not be aware of the need to include it in the baseline care plan. Review of the facility's policy and procedures for Baseline Care Plans, issued on 4/01/22, revealed the facility would develop and implement a baseline care plan within 48 hours of admission that included instructions necessary to meet residents' person-centered care needs.

Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan to address dental care and services required by 1 of 2 residents reviewed for dental services, out of a total sample of 44 residents, (#26). Findings: Review of the medical record revealed resident #26 was admitted to the facility on [DATE] with diagnoses including arthritis of both knees, type 2 diabetes, legal blindness, and a history of falls. Review of the Minimum Data Set (MDS) Admission assessment with assessment reference date of 5/22/23 revealed resident #26 had a Brief Interview for Mental Status score of 14 which indicated he was cognitively intact. The document showed the resident had no obvious or likely cavity or broken natural tooth. On 7/11/23 at 11:18 AM, resident #26 pointed to his left lower jaw and stated he had a broken tooth. The brown, jagged surface of an obviously broken and possibly decayed lower left tooth was clearly visible during conversation with the resident. Review of the resident's comprehensive care plan as of 7/11/23 revealed no care plan focus, goals, or interventions related to dental issues. On 7/12/23 at 2:33 PM, the Social Services Director (SSD) stated she was not aware of any dental concerns for resident #26. She reviewed the resident's medical record and confirmed the admission nursing assessment and the initial MDS assessment showed resident #26 had no dental issues. When the SSD was informed the resident did not have a dental care plan, she began to type on her computer keyboard and said, He did not have a dental care plan, but I just put one in. On 7/13/23 at 3:16 PM, the MDS Licensed Practical Nurse (LPN) stated resident #26's broken tooth should have been identified by the admission nurse and/or the MDS nurse who conducted the admission assessment. She verified if nurses had noted the resident's broken tooth, an appropriate care plan would have been initiated. Review of the facility's policy and procedure for Comprehensive Assessments and Care Plans, issued on 4/01/22, revealed the facility would conduct a comprehensive and accurate assessment of a resident's needs and goals which would include his/her dental status. The policy indicated the results of the assessment would be used to develop and implement a comprehensive person-centered care plan for the resident.

Based on interview and record review, the facility failed to implement its policy and procedures for prohibition of Abuse for 1 of 4 residents reviewed for Abuse, of a total sample of 44 residents, (#252). Findings: Review of the medical record revealed resident #252 was admitted to the facility on [DATE] with diagnoses including fracture of the sacrum or tailbone, Multiple Sclerosis, Parkinson's Disease, spinal stenosis, generalized muscle weakness, and a history of falls. Review of the Minimum Data Set Admission assessment with assessment reference date of 6/30/23 revealed resident #252 had a Brief Interview for Mental Status score of 13 which indicated she was cognitively intact. On 7/11/23 at 1:12 PM, resident #252 expressed concerns regarding a bad experience with staff on her first night in the facility that made her feel afraid. The resident stated in the morning she informed the [NAME] Wing Unit Manager (UM) that she was scared and staff were mean to her. On 7/11/23 at 1:27 PM, the [NAME] Wing UM confirmed resident #252 told him about an incident with staff which caused her to feel afraid. The [NAME] Wing UM stated he felt the Certified Nursing Assistants (CNAs) treated residents well and resident #252's fear might have been caused by her perception of the way people of other cultures expressed themselves. He explained he interviewed the resident and she clarified she did not feel like there was a physical threat to her well being. The [NAME] Wing UM stated what he understood from the resident was that the CNA was probably a little gruff. He recalled he mentioned the issue at the daily clinical meeting and it was discussed briefly, but the team decided it did not meet the criteria for Abuse or Neglect. He explained the incident was not investigated as it did not arise to the level of Abuse. On 7/11/23 at 1:33 PM, the Director of Nursing (DON) confirmed she was the facility's Abuse Coordinator but she was not sure if an allegation of Abuse for resident #252 was investigated as she had not yet started work in her current position on the day the resident was admitted . Review of the facility's log of Abuse, Neglect, and Misappropriation allegations for June and July 2023 revealed no documentation of an Abuse allegation by resident #252. On 7/11/23 at 1:41 PM, the Executive Director, Corporate Nurse, DON and the [NAME] Wing UM were informed of concerns related to the absence documentation of resident #252's allegation of possible Abuse in her medical record or on the log of reportable incidents. The Corporate Nurse was informed the resident informed the [NAME] Wing UM she felt afraid on her first night in the facility, and although he notified the interdisciplinary team (IDT), an investigation was not initiated. The Corporate Nurse validated if the resident expressed fear of an employee, the facility should conduct an investigation. On 7/13/23 at 12:05 PM, the [NAME] Wing UM was informed resident #252's electronic medical record was updated on 7/12/23 to reflect an Interdisciplinary Plan of Care Review Meeting Summary dated 6/23/23. He stated he wrote the note after the IDT discussion. The [NAME] Wing UM was reminded both he and resident #252 stated they discussed the incident on 6/24/23, the morning after she was admitted . He explained he was not aware the allegation was reportable, but had since been made aware. Review of the job description for Unit Manager dated 1/01/15 revealed he/she would review complaints and grievances made by residents and make written and oral reports to the DON. The UM was expected to report and investigate all allegations of Abuse and/or Neglect. Review of the facility's policy and procedures for Abuse, Neglect, Exploitation and Investigations, issued on 4/01/22, revealed all alleged violations of Federal or State laws would be reported immediately to the facility's Executive Director, DON, or Abuse Coordinator. The document defined Abuse as inclusive of intimidation with resulting mental anguish. The policy indicated all staff would be trained to recognize and report possible Abuse to the appropriate staff and the facility would notify State agencies and file required Federal reports. The facility would notify the attending physician and the resident's representative, and involved staff would be removed from the schedule while the facility conducted a thorough internal investigation.

Based on interview and record review, the facility failed to appropriately record and investigate a grievance to ensure resolution in a timely manner for 1 of 1 resident reviewed for grievances, of a total sample of 44 residents, (#71). Findings: Review of the medical record revealed resident #71 was admitted to the facility on [DATE] with diagnoses including left shoulder osteoarthritis, aortic stenosis, generalized weakness, and chronic kidney disease. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 6/23/23 revealed resident #71 had a Brief Interview for Mental Status score of 15 out of 15 which indicated he was cognitively intact. The MDS assessment showed the resident was independent with all activities of daily living, except for supervision with dressing, and he was always continent of bowel and bladder. On 7/10/23 at 1:18 PM, resident #71 explained the main concerns that affected his life in the facility was the bad condition of his bathroom. He said, It's never clean. Since the new guy came in, none of us can really use it. Everybody knows about it. Resident #71 stated he reported the situation to Certified Nursing Assistants (CNAs) and the Concierge much more than once. He explained the CNAs knew about the problem because they saw it all the time, in addition to his complaints. Resident #71 explained the bathroom was shared by four residents including himself, and they were all affected by its condition. Observation of the shared bathroom revealed a large puddle of yellow liquid with an odor of urine on the floor to the left of the toilet. The resident said, It's like that all the time. It might not be normal to you, but I'm accustomed to it. On 7/10/23 at 1:24 PM and 1:34 PM, the Environmental Services Director inspected the shared bathroom and confirmed there appeared to be urine on the floor around the toilet. Resident #71 informed him the bathroom was like that very often and he had reported it to multiple staff including the Concierge and CNAs. The Environmental Services Director stated he was never made aware of the resident's grievance regarding the bathroom. On 7/10/23 at 1:31 PM, CNA H stated resident #71 and the other residents who used the shared bathroom complained to her and stated they were upset about the condition of the bathroom. She confirmed she reported the situation to the [NAME] Wing Unit Manager (UM) and nurses assigned to the residents. On 7/10/23 at 1:38 PM, the facility's Concierge confirmed resident #71 complained to her about the condition of his bathroom and she asked a housekeeper to clean the floor. The Concierge could not recall the date of the reported concern, nor the name of the housekeeper. She acknowledged she did not complete a grievance form regarding the issue as she believed it was resolved once the bathroom was cleaned. On 7/12/23 at 2:59 PM, the Social Services Director (SSD) explained grievance forms were accessible to anyone as they were placed in multiple locations throughout the facility. She provided a Grievance-Complaint Report dated 7/1 written by the Concierge regarding resident #71's complaint about the condition of his bathroom. The SSD stated she received the form yesterday, 7/11/23, and was not aware the resident reported concerns prior to that day. She was informed the resident stated he complained to multiple staff about the issue which began soon after a new resident was admitted to the adjoining room in the past month. The SSD acknowledged if staff followed the grievance process, the interdisciplinary team would have been notified of the concerns and conducted an investigation. On 7/12/23 at 3:02 PM, the Concierge validated she wrote the grievance form yesterday, 7/11/23. She explained she did not remember the actual date resident #71 complained about the shared bathroom so she tried to back date the document and meant to put a question mark following the date of 7/1. The Concierge stated she believed the resident expressed his concerns possibly around the first of July. On 7/12/23 at 6:06 PM, the facility's Executive Director stated the Concierge wanted to clarify her previous statements regarding resident #71's grievance about the condition of his bathroom. The Concierge stated the date of 7/1 on the grievance form she wrote was wrong and it was supposed to be 7/10, the past Monday, as that was the day she informed the housekeeper the bathroom needed to be cleaned. The Executive Director and Concierge were informed the correction would be added to the survey documentation but interviews with resident #71 and staff indicated the problem existed prior to Monday 7/10/23. They were told Housekeeper M was the staff who worked on 7/10/23, not potential housekeepers named by the Concierge, and Housekeeper M stated she discussed resident #71's bathroom with a CNA that day. Review of the facility's Grievance Log for June and July 2023 revealed no entries regarding resident #71's grievance. Review of the facility's policy and procedure for Grievances, issued on 4/01/22, revealed staff would assist residents to write formal grievances, and if expressed verbally, staff would record the grievance on the appropriate form. The policy indicated the individual who filed a grievance had the right to resolution in a reasonable timeframe, and the facility would document a written decision to include investigation findings, conclusions, and corrective actions if indicated. Review of the undated job description for Concierge revealed duties and responsibilities included reporting all complaints and grievances made by residents to a nursing supervisor or any member of management.

Based on observation, interview, and record review, the facility failed to ensure a bathroom shared by residents in 1 of 18 bathrooms on the East Wing (room [ROOM NUMBER]) and 2 of 29 rooms on the [NAME] Wing (rooms #154 & #156) were maintained in a clean and homelike condition. Findings: 1. Observations conducted on 07/10/23 at 3:10 PM, 07/11/23 at 12:17 PM, 7/12/23 at 9:29 AM, 12:52 PM, and 5:44 PM and on 07/13/23 at 10:27 AM and 1:24 PM revealed room [ROOM NUMBER] bathroom (East Wing) with 7 pink plastic wash basins stacked inside each other on the bathroom floor under a white plastic shower/commode chair. The basins were not labeled with resident names and they were not covered. A pink plastic bedpan (not labeled with resident name or covered) was inside the top wash basin. A yellow plastic fracture bedpan (not labeled with resident name or covered) had been placed in the pink bedpan. On 07/13/23 at 10:27 AM and 1:24 PM, there was a small plastic laboratory specimen collection bag with a biohazard symbol inside of the yellow fracture bedpan. The resident in room [ROOM NUMBER]-B used the bathroom. On 07/13/23 at 1:25 PM, an interview with the East Wing Unit Manager and the Assistant Director of Nursing (ADON) was conducted. The East Wing Unit Manager said she had been conducting resident room rounds which included observations of the resident's room and bathroom. She said she observed for safety issues, checked if the rooms were neat, clean, and uncluttered and were free of trash. She explained there was a Guardian Angel Rounds program in place where management staff were assigned to resident rooms and completed a form which indicated what areas were to be observed. The ADON explained the resident room rounds were conducted daily, and issues were documented on the form then submitted to the Administrator. The ADON stated, All staff are responsible for insuring the resident rooms and bathrooms are clean. Observation of room [ROOM NUMBER]'s bathroom was then conducted with the East Wing Unit Manager and the ADON The East Wing Unit Manager and the ADON confirmed the findings and they stated, Nothing is to be stored on the floors and all resident care items are to be labeled with the resident's name, placed in a plastic bag, and stored in the resident's area to prevent cross-contamination. On 07/13/23 at 1:59 PM, the Administrator identified the East Wing Unit Manager was assigned and responsible for rounds in room [ROOM NUMBER] on the East Wing. The ADON said the East Wing Unit Manager was a new employee and she had just received her room assignment on 07/13/23. Review of the Observation For Action Rounds Guardian Angel Program form revealed room and bathroom were clean and odor free, nothing was stored in bathroom (unless separated and labeled with resident/roommate identifier i.e. urinal/bedpan/graduate). Review of the facility's Disposable Resident Care Product Utilization Policy, dated 4/1/2022, read, Policy: It is the policy of the facility to ensure products utilized for the provision of personalized resident care are available, utilized appropriately and discarded when no longer needed. Procedure: . 3. Disposable resident care products can be stored in resident bedside dressers, cabinets, closets and bathrooms. If a room has more that one resident that utilizes the same disposable care product, that is reusable, it is permissible to store in the same location if the item is labeled or otherwise indicates for which resident the item is to be used. Review of the Facility Assessment last updated 10/31/2022 under General Care: revealed the facility is responsible for infection identification, containment and prevention. 36489 2. On 7/10/23 at 1:18 PM, during tour of the [NAME] Wing, a large puddle of yellow liquid with an odor of urine was noted on the floor to the left of the toilet, in the shared bathroom between rooms #154 and #156. On 7/10/23 at 1:24 PM and 1:34 PM, the Environmental Services Director inspected the shared bathroom and confirmed there appeared to be urine on the floor. He stated he was not aware of any ongoing concerns regarding the cleanliness of the bathroom. The Environmental Services Director explained he conducted daily rounds of the facility but never noticed a problem with the bathroom. On 7/10/23 at 1:31 PM and 7/12/23 at 1:16 PM, Certified Nursing Assistant (CNA) H verified there was a problem with the cleanliness of the shared bathroom for approximately the past two weeks. She explained one of the four residents who used the shared bathroom regularly urinated everywhere. She recalled during one particular shift she had to clean up urine on the bathroom floor three times. CNA H stated the residents in room [ROOM NUMBER] used urinals at bedside to avoid using the bathroom as much as possible, and they also sometimes walked to the shower room at the end of the hallway to use the toilet. On 7/10/23 at 1:36 PM and 1:44 PM, Housekeeper M stated earlier that morning, CNA O expressed concerns about the shared bathroom and she cleaned it. Housekeeper M stated her supervisor, the Environmental Services Director, never instructed her to monitor that bathroom more closely. She explained the facility's housekeepers worked from 7:00 AM to 3:00 PM and the CNAs were responsible for cleaning up after the housekeepers left for the day. On 7/13/23 at 10:00 AM, CNA O verified on the morning of Monday 7/10/23 she informed Housekeeper M there was feces on the floor of the shared bathroom. She explained the urine noted later that day was a separate incident. On 7/10/23 at 1:38 PM, the facility's Concierge explained rooms #154 and #156 were assigned to her for Guardian Angel Rounds. Review of the form utilized for the task revealed the Concierge was responsible for identifying any concerns related to cleanliness and odors of the rooms and bathrooms. The Concierge stated during rounds, one of the residents in room [ROOM NUMBER] complained about the state of the bathroom and she told the housekeeper who cleaned it. The Concierge could not recall the date of the reported concern, nor the name of the housekeeper, but she denied it was Housekeeper M. On 7/10/23 at 1:40 PM, the [NAME] Wing Unit Manager (UM) stated he was aware one of the residents in room [ROOM NUMBER] urinated on the floor in the shared bathroom. He acknowledged the situation warranted more frequent monitoring and cleaning of the floor. The facility's policy and procedure for Environment of Care, issued on 4/01/22, revealed the facility would provide residents a safe, clean, comfortable, and homelike environment. The document indicated the facility would provide adequate housekeeping services to ensure sanitary surroundings.

Based on interview and record review, the facility failed to promote dignity and positive interactions through courteous behavior and respectful attitude by direct care staff for 1 of 4 residents reviewed for Dignity of a total sample of 44 residents, (#252). Findings: Review of the medical record revealed resident #252 was admitted to the facility on [DATE] with diagnoses including fracture of the sacrum or tailbone, Multiple Sclerosis, Parkinson's Disease, spinal stenosis, generalized muscle weakness, and history of falls. Review of the Minimum Data Set Admission assessment with assessment reference date of 6/30/23 revealed resident #252 had a Brief Interview for Mental Status score of 13 which indicated she was cognitively intact. Review of the medical record revealed resident #252 had a care plan for self-care deficit initiated on 6/30/23. Interventions included instructions to staff to anticipate the resident's needs, use a calm approach, and explain actions during care. On 7/10/23 at 5:18 PM, resident #252 expressed concerns regarding how she was treated by staff. She stated sometimes she pressed the call light and staff either responded slowly or not at all. She said, They seem really angry. It's more important to pick up trays than change me. Resident #252 stated this morning, while two Certified Nursing Assistants (CNAs) got her dressed for a Physical Therapy session, they conversed with each other about their problems with a popular social networking website. The resident said, It's insulting to me to be ignored. On 7/11/23 at 1:12 PM, resident #252 described an incident that occurred the previous night. She stated she was asleep at about 11:00 PM when the arriving night shift staff, CNA L, awakened her during rounds. The resident stated her incontinence brief was dry and she told the CNA she did not need to be changed, but the staff member decided to change her anyway. Resident #252 stated at the end of the shift this morning, her brief was wet and CNA L placed a clean brief on her without washing or wiping the urine from her skin. On 7/11/23 at 1:19 PM, CNA N stated she was assigned to resident #252 yesterday on the 3:00 PM to 11:00 PM shift and confirmed she conducted change of shift report with CNA L at 11:00 PM. CNA N stated she informed CNA L she had changed all residents on the assignment between 8:00 PM and 9:00 PM. CNA N explained oncoming night shift CNAs usually preferred residents to be changed closer to the end of the shift, at about 10:00 PM. CNA N stated she did not see what happened inside resident #252's room last night, but she described CNA L as being in a little rush as the residents might have been changed too early for her. Review of the facility's policy and procedure for Resident Rights, Dignity, and Visitation Rights, issued on 4/01/22, revealed staff would treat residents with kindness, respect, and dignity.

Based on observation, interview, and record review, the facility's nursing staff neglected to perform regular and change of shift rounds to provide adequate supervision and monitoring of resident status, activities, and well-being; and the facility failed to install, maintain, and check locks to ensure a secure environment and prevent a vulnerable, cognitively impaired resident from exiting the facility, for 1 of 7 residents reviewed for elopement, out of a total sample of 9 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, been accosted by unknown persons, become lost or been hit by a car. Resident #1 was seen by facility staff on 2/24/22 at approximately 2:30 AM. During the night, he left the East Wing unnoticed by staff, and entered the unit's enclosed courtyard. The resident opened an unlocked exterior exit gate and walked approximately 0.3 miles in the darkness, wearing socks but no shoes, until he stopped near a fast-food restaurant. Restaurant staff observed the resident seated in the grass at approximately 4:30 AM when they arrived at work and initially assumed he was one of the homeless people who frequented the area. The resident remained across the street from the fast-food restaurant until a Good Samaritan drove by and noticed the elderly man who was still seated on the ground at approximately 8:15 AM. The Good Samaritan bought breakfast for him, assisted him into her car, and then drove to the nearby police station. The resident provided his name to police officers who were able to ascertain his address from their records. Staff were unaware resident #1 was missing until a police officer telephoned the facility at approximately 8:30 AM and notified the receptionist that a Good Samaritan found the resident and would drive him back to the building. The facility's failure to provide adequate supervision and maintain a secure environment placed all residents who wandered at risk. This failure resulted in Immediate Jeopardy starting on 2/24/22. The Immediate Jeopardy was removed on 3/01/22. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F689 and F607 Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE] from an acute care hospital. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed resident #1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing Alert Note dated 10/17/20 indicated the device was required as the resident was at risk for elopement. The note revealed resident #1 frequently made trigger statements such as I need to get my car [to] drive to my Dr. Appt in Key [NAME]. A state map showed Key [NAME] was over 250 miles away from the facility (www.google.com/maps). A nursing progress note dated 10/28/20 at 11:17 PM, revealed resident #1 opened an exterior exit door on the West Wing and left the facility. A nurse followed the resident outside, retrieved him and placed him on 15-minute behavioral checks. The Minimum Data Set (MDS) Significant Change in Status assessment with assessment reference date of 1/19/22 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. He required supervision for walking and had unsteady balance but was able to stabilize himself without staff assistance. The resident received antipsychotic and antidepressant medications every day and used a wander/elopement alarm daily. A progress note dated 2/08/22, revealed resident #1 was assessed by a psychiatric mental health provider. The note indicated the resident reported . feeling a little anxious because I'm in a weird place. A mental status assessment revealed he was oriented to person only and had poor impulse control, poor insight and judgement, and poor memory. Resident #1 had a care plan for elopement risk and wandering initiated on 10/14/20. The care plan goals included the resident's safety would be maintained, and he would not leave the facility unattended. The interventions included distract the resident from wandering and facilitate a call to close family or friend for reassurance when he exhibited exit-seeking behavior. The care plan indicated resident #1 required direct staff supervision when out of the facility. Resident #1's care plan initiated on 9/14/21, directed staff to Increase observation for resident's safety when resident refuses safety measures. A care plan initiated on 2/02/22 indicated resident #1 was in the facility for long term placement due to his need for 24-hour supervision. Review of resident #1's medical record revealed a change in condition SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 2/24/22 that showed he left facility. A late entry Structured Progress Note dated 2/24/22 read, Resident had left facility and was brought back around 0845. On 3/21/22 at 11:14 AM, the Executive Director (ED) and the Director of Nursing (DON) were asked to provide additional information regarding the circumstances of resident #1's elopement. The DON explained the resident left the facility and went to a nearby fast-food restaurant. She stated the receptionist received a phone call from a Good Samaritan who asked if a man by resident #1's name belonged to the facility. The DON recalled the phone call was at about 8:30 AM on 2/24/22, and the Good Samaritan returned the resident to the facility soon afterward. On 3/21/22 at approximately 11:18 AM, the DON and ED provided staff statements collected during the incident investigation. The documents indicated Certified Nursing Assistant (CNA) A was assigned to care for resident #1 during the 11:00 PM to 7:00 AM night shift and last saw him during rounds at 6:40 AM. A statement by assigned day shift CNA C, revealed she noted resident #1 was not in his room at the start of the 7:00 AM shift and was still not there when she took his breakfast tray in an hour later. Licensed Practical Nurse (LPN) D's statement showed she received verbal report from the off-going nurse, LPN B, at the start of the 7:00 AM shift and also noted resident #1 was not in his room. LPN D was passing medications approximately one and a half hours later when someone informed her resident #1 was being returned to the facility. On 3/21/22 at approximately 11:25 AM, the DON explained facility staff were not concerned when resident #1 was not observed in his room or on the unit, as his normal routine was to walk around the facility. She stated their investigative findings led to the decision that neglect could not be substantiated. The DON explained the rationale for that decision was resident #1 suffered no adverse outcomes as a result of leaving the facility, and staff conducted regular rounds and monitored him throughout the night shift. The DON explained although neither LPNs B and D nor CNAs A and C did rounds during the 7:00 AM shift change report, assigned staff visualized resident #1 throughout the night shift. The DON stated the facility's timeline showed CNA A saw resident #1 in his room at 6:40 AM so he probably exited the courtyard at about 6:55 AM, which was approximately two hours before he was returned to the facility. She explained CNA C noted the resident did not come for breakfast, started to search for him, and alerted the nurse within two hours of him being seen by CNA A. The DON clarified the significance of the two-hour window as it was the accepted minimum interval for CNAs to conduct regular resident care rounds. On 3/21/22 at approximately 11:31 AM, the ED stated after resident #1 was returned, he toured the facility and discovered the magnetic lock on the northeast courtyard gate had malfunctioned, so the gate was not locked, and the alarm system was not engaged. He stated if the magnetic lock was functional, the open gate would have triggered alarms on both the East and West Wings as resident #1 left the courtyard. The ED explained at the time of the elopement, facility maintenance staff checked the exit doors weekly and he could not say exactly how long the gate had been defective prior to the incident. An invoice dated 2/24/22 revealed an outside security service provider made a service call after the incident. It read, Patio gate maglock is not locking properly. The technician noted the lock on the gate was installed improperly and had to be removed and reinstalled after the gate was adjusted. On 3/21/22 at 1:53 PM, the facility's Maintenance Director stated he was hired after the elopement incident and replaced the previous Maintenance Director who left suddenly. He explained since the incident, the facility now required all doors and exterior gates to be checked daily for functionality. The Maintenance Director stated to his knowledge there were no records to indicate exterior exit gates in the courtyards were checked every day before he assumed the position. On 3/21/22 at 11:48 AM, the East Wing Unit Manager (UM) recalled on 2/24/22 at approximately 8:30 AM, a staff member informed her resident #1 eloped and would be returned to the facility by the person who found him. She described the resident as alert with periods of confusions and said, He comes and goes. The East Wing UM explained the fast-food restaurant where the resident was found was near railroad tracks and a major thoroughfare with heavy traffic flow. She stated resident #1 might have been able to navigate sidewalks without incident but could not safely cross streets and intersections, The East Wing UM confirmed resident #1 ambulated independently and could have reached the major road and even gone much further distance in the time he was missing. She said, Any resident in here, I would not consider really totally safe out there. On 3/21/22 at 2:42 PM, in a telephone interview, CNA A stated she was assigned to care for resident #1 regularly. She recalled she assumed care of the resident at 11:00 PM that night but did not see him until 2/24/22 between 2:00 AM and 2:30 AM when she gave him a snack during her first resident care rounds for the shift. CNA A stated she was somewhat afraid of resident #1 as he could be verbally aggressive and threatening. She explained he did not need assistance with walking or going to the bathroom, so if his privacy curtain was drawn around the bed as it was that night, she never disturbed him. She denied seeing the resident at 6:40 AM as noted in the facility's timeline and reiterated she did not see resident #1 after 2:30 AM. On 3/21/22 at 3:21 PM, the DON and ED were informed CNA A stated she saw resident #1 only once during the night shift at approximately 2:30 AM, six hours before facility staff were made aware he was missing. They were told interviews with staff at the fast-food restaurant and a nearby business supported CNA A's account of the night shift as these witnesses observed the resident on the sidewalk across from the restaurant as early as 4:30 AM. On 3/22/22 at 10:46 AM, Registered Nurse (RN) K recalled interdisciplinary team discussions about resident #1's behaviors prior to the elopement incident. She explained his cognition varied and his behavioral symptoms such as verbal aggression and wandering fluctuated. RN K said, I think he would have some difficulties unsupervised outside the facility . He needs assistance in making new decisions . He is very unpredictable. He requires supervision. She acknowledged normal rounding frequency was every two hours which was a standard of practice. On 3/23/22 at 10:19 AM, LPN D stated on the morning the resident was found outside the facility, she received change of shift report from the off-going nurse, LPN B, at the nurses' station. She acknowledged she did not do walking rounds with LPN B when she assumed the assignment. LPN D confirmed resident #1 was not in his room when she passed by after change of shift report. She explained the resident often ambulated throughout the facility and she was not concerned about his whereabouts. LPN D acknowledged resident #1 continuously wandered throughout the facility and staff were responsible for ensuring he did not go through exit doors. She described the resident as having changing cognitive levels with varying degrees of confusion. When asked if she felt resident #1 would have been safe if unsupervised outside the facility, she said, Is anybody safe outside at 4:00 AM, in the dark? On 3/23/22 at 10:41 AM, the East Wing UM stated her expectation was CNAs and nurses would conduct walking rounds at the change of shift and the assigned CNA should do rounds at least every two hours during the shift. The East Wing UM explained the purpose was to visualize every resident regularly, and even if resident #1's privacy curtain was closed, staff should have checked on him. On 3/23/22 at 11:14 AM, CNA C stated at the start of the day shift on 2/24/22, she received change of shift report from CNA A at the nurses' station. She acknowledged she did not complete walking rounds with the off-going CNA to verify all her assigned residents were there. She recalled CNA A said, Everybody was good. CNA C described CNA A as a good worker so she did not feel it was necessary to do rounds to check the residents. CNA C stated she noticed resident #1 was not in his room early in the shift and assumed he was walking around the facility or sitting on the patio. She recalled she started to search for him when he did not return to his room for breakfast. CNA C said, He doesn't stay in any one place for long. He wanders from wing to wing. She confirmed the resident could have traveled a far distance in the time he was gone from the facility. Review of the job description for a Certified Nursing Assistant revised on 1/01/15 revealed a purpose of providing . routine daily nursing care and services in accordance with the resident's assessment and care plan. The CNA's duties and responsibilities included routinely checks of residents to ensure personal care needs were met and observed disoriented residents. Review of the job description for a Licensed Practical Nurse/Registered Nurse revised on 1/01/15 revealed nurses would supervise CNAs to ensure they followed the facility's policies and procedures. The job description directed nurses to periodically check residents throughout the shift . to evaluate the resident's physical and emotional status. The policy and procedure for Abuse and Neglect - Clinical Protocol revised in January 2021 defined neglect as The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the Facility Assessment, updated on 2/24/22, revealed the facility could meet the mental health and behavioral care needs of residents with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The document indicated the facility would provide person-centered care to include identification of hazards and risks for each resident. The Facility Assessment noted the preventative maintenance program involved daily review of the physical plant to identify areas that required repairs. Review of immediate measures implemented by the facility revealed the following, which were verified by the survey team: *On 2/24/22 at approximately 8:50 AM, a Good Samaritan returned resident #1 to the facility. The resident was evaluated by the East Wing UM, noted to have no injuries. Notifications were made to the physician and family. *On 2/24/22, resident #1's electronic monitoring device was checked for function and placement, and he was placed on one to one supervision. A visual head count of all residents was conducted and there were no concerns. All residents with electronic monitoring devices had the devices checked for proper placement and function *On 2/24/22, all residents in the facility were re-evaluated for elopement risk, care plans were updated as indicated, and elopement binders were reviewed for accuracy. *On 2/24/22, the Maintenance Director checked exit doors and electronic wander monitoring system for function. A magnetic lock on the gate in the northeast enclosed courtyard was found to be improperly installed and was replaced. *On 2/24/22, the facility initiated staff education on the Abuse/Neglect standard and guidelines, reporting, elopement evaluation screening, one to one supervision for active wandering behaviors, alarm response, and checking for electronic wander monitoring devices for placement and function. As of 3/01/22, 135 of 135 full time staff had been educated. All other employees will be educated at the start of next shift working. Newly hired staff will receive this education in orientation. * From 2/24/22 to 3/01/22, a total of 12 elopement drills were completed on all shifts. * On 2/24/22, an ad hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held. The committee conducted a Root Cause Analysis, accepted plans, and discussed recommendations. Audit forms were developed to monitor proper function of doors, elopement evaluations, elopement binders and to validate staff comprehension of education. *On 3/01/22, the QAPI committee held a scheduled monthly meeting which included a review of the audit forms. No changes were made, and audits continue weekly. Review of in-service and drill attendance sheets and reconciliation with staff roster validated education was completed according to the facility's plan. From 3/21/22 to 3/23/22, interviews conducted with 22 facility staff representing all shifts including 2 Registered Nurses, 5 LPNs, 14 CNAs and 1 Rehab staff revealed staff participated in elopements and were knowledgeable of the facility's elopement standard and guidelines and verbalized the importance of monitoring wandering residents, conducting change of shift and regular rounds, reporting behavior changes, and responding to alarms. The sample was expanded to include 6 additional residents at risk for wandering, exit-seeking, and elopement. Observations, interviews and record reviews revealed residents #2, #3, #4, #5, #6, and #7 had elopement risk re-assessments, appropriate care plans, and demographic information placed in the elopement binders.

Based on observation, interview, and record review, the facility failed to maintain a secure environment in an enclosed courtyard and failed to provide adequate supervision to prevent a vulnerable, cognitively impaired resident from exiting the facility, for 1 of 7 residents reviewed for elopement, out of a total sample of 9 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, been accosted by unknown persons, become lost or been hit by a car. Resident #1 was seen by facility staff on 2/24/22 at approximately 2:30 AM. During the night, he left the East Wing unnoticed by staff, and entered the unit's enclosed courtyard. The resident opened an unlocked exterior exit gate and walked approximately 0.3 miles in the darkness, wearing socks but no shoes, until he stopped near a fast-food restaurant. Restaurant staff observed the resident seated in the grass at approximately 4:30 AM when they arrived at work and assumed he was one of the many homeless people who frequented the area. The resident remained across the street from the fast-food restaurant until a Good Samaritan drove by and noticed the elderly man who was still seated on the ground at approximately 8:15 AM. The Good Samaritan bought breakfast for resident #1, assisted him into her car, and then drove to the nearby police station. The resident provided his name to police officers who were able to ascertain his address from their records. Facility staff were unaware resident #1 was missing until a police officer telephoned the facility at approximately 8:30 AM and notified the receptionist that a Good Samaritan found the resident and would drive him back to the building. The facility's failure to provide adequate supervision and maintain a secure environment placed all residents who wandered at risk. This failure resulted in Immediate Jeopardy starting on 2/24/22. The Immediate Jeopardy was removed on 3/01/22. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F600 and F607 Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE] from an acute care hospital. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated 9/30/20 indicated the resident was hospitalized for [CONDITION(S)], tremors, alcohol withdrawal, and [CONDITION(S)] which is a neurological emergency in which a patient experiences continuous [CONDITION(S)] activity for five or more minutes or has recurrent [CONDITION(S)] activity without recovery between the seizures (retrieved on 3/29/22 from https://pubmed.ncbi.nlm.nih.gov/ 459). Resident #1 had additional diagnoses including [CONDITION(S)], generalized muscle weakness, dementia with behavioral disturbance, alcohol dependence with alcohol-induced mood disorder, [CONDITION(S)] disorder, and delusional disorder. Review of the medical record revealed resident #1 had a physician's order dated 10/13/20 for application of an electronic wandering device to his right ankle for poor safety awareness. A nursing Alert Note dated 10/17/20 indicated the device was required as the resident was at risk for elopement. The note revealed resident #1 frequently made trigger statements such as I need to get my car [to] drive to my Dr. Appt (appointment) in Key [NAME]. A state map showed Key [NAME] was over 250 miles away from the facility, (www.google.com/maps). A nursing progress note dated 10/28/20 at 11:17 PM, revealed resident #1 opened an exterior exit door on the West Wing and left the facility. A nurse followed the resident outside, retrieved him and placed him on 15-minute behavioral checks. The Minimum Data Set (MDS) Significant Change in Status assessment with assessment reference date of 1/19/22 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. He required supervision for walking and had unsteady balance but was able to stabilize himself without staff assistance. The resident received antipsychotic and antidepressant medications every day and used a wander/elopement alarm daily. A progress note dated 2/08/22 revealed resident #1 was assessed by a psychiatric mental health provider. The note indicated the resident reported . feeling a little anxious because I'm in a weird place. A mental status assessment revealed he was oriented to person only and had poor impulse control, poor insight and judgement, and poor memory. The Care Area Assessment (CAA) worksheet dated 2/02/22 reflected the MDS assessment areas that triggered care planning decisions. The care area related to cognitive loss and dementia indicated the resident had dementia, inappropriate behaviors, rejected care and medications, and wandered. Resident #1 had a care plan for elopement risk and wandering initiated on 10/14/20. The care plan goals noted the resident's safety would be maintained and he would not leave the facility unattended. The interventions included distract the resident from wandering and facilitate a call to close family or friend for reassurance when he exhibited exit-seeking behavior. The care plan indicated resident #1 required direct staff supervision when out of the facility. Resident #1's care plan for deviation from the plan of care, initiated on 9/14/21, directed staff to Increase observation for resident's safety when resident refuses safety measures. A care plan initiated on 2/02/22 indicated resident #1 was in the facility for long term placement due to his need for 24-hour supervision. Review of Elopement Risk Evaluation forms dated 9/20/21 and 2/01/22 indicated resident #1 did not wander, had never eloped, and was content with placement. The forms showed elopement risk scores of 7, which deemed the resident to be low risk for elopement. The documents read, No interventions at this time. The evaluation forms did not reflect the incident of 10/28/20 when the resident wandered outside through the West Wing exit door and had to be brought back inside by staff, nor his wandering and exit-seeking behaviors as documented in the progress notes, CAA worksheet and elopement care plan. Review of resident #1's medical record revealed a change in condition SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 2/24/22 that showed he left facility. A late entry Structured Progress Note dated 2/24/22 read, Resident had left facility and was brought back around 0845. The facility's Standards and Guidelines: Resident Elopement revised on 3/27/21 read, Elopement occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so. On 3/21/22 at 11:14 AM, the Executive Director (ED) and the Director of Nursing (DON) were asked to provide additional information regarding the circumstances of resident #1's elopement. The DON explained the resident left the facility and went to a nearby fast-food restaurant. She stated the receptionist received a phone call from a Good Samaritan who asked if a man by resident #1's name belonged to the facility. The DON recalled the phone call was at about 8:30 AM on 2/24/22, and the Good Samaritan returned the resident to the facility soon afterward. On 3/21/22 at approximately 11:18 AM, the DON and ED stated the facility conducted a thorough incident investigation and obtained statements from staff. Review of the facility's investigation with the ED and DON showed Certified Nursing Assistant (CNA) A was assigned to care for resident #1 during the 11:00 PM to 7:00 AM night shift. The statement attributed to CNA A indicated on 2/24/22 she made rounds at 6:40 AM, passed water, observed the resident walk to bathroom and then saw him leave the room. CNA C, who was assigned to the resident during the 7:00 AM to 3:00 PM shift, provided a statement regarding resident #1 not being in his room when she brought his breakfast tray at approximately 8:00 AM. CNA C looked around the facility and could not locate the resident. By the time CNA C returned to the East Wing to inform the day shift nurse, Licensed Practical Nurse (LPN) D, someone told her resident #1 had been found outside. LPN D's statement showed she received verbal report from the off-going nurse, LPN B, and was passing medications when someone informed her resident #1 was being returned to the facility. The DON stated the facility was unable to reach LPN B, the assigned night shift nurse, to obtain her statement. On 3/21/22 at approximately 11:25 AM, the DON provided resident #1's verbal statement which indicated it was already light outside when he walked to the fast-food restaurant, and he left the facility because he wanted to get breakfast. The DON explained facility staff were not concerned when the resident was not observed in his room at 8:00 AM because his normal routine was to walk around. She stated the facility's timeline showed resident #1 exited the courtyard at about 6:55 AM, approximately two hours before he was returned to the facility. On 3/21/22 at approximately 11:31 AM, the ED stated after resident #1 was returned, he toured the facility and discovered the magnetic lock on the northeast courtyard gate had malfunctioned, so the gate was not locked, and the alarm system was not engaged. The ED explained at that time, facility maintenance staff checked the exit doors weekly and he could not say exactly how long the gate had been defective prior to the incident. An invoice dated 2/24/22 revealed an outside security service provider made a service call after the incident. It read, Patio gate maglock is not locking properly. The technician noted the lock on the gate was installed improperly and had to be removed and reinstalled after the gate was adjusted. On 3/21/22 at 8:30 AM, fast-food restaurant Counter Staff stated when she arrived at work on 2/24/22 at approximately 4:30 AM, she saw an elderly man seated on the ground, under a palm tree, across the street from the restaurant. Fast food restaurant Counter Staff recalled a few hours later she was at the drive through window when a woman and her son drove up, ordered two breakfast sandwiches, and told her they were for the homeless man across the street. On 3/21/22 at approximately 8:40 AM and on 3/22/22 at 8:20 AM, fast-food restaurant Maintenance Staff verified he saw an elderly man seated on the ground across from the restaurant when he arrived at work between 4:30 AM and 4:45 AM on 2/24/22. He stated he also witnessed the elderly man's unsuccessful efforts to stand up. He explained he crossed the street to ask the man if he was alright, but the man just looked up at him and did not respond. Fast food restaurant Maintenance Staff stated he returned work for a while and when he looked outside again he noticed the man was still attempting to get up from the ground. Fast food restaurant Maintenance Staff stated he usually chased away the homeless people who hung around the restaurant's parking lot in the morning. He explained they continuously harassed anyone in the area by asking for money and cigarettes. Fast food restaurant Maintenance Staff described the condition of the parking lot and surrounding area as unsafe since every morning he had to collect used injection needles from the ground before the restaurant opened. He recalled one morning he even found a woman asleep between the [NAME] and a wall. Fast food restaurant Maintenance Staff stated the woman informed him she was released from jail the night before and was tired, so she stopped there and went to sleep. He stated the elderly man on the sidewalk did not seem to be one of the regular homeless people, so he called the local police department. Fast food restaurant Maintenance Staff recalled within five minutes officers responded, spoke to the man for a while, but drove off and left him on the sidewalk. On 3/21/22 at 12:50 PM, another fast food restaurant Counter Staff stated she got to work early on 2/24/22 and was seated in the lobby at 4:30 AM. She recalled there was an elderly man seated on the sidewalk across the street. The second fast food restaurant Counter Staff stated the man was on the ground with his back against the speed limit signpost and tried to stand but could not. She explained she became concerned as he appeared too clean to be homeless. She stated the man remained there for hours and she even tried to call the nearby nursing facility to find out if they had a missing resident, but the phone rang without an answer. She showed the call log on her cell phone to validate her attempts to call the facility at 8:12 AM and 8:14 AM. The second fast food restaurant Counter Staff stated she heard that someone bought sandwiches for the man and when she walked back to the lobby she saw a woman assisting the man into her car. On 3/21/22 at 12:30 PM, resident #1's probable elopement route was retraced. He left his room on the East Wing and headed towards the door to the enclosed courtyard. He was not observed or redirected by staff as he wandered along the hallway and exited the unit. The resident then walked to the far end of the courtyard, opened the unlocked exterior exit gate, and followed the circular driveway to the sidewalk. He turned right and walked on the sidewalk adjacent to a four-lane divided road that connected two major thoroughfares. The resident passed hazards including drainage ditches and culverts and crossed ten driveways that led to commercial establishments including a sandwich shop, a liquor store, a gas station, a strip mall, and a bus stop. Empty alcohol containers were strewn in the drainage ditches along the route. Resident #1 crossed one intersection with a traffic light and turned right on a side street at a second intersection. He walked a short distance along the side street and then sat in the grass by a signpost. Resident #1 traveled a total distance of over 0.3 miles from his room to his stopping point across the street from the fast-food restaurant. On 3/21/22 at 2:42 PM, in a telephone interview, CNA A stated she was assigned to care for resident #1 regularly. She recalled she assumed care of the resident at 11:00 PM that night and saw him during her first resident care rounds on 2/24/22 between 2:00 AM and 2:30 AM when she gave him a snack. CNA A stated she was somewhat afraid of resident #1 as he could be verbally aggressive and threatening. She explained he did not need assistance with walking or going to the bathroom, so if his privacy curtain was drawn around the bed as it was that night, she never disturbed him. She denied seeing the resident at 6:40 AM as noted in the facility's timeline, and reiterated she did not see resident #1 after 2:30 AM. On 3/21/22 at 3:21 PM, the DON and ED were informed of inconsistencies with the facility's timeline for the elopement incident as CNA A stated she did not visualize resident #1 at 6:40 AM. The DON and ED did not explain the conflicting information provided by CNA A which was supported by statements from the fast-food restaurant staff. On 3/22/22 at 9:37 AM, a Police Officer from [NAME] Police Department recalled the incident involving resident #1 who eloped from a nearby nursing home. He stated a Good Samaritan found an elderly man near a fast-food restaurant and arrived at the Police Department with him on 2/24/22 at 8:27 AM. The Police Officer stated the police could not transport the resident so they called the facility to ask them to retrieve the man from the Police Department. The Police Officer stated since the man was already in the Good Samaritan's care, she offered to drive him back to the facility. He explained he called the facility a short time afterward to verify the man was again in their custody. Review of the Police Department Incident Report revealed a Walk In incident occurred on 2/24/22 at 8:27 AM. The document indicated a female Good Samaritan picked up an elderly White male . who appears to have wandered away from his residence. The female reported the man had an ankle monitor device, did not have shoes, and could not explain where he lived. The report indicated the police telephoned the facility, provided the man's name, and staff informed them he was a resident there and . they did not know he was missing. On 3/22/22 at 11:33 AM, resident #1 was in bed. CNA J, his assigned 1:1 sitter, brought in coffee and sandwich. Resident #1 thanked her and invited CNA J and two State Survey Agency staff members to sit down and join him for cocktails. In response to basic screening questions to ascertain the resident's cognitive status, he stated he was in a city that was approximately three miles away. He explained he did not live in the facility, rather he had only been there for 30 minutes. The resident said, I am only staying here for about 20 minutes until I get tired. When asked if he recently went to a fast-food restaurant he said, I caught a ride with some guy. When asked if he wore shoes when he left the facility, resident #1 paused briefly to think and then responded, I think I left my shoes on the plane. CNA J searched the resident's room including both closets and underneath the beds and validated he did not have shoes. On 3/22/22 at 5:45 PM, an Elopement Risk Evaluation form dated 2/24/22 at 8:52 AM, was reviewed with the DON. She confirmed the form deemed resident #1 to be at risk for elopement with a score of 10. The DON acknowledged the evaluation was inaccurate as it noted the resident Does NOT wander; has NEVER eloped and was Content with placement although he eloped earlier that morning. She acknowledged the form should have noted resident #1 Has history of elopement OR Wanders with history of exit seeking. The DON was informed review of the resident's medical record showed rather than being content with placement, he had expressed a desire to leave and displayed exit seeking behavior. She confirmed if completed correctly, the evaluation form would have resulted in a score of 15 or above, which would have deemed the resident at HIGH RISK for elopement. The DON acknowledged nursing staff including herself completed elopement evaluations that represented the resident's status on the day of the evaluation, but did not account for previous, known behaviors, labile moods and variable mental status. She said, He might have been having a good day. On 3/23/22 at 10:19 AM, LPN D stated she was resident #1's day shift nurse on the morning he was found outside the facility. She confirmed the resident was not in his room when she passed by his room after change of shift report. LPN D explained the resident often ambulated throughout the facility and she was not concerned about his whereabouts. She recalled at approximately 8:30 AM, CNA C informed her resident #1 was still not in his room and simultaneously the East Wing Unit Manager (UM) told her the resident was on his way back to the facility. LPN D acknowledged resident #1 continuously wandered throughout the facility and staff were responsible for ensuring he did not go through exit doors. She described the resident as having changing cognitive levels with varying degrees of confusion. When asked if she felt resident #1 would have been safe if unsupervised outside the facility, she said, Is anybody safe outside at 4:00 AM, in the dark? On 3/23/22 at 10:41 AM, the East Wing UM stated her expectation was CNAs and nurses would conduct walking rounds at the change of shift and the assigned CNA should do rounds at least every two hours during the shift. The East Wing UM explained the purpose was to visualize every resident regularly, and even if resident #1's privacy curtain was closed, staff should have checked on him. The East Wing UM stated she evaluated resident #1 for injuries on his return to the facility. She recalled removing the resident's socks to complete his skin check and confirmed he was not wearing shoes. The East Wing UM said, He was tired and slept the rest of the day. He did not tell me he left the facility to go for breakfast. She confirmed the resident had been in the facility for over one year and due to his cognitive level, memory problems and diagnoses he would probably not have known his location or if there were restaurants nearby. On 3/23/22 at 11:14 AM, CNA C stated at the start of the day shift on 2/24/22, she noticed resident #1 was not in his room. She stated his regular routine included walking around the facility and sitting on the patio so she did not start looking for him until almost 8:30 AM as he did not return to his room for breakfast. CNA C said, He doesn't stay in any one place for long. He wanders from wing to wing and will use public bathrooms. He is confused most of the time and he can be verbally aggressive. She stated the resident walked independently and could have traveled a far distance in the time he was gone from the facility. Review of the Facility Assessment, updated on 2/24/22, revealed the facility could meet the mental health and behavioral care needs of residents with diagnoses including hallucinations, delusions, impaired cognition, anxiety, [CONDITION(S)] and [CONDITION(S)] disorders. The document indicated the facility would provide person-centered care to include identification of hazards and risks for each resident. The Facility Assessment noted the preventative maintenance program involved daily review of the physical plant to identify areas that required repairs. Review of immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team: *On 2/24/22 at approximately 8:50 AM, a Good Samaritan returned resident #1 to the facility. The resident was evaluated by the East Wing UM, and noted to have no injuries. Notifications were made to the physician and family. *On 2/24/22, resident #1's electronic monitoring device was checked for function and placement, and he was placed on one to one supervision. A visual head count of all residents was conducted and there were no concerns. All residents with electronic monitoring devices had the devices checked for proper placement and function *On 2/24/22, all residents in the facility were re-evaluated for elopement risk, care plans were updated as indicated, and elopement binders were reviewed for accuracy. *On 2/24/22, the Maintenance Director checked exit doors and electronic wander monitoring system for function. A magnetic lock on the gate in the northeast enclosed courtyard was found to be improperly installed and was replaced. *On 2/24/22, the facility initiated staff education on the elopement standard and guidelines, elopement evaluation screening, one to one supervision for active wandering behaviors, alarm response, and checking for electronic wander monitoring devices for placement and function. As of 3/01/22, 135 of 135 full time staff had been educated. All other employees will be educated at the start of next shift working. Newly hired staff will receive this education in orientation. * From 2/24/22 to 3/01/22, a total of 12 elopement drills were completed on all shifts. * On 2/24/22, an ad hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held. The committee conducted a Root Cause Analysis, accepted plans, and discussed recommendations. Audit forms were developed to monitor proper function of doors, elopement evaluations, elopement binders and to validate staff comprehension of education. *On 3/01/22, the QAPI committee held a scheduled monthly meeting which included a review of the audit forms. No changes were required and audits continue weekly. Review of in-service and drill attendance sheets and reconciliation with staff roster validated education was completed according to the facility's plan. From 3/21/22 to 3/23/22, interviews conducted with 22 facility staff representing all shifts including 2 Registered Nurses, 5 LPNs, 14 CNAs and 1 Rehab staff revealed staff participated in elopements and were knowledgeable of the facility's elopement standard and guidelines and verbalized the importance of monitoring wandering residents, conducting change of shift and regular rounds, reporting behavior changes, and responding to alarms. The sample was expanded to include 6 additional residents at risk for wandering, exit-seeking, and elopement. Observations, interviews and record reviews revealed residents #2, #3, #4, #5, #6, and #7 residents had elopement risk re-assessments, appropriate care plans, and demographic information placed in the elopement binders.

Based on interview and record review, the facility failed to ensure a resident was free from neglect. The facility failed to obtain appropriate physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1). These failures contributed to resident #1 suffering critically low blood glucose levels and placed him at risk for serious injury/impairment/death. While resident #1 experienced critically low blood glucose levels, there was likelihood he could have become comatose, sustained permanent brain damage and/or died . On [DATE] at approximately 4:30 PM, facility staff found resident #1 in bed, unresponsive and in respiratory distress. When Emergency Medical Services (EMS) personnel arrived, they discovered his blood glucose level was critically low and transported him to the hospital for treatment. Resident #1 had received two types of insulin and two oral medications for type 2 diabetes daily since admission three days before, but facility staff had not checked his blood glucose level. Nurses did not obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 returned from the hospital a few hours later with instructions to check his blood glucose level three times daily and monitor his food intake, but the new orders were not verified with the attending physician on re-admission. Resident #1's blood glucose level was not checked the following morning, and by 11:30 AM he experienced [CONDITION(S)]-like symptoms and was once more found to have a critically low blood glucose level. For the second time in less than 24 hours, EMS personnel were called, and again transported resident #1 to the hospital for evaluation and treatment. The facility's failure to ensure resident #1 had appropriate and accurate physician orders, and failure to provide necessary monitoring, care and services for diabetes management placed all newly admitted and readmitted residents with diabetes at risk, particularly those with hypoglycemic unawareness (experiencing low blood glucose without feeling or noticing symptoms). These failures resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to E, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F635 and F609 Resident #1, an [AGE] year-old male, was admitted to the facility from the hospital on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1 was alert and disoriented but could follow simple instructions. He required a surrogate to make healthcare decisions. The transfer form indicated a discharge medication list, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital Home Medication List dated [DATE] revealed instructions for resident #1 to continue current medications including [MEDICATION(S)] (an oral medication for diabetes) 10 milligrams (mg) by mouth once daily, [MEDICATION(S)] (an oral medication for diabetes) ,d+[DATE] mg by mouth twice daily and [MEDICATION(S)] insulin (long acting insulin) 22 units injected once daily. The document indicated new medications ordered for resident #1 in the hospital included [MEDICATION(S)] insulin (long acting insulin) 22 units to be injected once daily at bedtime. Review of the Order Summary Report revealed resident #1's hospital discharge medication orders dated [DATE] were transcribed to the facility's electronic medical record (EMR). The order for [MEDICATION(S)] was entered into the EMR incorrectly as two 10 mg tablets once daily for a total of 20 mg, rather than one 10 mg tablet once daily as noted on the hospital discharge medication list. The document did not include physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #1's Baseline Care Plan dated [DATE] revealed a care plan was initiated for diabetes. The goal was resident #1 would remain free of complications related to high or low blood glucose levels. The interventions included perform blood glucose monitoring as ordered, administer oral medications and insulin as ordered, and observe for signs and symptoms of high or low blood glucose levels. Review of the Progress Notes for [DATE] showed neither documentation regarding verification of resident #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no nursing notes to indicate the need for blood glucose monitoring was recognized or addressed by the nurses on the day of admission or at any time afterwards. Review of resident #1's medical record revealed electronic signatures on the [DATE] Medication Administration Record (MAR) that showed administration of oral and injectable diabetic medication. The document indicated four nurses, Registered Nurse (RN) A and Licensed Practical Nurses (LPNs) B, C and D administered scheduled doses of [MEDICATION(S)] and [MEDICATION(S)] insulin without verifying that blood glucose levels were in a safe range. The double dosage of [MEDICATION(S)] 20 mg was administered on [DATE] and [DATE] by RN A, and on [DATE] by LPN B. An eINTERACT Transfer Form dated [DATE] revealed resident #1 was transferred to the hospital by ambulance for an abnormally low blood glucose level. The assigned nurse, LPN C did not complete a Change in Condition evaluation form or write a progress note regarding the events preceding resident #1's transfer to the hospital. Review of the Fire Rescue Patient Care Record dated [DATE] revealed EMS personnel arrived at resident #1's bedside at 4:41 PM, in response to a 911 call placed at 4:29 PM regarding a resident in respiratory distress. Their initial assessment at 4:43 PM showed the resident was unconscious and sweating excessively, with snoring respirations at a rate of 8 breaths per minutes and an oxygen saturation level of 87%. A normal respiratory rate for an adult ranges from 12 to 18 breaths per minute and a normal oxygen saturation level is between 95% and 100% (retrieved on [DATE] from www.medlineplus.gov). Resident #1's blood glucose level was not detectable and registered as LO on the glucometer. The primary impression documented by EMS personnel was Diabetic [CONDITION(S)] with signs and symptoms of Altered Mental Status. [CONDITION(S)] or low blood sugar refers to a blood sugar level below 70 milligrams per deciliter (mg/dL). If untreated, a low blood sugar level can be dangerous. A blood sugar level below 54 mg/dL is categorized as severe and can cause altered mental status, weakness, and seizures. A blood sugar level below 40 mg/dL is critical as it is life-threatening and can lead to cardiac and/or brain damage. Excessive or disproportionate doses of insulin and eating an insufficient amount of carbohydrates can cause [CONDITION(S)] (retrieved on [DATE] from www.cdc.gov). The document indicated staff informed EMS personnel resident #1 was found unresponsive with shallow breathing. EMS personnel interviewed facility staff and noted they were not familiar with the resident's history as he was a recent admission. The document read, Staff relate they are unable to give a last seen normal time. Staff relate he is a diabetic but they are unaware if he is prescribed insulin. Staff relates the nurse that has been assigned to him is a contract nurse, and has gone home for the day. Upon treatment, [patient] relates he is given his insulin nightly and has not eaten anything since he got his insulin dose last night. The report showed EMS personnel treated resident #1 with high-flow oxygen at 20 liters per minute and administered an intravenous (IV) glucose solution. The document read, . staff unaware why [patient] has IV access. Resident #1 was transported to the hospital at 5:04 PM. The hospital Emergency Department Document dated [DATE] revealed the resident had a hypoglycemic episode due to facility staff medical error. The note indicated resident #1 informed hospital staff he did not eat much the previous day but received scheduled insulin doses twice daily. The document indicated resident #1 was found unresponsive, not breathing, and his blood glucose was too low to register on the monitoring device. EMS personnel reported to hospital staff that on arrival at the facility they assessed resident #1 as Glasgow Coma Scale score of 3, which indicated he was totally unresponsive with no verbal, eye opening or motor responses (retrieved on [DATE] from www.cdc.gov). Resident #1 was treated at the hospital and his blood sugar level stabilized. He was also diagnosed with dehydration and a urinary tract infection ([CONDITION(S)]). The Emergency Department Document dated [DATE] included a Discharge Plan section with care plan goals of [Facility name]: Please check pt blood glucose at least three times a day. Please avoid administering insulin when pt (patient) is not eating to prevent mental status change due to iatrogenic error. An iatrogenic error is one that is unintentionally caused by medical treatments or procedures (retrieved on [DATE] from www.merriam-webster.com). Resident #1's discharge medication list indicated no action was necessary with his current medications. The list reflected his original hospital discharge order for [MEDICATION(S)] 10 mg once daily, not two tablets or 20 mg as transcribed and administered by the facility for three days. According to the manufacturer, [MEDICATION(S)] can cause serious side effects including dehydration, serious UTIs and [CONDITION(S)]. The manufacturer indicates it may be necessary to lower the dosages of insulin and some oral diabetic medications if taken in conjunction with [MEDICATION(S)] to lower the risk of [CONDITION(S)] (retrieved on [DATE] from www.[MEDICATION(S)].com). Resident #1's medical record did not contain any documentation regarding his re-admission from the hospital. The Progress Notes reflected no information on the resident's arrival date and time nor his clinical condition including vital signs and level of consciousness. The assigned nurse, LPN E, entered an order in the EMR on [DATE] at 1:37 AM for Accu-checks (fingerstick blood glucose checks) three times daily before meals to monitor for [CONDITION(S)], according to the hospital emergency department discharge orders. LPN E did not notify resident #1's attending physician of his re-admission or his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation regarding review and verification of resident #1's re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The transcription error related to [MEDICATION(S)] 20 mg was once again overlooked and no order was entered to alert nurses to closely monitor resident #1's food intake. The facility's policy and procedure Reconciliation of Medication on Admission (revised 2021) revealed a purpose . to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. The guidelines indicated medication reconciliation reduced medication errors and ensured information was communicated accurately to the attending physician. Review of resident #1's Medication Administration Record revealed Accu-checks were to begin on [DATE], scheduled three times daily at 8:00 AM, 11:30 AM and 5:00 PM. Review of the Blood Sugar Summary for resident #1 revealed his Accu-check was not done by his assigned nurse, RN A, on [DATE] at 8:00 AM as ordered. Instead, over three hours later, RN A noted a blood glucose level of 35 mg/dL at 11:25 AM. The document indicated RN A obtained a follow-up blood glucose level of 66 mg/dL at 11:43 AM. An eINTERACT Transfer Form dated [DATE] revealed resident #1 was again transferred to the hospital by ambulance, this time for altered mental status. The document indicated he was alert, disoriented, and could not follow simple instructions. RN A's documentation described resident #1 with jerking body movements, unable to answer questions and experiencing severe [CONDITION(S)] for the second time in less than 24 hours, with a blood sugar level of 35 mg/dL. RN A did not complete a change in condition form regarding the incident, but she wrote a Health Status Note the following day, [DATE]. The note revealed she was called to resident #1's room as he had . excessive movements and could not stay on the bed. RN A checked his blood glucose level, attempted to administer oral glucose solution, but the resident vomited and was unable to swallow any more. She administered an injectable glucose solution, then obtained a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR showed resident #1 did not receive any of his scheduled 9:00 AM medications on [DATE] prior to his hypoglycemic crisis. However, there was no corresponding nursing progress note written by RN A to explain why the medications were withheld and no documentation that the attending physician was notified. Review of the Fire Rescue Patient Care Record dated [DATE] revealed EMS personnel arrived at resident #1's bedside at 11:50 AM, in response to a 911 call placed at 11:39 AM. The document listed a primary impression of Diabetic [CONDITION(S)], and a secondary impression of Generalized Weakness. The EMS record revealed facility staff reported the resident's blood glucose level was in the 20s and he was not responsive. The document read, Staff relates that he was transported yesterday for the same issue. EMS personnel noted, Staff dropped paper work and left the room. They obtained pertinent information from resident #1 and the paperwork that was left by staff, then transported the resident to the hospital at 12:02 PM. On [DATE] at 12:01 PM, the West Wing Unit Manager (UM) stated she entered resident #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She explained it slipped her mind to ask the physician for an order to check the resident's blood glucose levels as he received insulin. She stated she was not familiar with the facility's clinical protocol related to diabetic residents. The UM added she would normally ask the physician for an order to conduct Accu-checks or blood glucose monitoring by fingersticks, twice daily for residents who received insulin twice daily. On [DATE] at 12:17 PM, RN A verified she was resident #1's assigned nurse on [DATE], [DATE], and [DATE]. She reviewed the resident's MAR and validated she administered [MEDICATION(S)] insulin 22 units at 9:00 AM on [DATE] and [DATE]. She acknowledged residents on insulin should have their blood sugar levels checked to prevent hypoglycemic episodes. She explained she worked on the 7:00 AM to 3:00 PM shift, and Accu-checks were usually done on other shifts, at 6:00 AM and 4:00 PM. RN A confirmed she was the assigned nurse when resident #1 was transferred to the hospital on [DATE] for a blood glucose level of 35 mg/dL. She explained she did not administer the resident's scheduled 9:00 AM insulin that morning as he did not eat much of his breakfast and seemed out of it. RN A said, I don't think he had bounced back from the night prior when he went to the hospital. On [DATE] at 11:31 AM, RN A stated when that she assumed care of resident #1 on the morning of [DATE], she was told in change of shift report that he was sent out to the hospital on the previous evening. She stated she was told he was unresponsive, but not that it was due to [CONDITION(S)]. RN A said, If I had known, I would have checked on him more frequently. She recalled withholding resident #1's insulin and other scheduled medications because he did not feel or look well. RN A confirmed she should have notified the attending physician of the resident's status and that the scheduled medications were not given. She said, If I had been told in report there was a blood sugar issue, I would have stopped medication pass and called the doctor. On [DATE] at 12:05 PM, RN A was informed resident #1's Accu-check was scheduled to be done on her shift at 8:00 AM. She stated Accu-checks were usually scheduled for 6:00 AM and she did not recall seeing this task in her computer that morning. On [DATE] at 2:59 PM, the DON and Assistant Director of Nursing (ADON) verified all residents who were prescribed insulin should have blood glucose levels monitored by scheduled Accu-checks. The DON stated if the physician did not want Accu-checks done for resident #1, the nurse should have documented the reason in the EMR as this would adhere to the facility's protocol. On [DATE] at 10:43 AM, the DON recalled on the night resident #1 was admitted , the UM verified his admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated resident #1's attending physician should have been notified when the resident returned from the hospital. She validated there was no nursing progress note in the medical record to indicate the physician was involved in the re-admission process. The DON was not aware resident #1's blood glucose was not checked at 8:00 AM as ordered. On [DATE] at 11:21 AM, the ADON stated nurses were to review hospital discharge paperwork, verify medication and treatment orders with the physician and transcribe them to the EMR. The ADON said, Anytime a resident is admitted or readmitted , whether new orders or not, the attending doctor should be contacted. The ADON confirmed the admission nurse did not obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She acknowledged during the 3-day period between admission and transfer to the hospital for [CONDITION(S)], none of the nurses who administered insulin twice daily attempted to correct this situation by seeking clarification or obtaining an order from the physician for blood glucose monitoring. The ADON stated resident #1 suffered a medical error related to a transcription error. She said, It was a serious incident. On [DATE] at 10:39 AM, the DON explained every newly admitted resident's chart was reviewed by the interdisciplinary team in the daily morning clinical meeting. She stated an essential part of this process was the review of medications with reconciliation for accuracy and possible omissions. The DON stated if any issues were identified with resident #1's orders, the West Wing UM would have been assigned to follow up. On [DATE] at 7:30 PM, LPN C stated she was assigned to resident #1 on [DATE] when he was found unresponsive. She recalled a staff member alerted her to a change in the resident's condition and on evaluation, she noted he was in respiratory distress. LPN C stated when EMS personnel arrived they checked the resident's blood glucose level and found it to be very low, possibly in the 20s. When asked if that reading was concerning, she said, Absolutely, it was a critical low. Review of the MAR revealed LPN C administered [MEDICATION(S)] 22 units to resident #1 on [DATE] at 9:00 PM. She did not recall giving insulin to the resident and could not explain why she did not notice the absence of Accu-check orders. LPN C validated resident #1 did not receive the necessary services to prevent hospitalization . On [DATE] at 9:52 AM, the facility's Consultant Pharmacist explained the frequency of blood glucose monitoring would be determined by the physician. He said, I don't know how stable [the resident] was, but I would say he should be checked at least once daily. He acknowledged resident #1's poor appetite while receiving a combination of two types of long-acting insulin and two oral medications for diabetes would be a cause for concern and warranted re-evaluation of the medication regimen. The facility's Diabetes - Clinical Protocol revised in [DATE] revealed during the initial assessment, the physician would assist with identification of residents with elevated blood glucose levels or confirmed diabetes, and order appropriate screening for those who required testing. The protocol instructed nurses to conduct and initial assessment of residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The document indicated the physician would order appropriate tests including monitoring by fingersticks . and adjust treatments based on these results and other parameters. which included hypoglycemic episodes. The protocol recommended monitoring of blood glucose levels should be done twice daily for residents on insulin whose diabetes was well controlled. The document indicated residents on intensive insulin therapy required an increased frequency of monitoring, up to three or four times daily. The protocol read, The Physician will order desired parameters for monitoring and reporting information related to blood sugar management. The document directed nurses to include the parameters on the resident's medication administration record and in the care plan. The Abuse and Neglect - Clinical Protocol (revised [DATE]) defined Neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The policy instructed nurses to conduct assessments and report findings to the physician, who would assist in identifying evidence of neglect. The document indicated the facility's frontline staff and management, in conjunction with the physician, would . identify situations that might constitute or could be construed as neglect. The policy indicated the facility would ensure residents' basic medical needs are met . and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately. Review of the Facility Assessment reviewed by the Quality Assurance and Performance Improvement (QAPI) Committee on [DATE], revealed the facility admitted residents with common diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Facility Assessment revealed the facility would manage medical conditions including diabetes by conducting assessments and ensuring early identification of problems or changes in condition. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE], resident #1 was transferred to the hospital via EMS for low blood sugar. *On [DATE], resident #1 returned to the facility with orders for Accu-checks. *On [DATE], resident #1 was transferred to the hospital via EMS for low blood sugar. *On [DATE], an Ad Hoc QAPI meeting was held, and a Performance Improvement Plan (PIP) was developed to ensure Accu-checks, documentation, and admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Director, who attended via telephone, approved the PIP. *On [DATE], all licensed staff were educated on ensuring accuracy of Accu-checks orders, notifying the physician of significant change, and completing Accu- checks as ordered. The facility achieved 100% compliance (20 of 20 licensed nurses). The facility continues to use a mandatory education packet which includes Abuse and Neglect education in addition to these topics for all agency nurses. *On [DATE], audits were conducted on 22 of 22 insulin-dependent residents. The medical records were audited for proper admission and re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *On [DATE], Abuse and Neglect education was provided for staff. Achieved 75% compliance with 93 of 125 educated. Education topic focused on provision of all care and services to meet residents' care needs. Validation done by reconciling attendance sheets with staff roster. *On [DATE], the facility will continue review of the charts of newly admitted and readmitted residents in morning clinical meeting. The DON and/or designee will use a revised morning meeting checklist that includes review of insulin-dependent residents for order accuracy, Accu-checks and appropriate monitoring. *On [DATE], a nurses' meeting was held to reinforce education on documentation, accuracy of physician orders, change of condition, and preventing return to hospital. The meeting was attended by 7 of 20 nurses. *On [DATE], audits of nine randomly selected insulin-dependent residents revealed proper admission and re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure contributed to resident #1 suffering critically low blood glucose levels and placed him at risk for serious injury/impairment/death. While resident #1 experienced critically low blood glucose levels, there was a likelihood he could have become comatose, sustained permanent brain damage and/or died . On [DATE] at approximately 4:30 PM, facility staff found resident #1 in bed, unresponsive and in respiratory distress. When Emergency Medical Services (EMS) personnel arrived, they discovered his blood glucose level was critically low and transported him to the hospital for treatment. Resident #1 had received two types of insulin and two oral medications for type 2 diabetes daily since admission three days before, but facility staff had not been checking his blood glucose level. Nurses did not obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 returned from the hospital a few hours later with instructions to check his blood glucose level three times daily and monitor his food intake, but the new orders were not verified with the attending physician on re-admission. Resident #1's blood glucose level was not checked the following morning, and by 11:30 AM he was experiencing [CONDITION(S)]-like symptoms and was once more found to have a critically low blood glucose level. For the second time in less than 24 hours, EMS personnel were called, and again transported resident #1 to the hospital for evaluation and treatment. The facility's failure to obtain and verify appropriate admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F600. Resident #1, an [AGE] year-old male, was admitted to the facility from the hospital on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1 was alert and disoriented but could follow simple instructions. He required a surrogate to make healthcare decisions. The transfer form indicated a discharge medication list, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital Home Medication List dated [DATE] revealed instructions for resident #1 to continue current medications including [MEDICATION(S)] (oral medication for diabetes) 10 milligrams (mg) by mouth once daily, [MEDICATION(S)] (oral medication for diabetes) ,d+[DATE] mg by mouth twice daily and [MEDICATION(S)] insulin (long acting insulin) 22 units injected once daily. The document indicated new medications ordered for resident #1 in the hospital included [MEDICATION(S)] insulin (long acting insulin) 22 units to be injected once daily at bedtime. Review of the Order Summary Report revealed resident #1's hospital discharge medication orders dated [DATE] were transcribed to the facility's electronic medical record (EMR) as telephone orders. The order for [MEDICATION(S)] was entered into the EMR as two 10 mg tablets once daily rather that one 10 mg tablet once daily as noted on the hospital discharge medication list. The document did not include physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Notes showed neither documentation regarding verification of resident #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #1's Baseline Care Plan dated [DATE] revealed a care plan was initiated for diabetes. The goal was resident #1 would remain free of complications related to high or low blood glucose levels. The interventions included perform blood glucose monitoring as ordered, administer oral medications and insulin as ordered, and observe for signs and symptoms of high or low blood glucose levels. An eINTERACT Transfer Form dated [DATE] revealed resident #1 was transferred to the hospital by ambulance for an abnormally low blood glucose level. The hospital Emergency Department Document dated [DATE] revealed the resident had a hypoglycemic episode due to facility staff medical error. The note indicated resident #1 informed hospital staff he did eat much on the previous day but received scheduled insulin doses twice daily. The document indicated resident #1 was found unresponsive, not breathing, and his blood glucose was too low to register on the monitoring device. EMS personnel reported to hospital staff that on arrival at the facility they assessed resident #1 as Glasgow Coma Scale score of 3, which indicated he was totally unresponsive with no verbal, eye opening or motor responses (retrieved on [DATE] from www.cdc.gov). [CONDITION(S)] or low blood sugar refers to a blood sugar level below 70 milligrams per deciliter (mg/dL). If untreated, a low blood sugar level can be dangerous. A blood sugar level below 54 mg/dL is categorized as severe and can cause altered mental status, weakness, and seizures. Excessive or disproportionate doses of insulin and eating an insufficient amount of carbohydrates can cause [CONDITION(S)] (retrieved on [DATE] from www.cdc.gov). Resident #1 was treated at the hospital and his blood sugar level stabilized. He was also diagnosed with dehydration and a urinary tract infection ([CONDITION(S)]). The Emergency Department Document dated [DATE] included a Discharge Plan section with care plan goals of [Facility name]: Please check pt blood glucose at least three times a day. Please avoid administering insulin when pt is not eating to prevent mental status change due to iatrogenic error. An iatrogenic error is one that is unintentionally caused by medical treatments or procedures (retrieved on [DATE] from www.merriam-webster.com). Resident #1's discharge medication list indicated no action was necessary with his current medications. The list reflected his original hospital discharge order for [MEDICATION(S)] 10 mg once daily, not 20 mg daily as administered by the facility since admission. According to the manufacturer, [MEDICATION(S)] can cause serious side effects including dehydration, serious UTIs and [CONDITION(S)]. The manufacturer indicates it may be necessary to lower the dosages of insulin and some oral diabetic medications if taken in conjunction with [MEDICATION(S)] to lower the risk of [CONDITION(S)] (retrieved on [DATE] from www.[MEDICATION(S)].com). Resident #1's medical record did not contain any documentation regarding his re-admission from the hospital. The Progress Notes reflected no information on the resident's arrival date and time nor his clinical condition including vital signs and level of consciousness. The assigned nurse, Licensed Practical Nurse (LPN) E, entered an order in the EMR on [DATE] at 1:37 AM for Accu-checks three times daily before meals to monitor for [CONDITION(S)], according to the hospital emergency department discharge orders. LPN E did not notify resident #1's attending physician of his re-admission, or his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation regarding review and verification of resident #1's re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An eINTERACT Transfer Form dated [DATE] revealed resident #1 was again transferred to the hospital by ambulance, this time for altered mental status. The document indicated he was alert, disoriented, and could not follow simple instructions. Registered Nurse (RN) A's documentation indicated resident #1 had jerking body movements, was unable to answer questions and was experiencing severe [CONDITION(S)] for the second time in less than 24 hours, with a blood sugar level of 35 mg/dL. On [DATE] at 12:01 PM, the West Wing Unit Manager (UM) stated she entered resident #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She explained it slipped her mind to ask the physician for an order to check the resident's blood glucose levels as he received insulin. She stated she was not familiar with the facility's clinical protocol related to diabetic residents. The UM added she would normally ask the physician for an order to conduct Accu-checks or blood glucose monitoring by fingersticks, twice daily for residents who received insulin twice daily. On [DATE] at 1:15 PM, in a telephone interview with resident #1's attending physician, he stated his expectation was the facility staff would follow the protocol for diabetic residents on insulin and check the resident's blood glucose levels at a minimum of twice daily. On [DATE] at 2:59 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) verified all residents who were prescribed insulin should have blood glucose levels monitored by scheduled Accu-checks. The DON stated if the physician did not want Accu-checks done for resident #1, the nurse should have documented the reason in the EMR as this would adhere to the facility's protocol. On [DATE] at 10:43 AM, the DON recalled on the night resident #1 was admitted , the UM verified his admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON validated resident #1 was sent to the hospital with a very low blood glucose level on [DATE] and returned later that night with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated resident #1's attending physician should have been notified when the resident returned from the hospital. She explained the expectation was nurses would verify all re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON acknowledged notifying resident #1's physician would have provided an opportunity to make changes to the resident's medications if indicated and select the appropriate frequency for Accu-checks. She validated there was no nursing progress note in the medical record to indicate the physician was involved in the re-admission process. On [DATE] at 11:21 AM, the ADON stated nurses were to review hospital discharge paperwork, verify medication and treatment orders with the physician and transcribe them to the EMR. The ADON said, Anytime a resident is admitted or readmitted , whether new orders or not, the attending doctor should be contacted. The facility's policy and procedure Reconciliation of Medication on Admission (revised 2021) revealed a purpose . to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. The guidelines indicated medication reconciliation reduced medication errors and ensured information was communicated accurately to the attending physician. On [DATE] at 9:52 AM, the facility's Consultant Pharmacist explained the frequency of blood glucose monitoring would be determined by the physician. He said, I don't know how stable [the resident] was, but I would say he should be checked at least once daily. The facility's Diabetes - Clinical Protocol revised in [DATE] revealed during the initial assessment, the physician would assist with identification of residents with elevated blood glucose levels or confirmed diabetes, and order appropriate screening for those who required testing. The protocol instructed nurses to conduct and initial assessment of residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The document indicated the physician would order appropriate tests including monitoring by fingersticks . and adjust treatments based on these results and other parameters. which included hypoglycemic episodes. The protocol recommended monitoring of blood glucose levels should be done twice daily for residents on insulin whose diabetes was well controlled. The document indicated residents on intensive insulin therapy required an increased frequency of monitoring, up to three or four times daily. The protocol read, The Physician will order desired parameters for monitoring and reporting information related to blood sugar management. The document directed nurses to include the parameters on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE], resident #1 was transferred to the hospital via EMS for low blood sugar. *On [DATE], resident #1 returned to the facility with orders for Accu-checks. *On [DATE], resident #1 was transferred to the hospital via EMS for low blood sugar. *On [DATE], an Ad Hoc QAPI meeting was held, and a Performance Improvement Plan (PIP) was developed to ensure Accu-checks, documentation, and admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Director, who attended via telephone, approved the PIP. *On [DATE], all licensed staff were educated on ensuring accuracy of Accu-checks orders, notifying the physician of significant change, and completing Accu- checks as ordered. The facility achieved 100% compliance (20 of 20 licensed nurses). The facility continues to use a mandatory education packet which includes these topics for all agency nurses. *On [DATE], audits were conducted on 22 of 22 insulin-dependent residents. The medical records were audited for proper admission and re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *On [DATE], the facility will continue review of the charts of newly admitted and readmitted residents in morning clinical meeting. The DON and/or designee will use a revised morning meeting checklist that includes review of insulin-dependent residents for order accuracy, Accu-checks and appropriate monitoring. *On [DATE], a nurses' meeting was held to reinforce education on documentation, accuracy of physician orders, change of condition, and preventing return to hospital. The meeting was attended by 7 of 20 nurses. *On [DATE], audits of nine randomly selected insulin-dependent residents revealed proper admission and re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *Interviews conducted from [DATE] to [DATE] with 14 nurses, 5 RNs and 9 LPNs, including 1 agency nurse. They were knowledgeable of the Diabetes Clinical Protocol including verification and reconciliation of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] *The sample was expanded to include 7 additional residents, #3, #886, #888, #889, #890, #891 and #892. Interviews and/or record reviews revealed no concerns related to accuracy, appropriateness, and implementation of diabetic medication orders.

Based on observation, interview and record review, the facility failed to effectively oversee and monitor the cleaning of glucose monitors to ensure they were properly cleaned and disinfected between resident use for 2 of 23 residents who required daily blood glucose monitoring, (#258, #51) . On 08/07/19 at 3:48 PM and at 4:29 PM, observations during medication administration on the West Wing and the East Wing showed that after obtaining the blood glucose for residents #258 and #51, two licensed practical nurses (LPN) A, and LPN B used alcohol wipes to clean/disinfect the multi resident use glucometers. The facility's failure to ensure glucometers were cleaned/disinfected appropriately between resident use resulted in Immediate Jeopardy starting on 5/18/19. The facility implemented actions to remove the Immediacy as of 8/09/2019. Additionally, the facility failed to ensure that measures were used to prevent cross-contamination during wound care for one of one resident (#53) and to ensure that staff wore Personal Protective Equipment for contact isolation precautions. Findings: Cross reference F880 Outbreaks of [MEDICAL CONDITION] virus (HBV) Infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes .where residents often require assistance with monitoring of blood glucose levels and or Insulin administration. www.cdc.gov A review of all residents requiring blood glucose monitoring revealed that a total of 23 residents required blood glucose monitoring daily. Resident #25 and #35 had [DIAGNOSES REDACTED]. Resident #249 and #253 had [DIAGNOSES REDACTED]. The two LPNs wiped the glucometers with alcohol wipes. They did not use a product designed to disinfect and kill blood-borne pathogens on the glucometers which were exposed to blood during blood glucose monitoring. The facility had Sani-cloth germicidal wipes available, but they were not being used to clean/disinfect the glucometers during the observations. Sani-cloth germicidal wipes are an Environmental Protection Agency (EPA) registered hospital-grade disinfectant. Cleans and disinfects in one step. Bactericidal, Tuberculocidal, Virucidal. www.medline.com A review of the Facility Assessment noted that the facility accepted residents with diabetes and indicated staff education/competencies for medication administration would be completed on hire, annually, and as needed through competency test and return demonstrations. Infection Control universal precautions would be completed on hire, annually, and on an as needed basis through computer-based learning, and town hall meetings. Although infection control was discussed, the Facility Assessment did not specifically address the cleaning/disinfecting of glucometers. On 08/08/19 at 9:27 AM, the East Wing UM stated that Sani-cloth germicidal wipes should be used for cleaning glucometers, not alcohol wipes. She stated that the Clinical Educator had conducted in-services and instructed that Sani-cloth germicidal wipes were to be used to clean/disinfect glucometers. The East Wing UM said that she and the Clinical Educator completed random observations/audits of cleaning/disinfecting of glucometers. She added that staff were aware that alcohol did not disinfect the glucometers. The UM/facility however could not provide any documentation to show that audits/monitoring was conducted by the Clinical Educator or the East Wing UM. On 08/07/19 at 5:40 PM, LPN A stated that she became a nurse in (MONTH) (YEAR) and started working at the facility on 2/06/19. LPN A stated that she had received education regarding glucometer cleaning/disinfecting during orientation. She was not sure whether alcohol was mentioned to clean the glucometers. She said that during orientation, she was observed doing an Accu-check (fingerstick blood glucose reading), and glucometer cleaning/disinfecting by her preceptors on the East and West Wings. LPN A stated that she had been using alcohol wipes to clean glucometers. Although she had received in-service regarding the policy and procedure for cleaning/disinfecting glucometers, she had not read the policy until today (8/07/2019). On 08/08/19 at 5:29 PM, LPN B said she had been working at the facility since (MONTH) 2019. She did not remember specifically going over Accu-checks during orientation. She confirmed that she used alcohol wipes for cleaning the glucometers and stated that's what I have been doing. LPN B stated that she had used the Sani wipes in the past and did not know why she used alcohol wipes. She added, I thought the Sani-cloth wipes and the alcohol wipes were interchangeable. A review of the competency showed that LPN B had completed glucometer disinfection competency testing on 4/22/19. When asked if she had been observed for glucometer cleaning/disinfecting, LPN B stated no staff member had evaluated her performance for glucometer cleaning/disinfecting since her competency on 4/22/19. On 08/08/19 at 4:36 PM, the Director of Nursing (DON) said, that staff were educated on a variety of subjects, including: blood borne pathogens, and glucometer cleaning/ disinfecting during orientation. Competency was completed as needed, along with random observations. The DON said she educated licensed nursing staff regarding cleaning/disinfecting glucometers, and all licensed nurses did return demonstration for competency in (MONTH) 2019. The DON reported that an accrediting organization conducted a survey at the facility between 4/29-30/19 and monitored cleaning/disinfecting of glucometer for all staff on duty that day. The DON said that the glucometer manufacturer came to the facility in (MONTH) 2019 and also did education including cleaning/disinfecting of the meters. She stated that she and the Clinical Educator were certified trainers for glucometers being used in the facility. When asked how staff were monitored to ensure education was effective, she said if it is brought to my attention, I will re-educate as often as necessary. The DON could not explain why the LPNs, A and B used alcohol wipes to clean/disinfect the glucometers. She stated that she had educated and did return demonstrations with both LPNs A and B with the Sani-cloth germicidal wipes, and with every other nurse in the facility. She stated that the actions of the LPNs were not because I have not given them the relevant education. Each staff was responsible to ensure that glucometers were cleaned and disinfected after each resident use. The DON did not explain why the two LPNs used alcohol wipes. When asked why the nurses used alcohol to clean the glucometers despite being educated, the DON had no answer. She could not provide any follow up competency evaluations showing staff's compliance with the training status [REDACTED]. On 8/09/19 at 9:49 AM a meeting was held with the DON, the Regional Director of Clinical Operations and the Corporate nurse. The Regional Director of Clinical operations said that mock surveys were conducted annually, and compliance surveys were conducted quarterly. She stated that observations of Accu-check including disinfection of glucometers were conducted by the Corporate nurse in either June, or (MONTH) 2019. The team however could not provide documentation to show that audits were conducted to evaluate staff's performance to ensure glucometers were cleaned/disinfected properly. It was incumbent upon the facility to ensure that all staff were educated with the most recent nursing practices for cleaning/disinfecting glucometers. The facility did not provide any audits or monitoring to determine if facility staff retained the education that they received on cleaning/disinfecting glucometers. The facility's Standard and Guideline:Infection Prevention and Control Program issued on 3/2018 read, It is the standard that this facility's Infection Prevention and Control Program (IPCP), is based upon information from the Facility Assessment and follows national standards to prevent, recognize and control the onset and spread of infection whenever possible Surveillance .will include monitoring, data analysis, documentation . Infection Preventionist: Responsibilities . Instruct on essential steps to cleaning equipment Follow-up competency evaluations identify staff compliance. The job description for the Administrator read, Manage, lead and direct the overall operations of the facility in accordance with customer needs, regulations and company policies .Monitor, train and direct staff in support of continuous practices that utilize Universal Precaution and Infection Control, Isolation, Fire Safety and Sanitation practices and procedures. The job description for Director of Nursing Services read, Responsible for planning, coordination, implementation, evaluation and supervision of the nursing services. The Director of Nursing Services is responsible for maintaining consistent, safe and effective nursing practices and the management of the overall operation of the Nursing Department in accordance with policies, standards of nursing practices and regulatory requirements .Responsible for .training, evaluation .of nursing personnel .Develop and maintain nursing care objectives and standards of nursing care practices for facility .communicates standards and guidelines, evaluate performance providing feedback and direction as needed .Monitor, train and direct staff in support of continuous practices that utilize universal Precautions, Infection Control practices. On 8/09/19 at 10:45 AM, the Executive Director, DON/ICP and the Regional Director of Clinical Operations were informed that concerns were identified at the Immediate Jeopardy level starting on 5/18/2019. Review of the Credible Allegation of Compliance for Removal of Immediate Jeopardy dated 8/09/19, showed that on 8/08/19 the Regional Director of Clinical Operations educated and reviewed job descriptions with the Executive Director (ED) and the Director of Nursing (DON). The corrective measures included: Beginning 8/09/19 the ED will hold Quality Assurance/Performance Improvement (QAPI) meetings weekly until substantial compliance is achieved. The DON/designee will conduct a weekly quality review on each unit to identify staff are maintaining proper infection control practices as it relates to glucometer disinfection for four weeks, then every two weeks for two months. The findings will be reported to the QAPI committee monthly, until the committee determines substantial compliance has been met and recommends moving to monthly monitoring by the Regional Director of Clinical Operations. On 8/09/19 a second Ad Hoc QAPI was reconvened to review and encompass new Standards and guidelines for individual glucometer use. Observation, interviews and record reviews verified sufficient implementation of the Immediate Jeopardy removal plan as of 8/09/19 at 5 PM.

Based on observation, interview and record review the facility failed to practice proper infection control measures by failing to clean/disinfect glucometers appropriately to prevent the likelihood of transmitting infection and blood borne pathogens for 2 of 23 residents who required daily blood glucose monitoring, (#258, #51), failed to practice proper handwashing during skin/wound assessment for 1 of 1 resident, (#53) and failed to follow proper infection control measures in a transmission based contact isolation room for 1 of 1 resident, (#61). Blood borne pathogens are infectious microorganisms in human blood that can cause disease in humans. These pathogens include, but are not limited to, [MEDICAL CONDITION] (HBV), [MEDICAL CONDITION] (HCV). On 08/07/19 at 3:48 PM and at 4:29 PM, observations during medication administration on the West Wing and the East Wing showed that after obtaining the blood glucose for residents #258 and #51, two licensed practical nurses (LPN) A, and LPN B used alcohol wipes to clean/disinfect the multi resident use glucometers. The facility's failure to ensure glucometers were cleaned/disinfected appropriately between resident use resulted in Immediate Jeopardy starting on 5/18/19. The facility implemented actions to remove the immediate jeopardy as of 8/09/2019. Finding: Cross reference to F835. Outbreaks of [MEDICAL CONDITION] virus (HBV) Infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes .where residents often require assistance with monitoring of blood glucose levels and or Insulin administration. www.cdc.gov 1. Resident #258 was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. On 8/07/19 at 3:48 PM, the West Wing LPN B took the glucometer with supplies to obtain the fingerstick blood glucose reading for resident #258. After completing the test, LPN B returned to her medication cart, discarded the used items, and proceeded to wipe the glucometer with an alcohol wipe. LPN B, was asked how she cleaned the glucometer after each resident use. LPN B stated she used alcohol wipes to clean the glucometer and then sets the glucometer on the medication cart to air dry. On 8/07/19 at 4:29 PM, LPN A took a glucometer out of a plastic bag from her medication cart. She gathered her supplies to obtain the fingerstick blood glucose reading for resident #51 and brought them into the resident's room. After the test LPN A took the glucometer out of the resident's room and placed the glucometer on her medication cart. She then proceeded to use an alcohol wipe to clean the glucometer. LPN A was asked how she cleaned/disinfected the reusable glucometer. She stated that she used alcohol wipes to clean the glucometer between resident use. She further stated that when she had completed doing glucose monitoring for all her residents, she then cleaned the glucometer with Sani-cloth disinfecting wipes. When LPN A was asked to show the Sani-cloth disinfecting wipes, there were no Sani-cloth wipes in LPN A's medication cart. When asked about the facility's policy and procedure regarding cleaning/disinfecting of glucometers, LPN A said glucometers should be cleaned after each resident use and she used alcohol wipes. The surveyor and LPN A proceeded to the nurses' station to verify the policy and procedure for cleaning/disinfecting glucometers with the unit manager (UM). On 08/07/19 at 4:33 PM, the East Wing UM said that each medication cart had two glucometers. She stated that glucometers should be cleaned with Sani-cloth germicidal wipes after each resident use. The meter should remain wet for two minutes, then allowed to air dry. At this time, LPN A informed the UM that she had been using alcohol wipes to clean the glucometers after each resident use. The East Wing UM then said that cleaning/disinfecting of the glucometer could be done with either Sani-cloth germicidal wipes, or alcohol. She stated that she would get the facility's policy and procedure regarding glucometer cleaning/disinfecting, to verify. On 08/07/19 at 4:43 PM, the Clinical Educator stated that glucometers should be cleaned with Sani-cloth germicidal wipes after each resident use, remain wet for two minutes, and allowed to air dry. LPN A reported that she had been using alcohol wipes to clean the glucometers. The Clinical Educator said, no alcohol. The Clinical Educator said that she had in-serviced staff to clean the glucometers with Sani-cloth germicidal wipes, and not alcohol wipes. Sani-cloth germicidal wipes are an Environmental Protection Agency (EPA) registered hospital-grade disinfectant. Cleans and disinfects in one step. Bactericidal, Tuberculocidal, Virucidal. www.medline.com 8/19/19 On 08/07/19 at 5:40 PM and 7:25 PM, LPN A stated that she became a nurse on 6/21/18 and started working at the facility on 2/06/19. LPN A stated that she had received education regarding glucometer cleaning/disinfecting during orientation. She was not sure if alcohol was mentioned. She said that during orientation, she was observed doing Accu-check (fingerstick blood glucose reading) and glucometer cleaning/disinfecting by her preceptors on the East and West Wings. LPN A stated that although she had received in-service regarding the policy and procedure for cleaning/disinfecting glucometers, she had not read the policy until today (8/07/2019). LPN A said she had three residents who required blood glucose monitoring today and verified using alcohol wipes to clean the glucometer after each resident use. On 08/08/19 at 9:27 AM, the East Wing UM stated that Sani-cloth germicidal wipes should be used for cleaning glucometers, not alcohol wipes. She stated that the Clinical Educator did in-services and that Sani-cloth wipes were to be used to clean/disinfect glucometers. The glucometer was to be left wet for two minutes, then air dry on barrier. The East Wing UM said that she and the Clinical Educator did random observations of cleaning/disinfecting of glucometers. She added that staff were aware that alcohol did not disinfect the glucometers. The facility however could not provide any documentation to show that observations were conducted by the Clinical Educator or the East Wing UM. On 08/08/19 at 4:36 PM, the Director of Nursing (DON) /Infection Control Preventionist (ICP) said, that staff were educated on a variety of subjects during orientation including: handwashing, isolation types, personal protective equipment, blood borne pathogens, and glucometer cleaning/ disinfecting. Competency was completed as needed, along with random observations. The DON /ICP said she had been at the facility since (MONTH) 2019. To establish a baseline, she educated licensed nursing staff regarding cleaning/disinfecting glucometers, and all licensed nurses did return demonstration for competency in (MONTH) 2019. The DON/ICP reported that an accrediting organization conducted a survey at the facility between 4/29-30/19 and monitored cleaning/disinfecting of glucometers for all nursing staff on duty that day. The DON/ICP said that the glucometer manufacturer came to the facility on (MONTH) 16, 2019 and also did education including cleaning/disinfecting of the meters. She stated that she and the Clinical Educator were certified trainers, for glucometers being used in the facility. She said the facility had a total of seven medication carts, with two glucometers on each cart. There were fourteen (14) glucometers in use at all times. The DON/ICP said she was made aware that LPN A and LPN B used alcohol wipes to clean/disinfect the glucometers. She said she could not explain why the LPNs, used alcohol wipes to clean/disinfect the glucometers. She stated that she had educated and did return demonstrations with both LPNs with the Sani-cloth germicidal wipes, and with every other nurse in the facility. She stated that the actions of the LPNs were not because, I have not given them the relevant education. Each staff was responsible to ensure that glucometers were cleaned and disinfected after each resident use. On 08/08/19 at 5:29 PM, LPN B said she graduated from nursing school in (YEAR). She had received diabetes education in nursing school but was not taught how to clean the glucometers. LPN B said she was hired at the facility in late (MONTH) 2019, and her orientation included two eight hours days in the classroom. Education included infection control, blood borne pathogens, sharps, and proper cleaning when administering injections. LPN B said she did not remember getting training on proper disinfection of the glucometers. She confirmed that she used alcohol wipes for cleaning the glucometer. She stated that after cleaning the glucometer with alcohol wipes, she would have proceeded to do Accucheck on the next resident. She said that this is how she had been cleaning the glucometers. The Disinfecting Glucometers Competency completed on 4/22/19 was reviewed with LPN B. She stated that alcohol wipes were not mentioned in the competency. LPN B said the Clinical Educator did education with her after the improper cleaning was brought to their attention on 8/07/19. She was taught that Sani-cloth germicidal wipes, and not alcohol wipes were to be used to clean/disinfect the glucometers, due to the possibility of transmitting blood borne disease. When asked why the procedure was not followed, LPN B said she was not sure. She said she had used the germicidal wipes in the past and did not know why she used alcohol wipes. She added, I thought the Sani-cloth wipes and the alcohol wipes were interchangeable. LPN B stated no staff member had observed her doing glucometer cleaning/disinfecting since the competency on 4/22/19. Review of the competency: Disinfecting Glucometers Competency showed competency was completed for LPN A on 4/22/19 and on 5/18/19. Competency was completed for LPN B on 4/22/19. Documentation indicated both LPNs met expectations. A review of all residents requiring blood glucose monitoring revealed that a total of twenty- three (23) residents required blood glucose monitoring daily. Resident #25 and #35 had [DIAGNOSES REDACTED]. Resident #249 and #253 had [DIAGNOSES REDACTED]. On 8/09/19 at 12:04 PM, the Medical Director stated he had been the Medical Director at the facility for more than ten years. He was aware of the concerns regarding glucometer cleaning/disinfecting. He was aware of the Center for Disease Control and Prevention (CDC) guidelines, and regulations pertaining to glucometer cleaning/disinfecting. The Medical Director said his recommendation was that staff should follow the protocol, that is why there is a protocol, recommendations should be followed. The facility's policy and procedure for, Disinfecting Glucometers issued on 4/18/2012 and revised on 3/2018 read, It is the policy of the facility to clean and disinfect multi-patient use blood glucose meters. Resident to resident transmission of bloodborne pathogens is a well-known risk when using lancets, needles, and syringes. Blood glucose monitors that are shared among residents must be cleaned and disinfected between each use .Follow manufacturer's guidelines for cleaning and disinfecting of glucose meters. The manufacturer's guidelines for the glucometers used by the facility . cleaning and Disinfecting the Blood Glucose Monitoring System read, The meter should be cleaned and disinfected after use on each patient .Environmental Protection Agency (EPA) registered disinfectant product may be used to clean and disinfect the blood glucose meter. The disinfectant wipes listed below have been shown to be safe for use with this meter .Super Sani-Cloth Germicidal Disposable Wipe. The nurses cleaned/disinfected the glucometers with alcohol wipes after resident use. They did not use a product designed to disinfect and kill blood-borne pathogens on the glucometers which were exposed to blood during blood glucose monitoring. The facility had Sani-cloth germicidal wipes available, but they were not being used to clean/disinfect the glucometers during the observations. On 8/09/19 at 10:45 AM, the Executive Director, DON/ICP and the Regional Director of Clinical Operations were informed that concerns were identified at the Immediate Jeopardy level starting on 5/18/2019. The DON/ICP said the facility conducted an AD H[NAME] quality assurance (QA) meeting on 8/08/19. The Medical director was involved, he reviewed the minutes and concurred with the performance improvement project (PIP). She said each staff received the manufacturer's handout for the glucometers, and copies were placed in each narcotic book on each medication cart, along with the policy and procedure for cleaning/disinfecting the glucometers. The facility initiated the following steps to remove the immediacy: 1. On 8/07/19, glucometers were removed from service by the DON 2. On 8/07/19, LPN A was immediately re-educated by the DON on components of the regulation with an emphasis on facility standards as it related to glucometer cleaning; competency with return demonstration was carried out, supervised medication observation initiated, and will continue until substantial compliance is achieved with pharmacy consultant check off. DON will review findings and determine substantial compliance. 3. On 8/07/19 visual inspection of glucometers in circulation were inspected by the DON and Clinical Educator for signs of soilage; glucometers were disinfected per manufacturer's guidelines. 4. On 8/07/19 the DON/designee reeducated nine (9) licensed nursing staff on the component of the regulation with an emphasis on facility standards as it related to glucometer cleaning; competency with return demonstration was conducted. Oncoming nurses received education prior to assuming assignment. 5. On 8/08/19 a quality review of registered nurse assessments was conducted for residents receiving blood glucose monitoring to ensure cross contamination did not occur. 6. On 8/08/19 LPN A and B were immediately re-educated for glucometer cleaning and sanitizing. Three (3) Accu-checks demonstration and teach-back method to include glucometer disinfection was carried out with oversight and approval by the DON prior to LPN A and B performing any additional glucometer testing. 7. On 8/08/19 a revision of current Standard and Guidelines was carried out to reflect the utilization of single use glucometers 8. On 8/08/19 individual glucometers were allocated to each resident requiring blood glucose monitoring. 9. On 8/08/19 the Regional Director of Clinical Operations educated the DON and clinical managers on the components of the regulation with an emphasis on facility standards as it related to glucometer cleaning; education included revised Standards and Guideline related to single use glucometers with a revision date of 8/08/19. 10. On 8/08/19 nineteen (19) licensed nurses received either education or re-education. Education/competency will be on-going until 100% of the licensed staff have been educated. Nurses will receive education prior to assuming a shift. Interviews conducted with randomly selected staff members, review of training records and observations on the East and West Wing on 8/09/19, confirmed mandatory education regarding glucometer cleaning/disinfecting. All staff interviewed and observed were knowledgeable of the procedure for cleaning/disinfecting glucometers. Observations, interviews and record reviews verified sufficient implementation of the plan to remove Immediate Jeopardy as of 8/09/19 at 5:00 PM. 2. On 08/06/19 at 11:30 AM, a foam dressing was observed on the left upper arm of resident #53 dated 7/21/19. The edges were rolled, and resident #53 stated he did not know why he had a dressing to his left upper arm. On 08/06/19 at 11:49 AM, the foam dressing to resident #53's left upper arm was observed with the East Wing UM and LPN F, the resident's primary nurse. LPN F stated she was not sure why the dressing was there and added that it may be for a skin tear. The East Wing UM and LPN F verified that the date on the dressing was 7/21/19. On 08/06/19 at 11:52 AM, the East Wing UM said she was trying to contact the wound care nurse because she was not sure why resident #53 had a dressing to his left upper arm On 08/06/19 at 11:57 AM, the wound care nurse said she was not aware of the dressing to resident #53's left upper arm. She stated the resident had a dressing to his right foot. The wound care nurse entered the resident's room, along with LPN F, and the East Wing UM. She sanitized her hands, donned gloves, then removed the soiled dressing from the resident's right foot and discarded the soiled dressing in the garbage bin. She then proceeded to remove the foam dressing from the resident's left upper arm without first removing gloves, washing/sanitizing hands and donning new gloves. The wound care nurse stated there was no open area. She then rubbed the area with her gloved hand. She did not change her gloves, or wash/sanitize her hands, but proceeded to do a complete skin assessment of the resident. The wound care nurse then applied ammonium [MEDICATION NAME] cream to the resident's bilateral lower extremities, with the same gloves, then positioned the resident's tray table within his reach, and opened the privacy curtains with the same gloves. The wound care nurse verified that she used the same gloves for all actions done, and did not change her gloves, or wash/sanitize her hands until after she had opened the privacy curtains. The wound care nurse stated that after removal of the right foot dressing, she should have discarded her gloves, washed/sanitized her hands, donned new gloves. She said she should have done the same after she removed the dressing from the resident's left upper arm and before doing the skin assessment. She also verbalized that she should not have positioned the resident's tray table, and opened the privacy curtains using the same gloves. The wound care nurse said she should have done about six glove changes. The facility's policy Disposable non-sterile/examination gloves read, Don clean gloves between tasks and procedures on the same resident after contact with blood, body fluids .Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces. Wash and or sanitize hands after the removal of gloves. 3. Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. ESBLs are spread via direct and indirect contact with colonized/infected patients and contaminated environmental surfaces. ESBLs are most commonly spread via unwashed hands of health care providers. (www.health.gov.nl.ca) 08/17/19. A physician order dated 7/23/19 revealed an order for [REDACTED]. On 08/06/19 at 10:33 AM, signage on the resident #61's door noted Contact Isolation Precautions. There was a notice posted on the door of the resident's room to check with the nurse before entering the room. There were Personal Protective Equipment (PPE) on the resident #61's door. Personal protective equipment (PPE) refers to protective clothing, helmets, gloves, face shields, goggles, facemask and/or respirators or other equipment designed to protect the wearer from injury or spread of infection or illness. (https://www.fda.gov/medical 08/17/19). On 08/06/19 at 10:35 AM, an interview was conducted with the resident in her room. During the interview, Physical Therapy Assistant (PTA) C entered the resident's room without donning any PPE. The PTA took a slide board and left the resident's room without cleaning the slide board or washing/sanitizing hands. On 08/06/19 at 10:39 AM, Registered Nurse (RN) T confirmed resident #61 had ESBL and was on contact isolation. Everyone entering the resident's room must wear PPE. On 8/6/19 at 11:00 AM, PTA C stated that he had a lapse in judgement. He said he should have worn PPE to enter the resident's room as she was on isolation. He should not have removed the slide board without properly cleaning it before removing it from the resident's room. 08/06/19 at 4:22 PM, the Therapy Director stated that PTA C should have worn PPE when entering resident #61's room and should have cleaned the slide board in the room. Review of the education sign in sheet dated 7/30/19 reflected PTA C had attended the in-service on PPE. On 08/07/19 at 9:14 AM, the West Wing UM stated that all staff were aware to use PPE when entering isolation rooms. She stated that all equipment in isolation room stays in the room for residents on precautions. Review of the facility Policy and Procedure for, Transition Based Precautions revealed, Healthcare personal caring for residents on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning PPE before entry and discarding before exiting the resident's room is done to contain pathogens, especially those that have been implicated in transition through environmental contamination. Review of the facility Policy and Procedure for Environmental Equipment Care, read, 6 .Routine cleaning between individual resident use is not required for all equipment, such as mechanical lifts, with the exception of use between rooms designated as isolation rooms.

Based on observation, interview and record review, the facility failed to observe and identify a safety hazard and placed residents at risk for potential life threatening injury or death from fire and burns. The facility did not observe an operating space heater resting on cotton blankets in the middle of resident #88's bed with the oxygen concentrator at 2 liters of oxygen per minute and the nasal cannula less than 3 feet from the heater. Resident #88 was not present in his room but his roommate, resident #6 was in bed at the time. This failure resulted in potential for serious injury and impairment such as thermal burns, lung injury from fire, smoke, and/or explosion and death for resident #6 and 21 other residents on the East unit as well as other residents, staff and visitors on the unit. There were 11 resident rooms, an activity area and a library at the end of the hallway. The failure to identify and monitor personal electrical equipment resulted in substandard quality of care resulting in Immediate Jeopardy starting on 2/03/19. The Immediate Jeopardy was removed on 2/06/19 and the severity was lowered from K to E. Findings: Cross Reference: F835 Resident #88 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was a smoker and required assistance with transfers using a mechanical lift. He was receiving oxygen via concentrator at 2 liters per minute by nasal cannula. A 14 day minimum data set (MDS) assessment completed on 1/13/19 identified his cognitive status with a Brief Interview for Mental Status with score of 15 indicating he was cognitively intact. During the lunch meal observation on 2/04/19 at 1:25 PM, the surveyor entered resident #88's room. The resident was not present in his room. His roommate, resident #6 was sitting in the middle side of his bed with his meal tray on the over bed table. The room was noted to be very warm. Observation of resident #88's bed area revealed a portable space heater/fan resting on a cotton blanket in the middle of the bed. The space heater was operating and set on maximum heat. Heat could be felt coming from the heater/fan. An oxygen nasal cannula was situated near the space heater, functioning at 2 liters per minute via concentrator. The space heater was connected to a power strip mounted on the wall along with the oxygen concentrator. There was a computer on the bedside hutch next to the oxygen concentrator. The administrator was immediately notified of the concern. She immediately disconnected the space heater/fan and turned off the oxygen. An interview with the resident #88 on 02/04/19 at 2:19 PM noted that he was alert and oriented. He stated that he had the fan/space heater for approximately one week. He stated that because of [MEDICAL CONDITION], he needed the fan part of the appliance, not the heat. He needed the cooling of the fan as his roommate, resident #6 constantly turned the room air conditioning/ heating unit on heat. He said that no one had ever said anything about the space heater. He stated the maintenance director helped secure the power strip to the wall so that he could plug in the space heater along with his computer, and cell phone. He confirmed that he earlier placed the fan/space heater on his bed before he went outside to smoke. He could not explain how the thermostat setting was on heat. When he used his computer on the bedside hutch, he would place the fan/space heater in the center of his bed so that the cooler air would blow upon his face to help his breathing. He could not explain how the fan/space heater was set on maximum heat. He said he was never educated to make sure he turned the oxygen concentrator off when he left the room. Resident #88's plan of care related to altered respiratory status/difficulty breathing, and history of [MEDICAL CONDITION] and [MEDICAL CONDITION] established a goal of maintaining respiratory baseline with a patent airway and unlabored breathing. Interventions including oxygen administration as ordered. There was no indication that resident #88 was educated about turning off the oxygen concentrator when not in room or use of a fan to assist with his [MEDICAL CONDITION] for comfort. Interview with certified nursing assistant (CNA) D on 2/4/19 at 2:32 PM confirmed that she assisted resident #88 out of bed with a mechanical lift at 10:30 AM. She said she had moved the fan/space heater to his bedside hutch. She confirmed that the room was warm and had not noticed that the fan was actually a space heater. Further interviews on 2/4/19 from 2:20-2:38 PM with Registered Nurse (RN) G, CNAs H, I and housekeeper J revealed that they had not identified that resident #88 had a space heater/fan. On 2/05/19 at 10:25 AM, RN F confirmed that she had worked with the resident for the past two months. She first saw the fan/space heater sometime last week. It was always on his over-bed table. She was unaware that it was a space heater/fan. On 2/5/19 at 4:30 PM, CNA I revealed that on 02/03/19 the resident had a small white fan in his room. She thought it was a fan and not a heater. She remembered that she saw it on 02/03/2019 as it was Superbowl Sunday. She did not remember seeing that fan in his room before 02/03/19. Interview on 02/06/19 at 9:17 AM with the housekeeping staff for resident #88's room revealed that she had not seen the space heater/fan in his room. She was aware that the resident left his oxygen concentrator on frequently when he left to go smoke outside. She recalled turning off the oxygen in the past. Further interviews on 02/06/19 at 3:26 PM revealed that CNA K worked with resident #88 last week. She had noticed the space heater/ fan and had asked the maintenance director about it. She had not documented a work order but had mentioned it to the MD in passing. She had questioned the use of the fan because it was also a heater. She stated, the MD told me the resident was using it as a fan. On 02/04/2019 at 2:30 PM, the maintenance director contradicted CNA K and stated that he was not aware that resident #88 had a space heater/fan in his room. He said the resident brought in the power strip about 2-3 weeks ago and asked him to attach it to the wall which he did. He did not check the strip for compliance with safety code. On 02/05/2019 at 1:00 PM the maintenance director was asked how resident's electrical equipment was screened and checked when it entered the facility. He stated that he did not have any system in place to check residents' electrical equipment. He was asked for a policy for monitoring of resident's personal electrical equipment and he stated that he was not aware of a policy. A review of the manufacturer's product guide for the space heater/fan specified under usage, To prevent overloading a circuit, do not plug the heater into a circuit that is servicing other electrical needs. Also on the guide under Important Instructions; Warning: Fire Hazard. Heater has hot and arcing or sparking parts inside. Do not use near combustible materials or flammable gases or sources of heat .Keep combustible materials such as furniture, pillows, bedding, papers, clothes and curtains at least 3 feet from the front of the heater and keep them away from the sides and rear .Do not use on soft surfaces, like a bed where openings may become blocked. Do not place the heater near a bed because objects such as pillows or blankets can fall on the bed and be ignited by the heater . On 02/05/19 at 4:45 PM, the east wing unit manager revealed that she was responsible for doing Guardian Angel rounds in resident #88's room. She had just returned from leave but did not recall seeing the space heater/fan in the resident's room. She did not know who was the alternate for doing rounds in the room while she was on leave. Interview with the administrator at approximately 1:35 PM on 02/04/19 revealed that she had identified the need for updating the Guardian Angel program as she had realized there was no back up guardian angel when staff were on leave. She had planned to roll out the updated program this week. Review of the Guardian Angel program (no date) purpose and goals noted, The purpose of the program is to increase communication between management of the building, residents and family. The ultimate goal is to increase quality of resident care and address concerns before they become a safety, care or compliance concern. Review of the Plant Operations Manual policy #13.06.07 Standards and Guideline: Personal Electrical Equipment issued 3/2018 noted, Patients (residents) all electrical appliances should be discouraged. If the resident insists, the appliance must be checked by Plant Operations Department (maintenance director) to ensure that is safe before it can be used. The equipment will be tagged and dated to indicate that it had been checked and passed inspection. Equipment cannot be used until it is checked. A review of the facility policy dated 3/2018 read, Portable space heaters are prohibited in all resident care/treatment areas. A meeting was held with the administrator, director of nursing, regional nurse consultant, regional compliance officer and the regional vice president on 2/07/19 at 12:15 PM informing them of the Immediate Jeopardy. The administrator provided the following corrective action plan (final version) on 02/08/2019. On 2/04/2019, the administrator immediately disconnected the space heater/fan and turned off the oxygen concentrator. The facility conducted an AD Hoc Quality Assurance meeting on 2/04/19 with the medical director via phone. The maintenance director was re-educated on 2/04/19 related to the prohibition of space heaters, power strips and extension cords. On 2/04/19 and 2/05/19, resident #88 was explained why the space heater and power strip were removed as well as prohibition of space heaters, power strips and oxygen safety. He was re-educated using return demonstration on turning off the oxygen concentrator, how to store nasal cannula and tubing. Notifying staff of receipt of new items including electrical appliances, power strips extension cords. All resident rooms were visually inspected on 2/04/2019 to ensure no other rooms had space heaters, power strips or unattended oxygen concentrators left on. Between 2/04-2/06/19, letters were given to all residents with a cognitive assessment score of 10 or greater (mild impairment to cognitively intact) and to all responsible parties for 105/105 residents explaining non-approved electrical devices. A letter was also added to the admission packet and reviewed with all new admissions. The director of nursing reeducated staff of non-approved electrical devices. On 2/04/19, the administrator assessed and revised the Guardian Angel rounds assignments and responsibilities to cover 100% of the resident rooms including coverage for staff not available. An ad hoc, Resident Council meeting was held on 2/05/2019 to discuss safety including prohibited items such as space heaters, power strips, extension cords and other non-approved devices, and discussed turning off the oxygen concentrators when leaving the room as applicable. As of 02/06/2019 100% of facility staff were re-educated on prohibited use of space heaters, power strips and safe use of oxygen. Weekly Quality Assurance Performance Improvement (QAPI) meetings will be held for 4 weeks or until such time the committee determines substantial compliance and recommends return to monthly meetings. Observations, record reviews, staff and resident interviews verified the sufficient implementation of the plan to remove the immediacy on 2/06/19, and the scope and severity was lowered from K to E.

Based on observation, interview and record review, the facility failed to administer its resources effectively and placed residents/families/staff at risk for potential life threatening injury or death from fire and burns. Administration failed to ensure that residents' personal electrical equipment (space heater/fan) were inspected, approved and monitored for safe use in the facility. There was an operating space heater/fan resting on cotton blankets in the middle of resident #88's bed with the oxygen concentrator at 2 liters of oxygen per minute and the nasal cannula less than 3 feet from the heater. Resident #88 was not present in his room but his roommate, resident #6 was in bed at the time. This failure resulted in potential for serious injury and impairment such as thermal burns, lung injury from fire, smoke, and or explosion and death for resident #6 and 21 other residents on the East unit as well as other residents, staff and visitors on the unit. There were 11 resident rooms, an activity area and a library at the end of the hallway. The failure to implement policies to monitor electrical equipment brought into the facility resulted in Immediate Jeopardy starting on 2/03/19. The immediate jeopardy was removed on 2/06/19 and the severity was lowered from K to E. Findings: Cross Reference F 689 During the lunch meal observation on 2/04/19 at 1:25 PM, resident #88's room was entered. The resident was not present in his room. His roommate, resident #6 was sitting in the middle side of his bed with his meal tray on the over bed table. The room was noted to be very warm. Observation of resident #88's bed area revealed a portable space heater/fan resting on a cotton blanket in the middle of the bed. The space heater was operating and set on maximum heat. Heat could be felt coming from the heater/fan. An oxygen nasal cannula was situated near the space heater, functioning at 2 liters per minute via concentrator. The space heater was connected to a power strip mounted on the wall along with the oxygen concentrator. There was a computer on the bedside hutch next to the oxygen concentrator. The administrator was immediately notified of the concern. She immediately disconnected the space heater/fan and turned off the oxygen. In an interview with the maintenance director on 2/05/19 at 1:00 PM, he was asked what system was in place for routine screening or annual testing of residents' electrical equipment. He stated that he did not have a system in place. He was asked for a policy for monitoring of personal equipment and he stated that he was not aware of a policy. During another interview with the maintenance director on 2/04/19 at 2:30 PM, he stated that resident #88 brought in the power strip about 2-3 weeks ago and asked him (maintenance director) to install it to the wall, which he did. He did not check the strip for compliance with safety code. He did not ask the resident as to why he needed the power strip and he did not use a facility regulatory approved power strip. He was not aware the resident had a space heater/fan in his room Interviews from 2/04/19 at 2:20 PM to 2/5/19 with direct care staff including nurses and CNAs providing care to resident #88 and resident #6 revealed that they had not identified a space heater in resident #88's room. No one had reported the fan or space heater to maintenance or management staff. Since it was in the room, they all thought it was okay. A review of the Guardian Angel Program documented, the ultimate goal was to increase the quality of resident care and address concerns before they become a safety, care or compliance concern. Each resident/room had a specific member of the management team assigned as a Guardian Angel. During the visit to the assigned rooms, they would assess for any care or potential safety concerns. On 2/08/19 at 11:10 AM the administrator revealed that she started working at the facility on 1/17/19. From 1/17/19 to 2/01/19, she had not observed the space heater/fan in resident #88's room. She stated, I do room rounds in the morning, lunch, afternoon and after change of shift. I probably do 7 to 8 rounds of the building daily. The administrator spoke about guardian angel rounds. She stated that the housekeeping director was responsible for the guardian angel rounds for resident #88's room. She stated that the housekeeping director resigned on 1/04/19 and there was no backup guardian angel to do rounds on those rooms. She said she became aware of the concern of coverage for guardian angel program on 2/1/19. I became aware of it because of my experience as an administrator. It made me realize that changes needed to be made in the guardian angel program. I had identified that there was no back-up staff to cover when the guardian angel was on leave. On the weekends, the manager on duty covers the facility. The process was immediately updated when the concern was identified related to the space heater. She stated that the space heater was not identified as it looked like a fan and no one realized that there was a thermostat for heat setting. If there had been back-up staff coverage for the guardian angel, it might have helped. The administrator's job description read, Manage lead and direct overall operations of the facility in accordance with customer needs, regulations and company policies. Duties included oversees regular rounds to monitor delivery of nursing care operation of support departments. Ensures the building . equipment and work area are clean, safe and orderly. Provides immediate attention to ensure any hazardous conditions are addressed. Monitor, train, and direct staff in support of continuous practices including fire safety practices and procedures. Ensure that all facility personnel residents and visitors follow established safety policies, to include fire protection and prevention and general safety. The maintenance director had been working at the facility for [AGE] years. His job description noted that he was responsible for the facility's compliance environmentally and with life safety regulations. Safety duties included ensuring fire and safety procedures including promptly addressing any hazardous equipment. There were three policies from the plant operations manual under the section of preventative maintenance. Policy #13.02.10 issued 3/18 Portable space heaters. It is the policy of this healthcare management company to limit the use of portable space heaters and to eliminate the fire hazard associated with the use of certain types of heaters. Portable heater are prohibited in all resident/care/treatment areas. Policy #13.04.09 was issued 3/18. To provide a safe, hazard free environment per NFPA101. Standard Plug strips may not be used as a substitute for adequate electrical outlets in the facility. Power strips may be used for computer, monitor, and printer. The guideline noted that use of extension cords in non-emergency situations is discouraged. Extension cords may only be utilized on a temporary basis until permanent electrical fixtures are installed. Procedures included that the plant operations department will be responsible for inspection and approval of any extension cord used within the facility. Department directors shall be responsible for the implementation of this policy and the Director of Plant operations shall be responsible for control of this policy. Policy #13.06.07 was issued 3/18. The guidelines noted that residents, staff and physicians shall not use any electrical equipment or appliances, except using the following conditions; all electrical appliances should be discouraged. If the resident insists, the appliance must be checked by plant operations to ensure it is safe before it can be used by the patient (resident). The Plant operations Department shall tag the equipment with the date to indicate it has been checked and passes inspection. Equipment cannot be used until it is checked. The maintenance director did not have a system in place to identify, inspect, approve or monitor electrical devices brought in to the facility for use by the residents. On 2/05/19 at 1:00 PM, the maintenance director confirmed that he was unaware of the above policies. The Guardian Angel program was ineffective as it did not have back up coverage to inspect rooms when staff were on leave. The guardian angel program did not document any concerns related to power strips, inadequate outlets for residents' electrical devices, or non-tagged electrical items brought in to the facility for resident use. The concierge program did not ensure all items for the resident were documented on the inventory list. There was no system in place to ensure that items brought into the facility for the resident after admission were documented on the inventory list. A meeting was held with the administrator, director of nursing, regional nurse consultant, regional compliance officer and the regional vice president on 2/08/19 at 11:05 AM informing them of the Immediate Jeopardy. The administrator provided the following corrective action plan (final version) on 02/08/2019. The facility conducted an AD Hoc Quality Assurance meeting on 2/04/19 with the medical director via phone. The maintenance director was re-educated on 2/04/19 related to the prohibition of space heaters, power strips and extension cords. An Electrical Appliance inventory checklist was completed for all 105 residents on 2/7/19. The list included radio, CD/DVD players, fans, lamps televisions, electric razors, toothbrushes, cell phone chargers, computers iPad/tablets game stations. The checklist documented that it was checked by maintenance. Items that were not acceptable were removed from resident rooms such as curling irons, blow dryers. All electrical devices had been identified, inspected and tagged by maintenance including televisions. If a device was electrically supplied, the device was inspected, tagged for safe use, and included on the resident's inventory list. On 2/4/19, the administrator assessed and revised the Guardian Angel rounds assignments and responsibilities to cover 100% of the resident rooms including coverage for staff not available. On 2/6/19, the Director of nursing/the regional director of clinical operations / designee educated all staff (151 of 151) on the prohibited use of space heaters, power strips and safe use of oxygen and non-approved electrical devices. On 2/4-2/6/19, letters were given to all residents with a cognitive assessment score of 10 or greater (mild impairment to cognitively intact) and to all responsible parties for 105/105 residents explaining non-approved electrical devices. A letter was also added to the admission packet and reviewed with all new admissions. The director of nursing reeducated staff of non-approved electrical devices. An Ad Hoc resident council meeting was held on 2/5/19 to discuss safety with emphasis on prohibited use of space heaters, power strips, extension cords and other non- approved electrical devices. Weekly Quality Assurance Performance Improvement (QAPI) meetings will be held for 4 weeks or until such time the committee determines substantial compliance and recommends return to monthly meetings. Observations, record review, staff and resident interviews verified the sufficient implementation of the plan to remove the immediacy on 2/06/19, and the scope and severity was lowered from K to E.