Every finding on record at Rose Hill Health and Rehab

Based on staff interview and facility document review, the facility staff failed to implement their policy to prevent misappropriation of resident property for three of thirteen residents in the survey sample, Residents #10, #11, and #12. The findings include: For Residents #10 (R10), #11 (R11), and #12 (R12), the facility staff failed to investigate and/or report an allegation of staff misappropriation of resident property to the state agency between July and November 2023. A review of the facility policy, Resident Abuse, revealed, in part: Misappropriation or resident property .means 'the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Investigation .Immediately upon report of an incident .the suspect(s) shall be segregated from the resident .An incident report shall be filed by the individual in charge who received the report .The facility shall report to the state agency and one or more law enforcement entities any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility .The Abuse Coordinator and/or Director of Nursing shall take written statements from the victim, the suspect(s), and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. Any suspect(s), once he/she has (have) been identified will be suspended pending the investigation. On 8/13/24, OSM (other staff member) #1's (the director of social services) employee folder was reviewed. This review revealed an Employee Progressive Action Memorandum dated 11/28/23. This document contained, in part, the following information: Employee Name [OSM #1] .Supervisor Name [ASM #3] .Date 11/28/23 .Type of Violation Category 2 Violation .The offenses are considered improper conduct subject to progressive discipline up to, and including, termination .You failed to follow the .protocol for processing, dispersing and record keeping for the Residents Trust Accounts .You were given funds in excess of $9,000 and tasked with purchasing items for residents .policy requires that receipts for all purchases are turned in within 24 hours. You failed to insure receipts were provided for purchases you made .policy requires that a list of items to be purchased and an estimated value be given to the Business Office Prior to receiving any funds. You also failed to make these estimates prior to taking money .Outcome of Violation .Step 3: 3rd Disciplinary Action .You must follow the .policy of providing a list of items to be purchased when requesting funds from the resident trust accounts. You must turn in receipts for money spent within 24 hours of receiving funds. If you are unable to complete shopping within 24 hours you must turn in receipts you have and account for the balance of the money drawn daily until shopping is completed. Violations of handling Resident Trust Funds could be considered level 1 violations resulting in immediate termination. On 8/13/24, OSM (other staff member) #2's (the former business office manager) employee folder was reviewed. This review revealed an Employee Progressive Action Memorandum dated 11/28/23. This document contained, in part, the following information: Employee Name [OSM #1] .Supervisor Name [ASM #3] .Date 11/28/23 .Type of Violation Category 2 Violation .The offenses are considered improper conduct subject to progressive discipline up to, and including, termination .You failed to follow the .protocol for processing, dispersing and record keeping for the Residents Trust Accounts .You knowing (sic) dispensed cash to another employee on more than one occasion in amounts in excess of $1000 without getting the receipts within 24 hours as specified. To compound the matter you allowed that condition to exist for more than 120 days with (sic) reporting the condition to anyone. When you did report the occurrence, you reported it to the HR (human resources) Generalist not the administrator or other person in your line of authority. A review of Resident Funds Account activity revealed checks were written and cashed out of petty cash for the following residents on these dates in these amounts: R10 - 7/6/23 - $3000; R11 - 7/6/23 - $2000; R12 - 7/6/23 - $2000. On 8/14/24 at 8:35 a.m., ASM (administrative staff member) #1, the administrator, was asked to provide evidence of an investigation related to these petty cash withdrawals, including documentation of who handled the cash, how much cash was exchanged among employees, copies of receipts, witness statements, resident interviews, and other staff interviews. ASM #1 was also asked to provide evidence that the facility reported the allegation of the misappropriation of resident funds, and that the employees involved (OSMs #1 and #2) were suspended pending the results of the investigation. On 8/14/24 at 10:29 a.m., OSM #1 was interviewed. She stated ASM #4, the administrator in July 2023, and OSM #2 instructed her that she needed to do a spend down for several residents because they had too much money in their account for Medicaid. She stated she could not recall all of the names of the residents for whom she received this instruction. She stated OSM #2 wrote one big check which was cashed by ASM #4. She stated the cash was given to her in an envelope, and she could not recall whether or not she verified the amount of cash she received, or whether or not she signed any sort of receipt for the large amount of cash. She stated: I think it was around $9000. She continued: I did the spend down. I went to Wal Mart, Ross, and lots of other places. She stated she bought televisions, hygiene products, hair products, nail care products, clothes, and accessories. She stated when she returned to the facility, she gave the receipts to OSM #2, but did not keep any copies for herself. She stated she had a witness to her providing the receipts immediately to OSM #2. She stated she now realizes she should have kept the copies. She stated approximately six months later, OSM #2 went to her and asked for all the receipts from the July 2023 spend down. OSM #1 stated she had already turned in all receipts to OSM #2, and did not have copies as back up. She stated she believes at the time OSM #2 asked again for the receipts, OSM #2 had already completed Medicaid renewals on some of the residents included in the July 2023 spend down. She stated Medicaid would not have renewed any resident's payment if receipts were not provided for the spend down. She also stated she actually overspent for some of the residents, and was personally reimbursed for these charges in cash immediately after the July 2023 spend down. OSM #1 stated she was never suspended from work pending an investigation of these events. On 8/14/24 at 10:45 a.m., ASM #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. ASM #1 stated if anyone is suspected of misappropriating resident property or funds, it becomes a part of the facility's abuse and neglect protocol. He stated the allegation should be reported to proper authorities, and an investigation should be started. He stated the employee who is the alleged perpetrator should be suspended pending the outcome of the investigation. Once the investigation has been thoroughly completed, the facility's policy guides the outcome for the employee and affected residents. ASM #1 and ASM #2 were informed of concerns regarding a lack of reporting, a lack of an investigation, and a lack of the facility's following its own policy. On 8/14/24 at 11:18 a.m., ASM #2 stated they had identified the witness to the receipt exchange as OSM #3, the admissions and marketing director. On 8/14/24 at 11:21 a.m., OSM #3 was interviewed. She stated she remembered seeing OSM #1 copying a large amount of receipts. OSM #3 had been in line at the copier behind OSM #1 as she copied the receipts and remembered remarking to OSM #1 about how long it was going to take her to get everything copied. She said OSM #2 walked into the area where OSM #1 was making the copies and said something to the effect of: Hurry up and give me the receipts. OSM #3 stated: I feel like there were receipts there for everything. There was a lot of stuff bought for the residents. It was spread out all over everywhere. When asked if she knew of any evidence that this was true, she stated she did not have evidence, but was only going by what she could see. On 8/14/24 at 12:19 p.m., ASM #3, the administrator in the facility in December 2023, was interviewed. He stated he was not working in the facility in July 2023 when the alleged spend down occurred, and only became aware of a problem when an internal complaint was filed through the corporate compliance line. He stated the complaint was about OSM #1 not providing receipts for purchases made out of resident personal funds accounts. He stated OSM #1 was adamant that she had provided some of the receipts, and had made copies of all of them. However, OSM #1's vehicle with some of the receipts and all of the copies was repossessed shortly after the shopping had occurred in July 2023 and OSM #1 had no way to retrieve the original receipts or the copies. He stated OSM #2 was equally adamant that most of the receipts had never been returned. He stated he was unclear about what happened to any leftover cash that would have been owed back to various resident funds accounts. He stated he did not remember any such records. He stated OSM #1 recreated, as best she could, lists of what she had bought for each resident in the spend down. He stated he took the list and went room to room for each resident to verify that what was on the list had made it into the residents' rooms. He stated: I didn't find anything in terms of misappropriation. It didn't appear like there was misappropriation. The value was approximately the value of the money attributed to each resident's account. When asked the location of documentation of the efforts he had made, he stated he could not recall for sure what, if any documentation he had made. He stated OSM #2 told him that she had initially reported this concern to ASM #4, who had not done anything about it. When asked if he had interviewed any residents or other staff members, he stated he had not. When asked if he had reported this allegation of possible misappropriation of resident property to the state agency or other agencies, he stated: Overall it appeared to me that the money taken from the PFAs was properly spent to buy things for residents. He stated it was more of an internal process problem than a concern about misappropriation of funds. He stated: What was presented to me was that someone purchased goods and did not turn in receipts. I did not take this to be an allegation of misappropriation of money. I understand now that it might be taken that way. When asked why, if he was not concerned about the possibility of misappropriation of funds, he needed to go room to room to verify what had been purchased, he did not answer. On 8/14/24 at 1:00 p.m., ASM #1 was asked if this allegation had been thoroughly investigated. He stated: We always go by facts. If I am doing an investigation, I get witness statements, and I would have documentation of everything I did. I would have a statement of my conclusion. Unfortunately there has been a large turnover of staff. I don't see those things here. On 8/14/24 at 1:35 p.m., ASM #2 stated she had heard from the corporate office staff. A corporate vice-president had called her and asked her to tell the surveyor that the corporate staff did not report this to the state because it was no misappropriation of funds. The staff members were disciplined because they did not follow internal policy; all items bought matched the money spent; the corporate office reconciled everything. When asked the possible consequences of staff not following the policy regarding cash disbursements from resident personal funds accounts, ASM #2 said: A misappropriation of the resident's money. When asked if she or ASM #1 had located any evidence of the corporate office's reconciliation of cash disbursed with items bought, she stated they had not. No further information was provided prior to exit.

Based on staff interview and facility document review, the facility staff failed to report an allegation of misappropriation of resident property to the state agency for three of thirteen residents in the survey sample, Residents #10, #11, and #12. The findings include: For Residents #10 (R10), #11 (R11), and #12 (R12), the facility staff failed to report an allegation of staff misappropriation of resident property to the state agency between July and November 2023. On 8/13/24, OSM (other staff member) #1's (the director of social services) employee folder was reviewed. This review revealed an Employee Progressive Action Memorandum dated 11/28/23. This document contained, in part, the following information: Employee Name [OSM #1] .Supervisor Name [ASM #3] .Date 11/28/23 .Type of Violation Category 2 Violation .The offenses are considered improper conduct subject to progressive discipline up to, and including, termination .You failed to follow the .protocol for processing, dispersing and record keeping for the Residents Trust Accounts .You were given funds in excess of $9,000 and tasked with purchasing items for residents .policy requires that receipts for all purchases are turned in within 24 hours. You failed to insure receipts were provided for purchases you made .policy requires that a list of items to be purchased and an estimated value be given to the Business Office Prior to receiving any funds. You also failed to make these estimates prior to taking money .Outcome of Violation .Step 3: 3rd Disciplinary Action .You must follow the .policy of providing a list of items to be purchased when requesting funds from the resident trust accounts. You must turn in receipts for money spent within 24 hours of receiving funds. If you are unable to complete shopping within 24 hours you must turn in receipts you have and account for the balance of the money drawn daily until shopping is completed. Violations of handling Resident Trust Funds could be considered level 1 violations resulting in immediate termination. On 8/13/24, OSM (other staff member) #2's (the former business office manager) employee folder was reviewed. This review revealed an Employee Progressive Action Memorandum dated 11/28/23. This document contained, in part, the following information: Employee Name [OSM #1] .Supervisor Name [ASM #3] .Date 11/28/23 .Type of Violation Category 2 Violation .The offenses are considered improper conduct subject to progressive discipline up to, and including, termination .You failed to follow the .protocol for processing, dispersing and record keeping for the Residents Trust Accounts .You knowing (sic) dispensed cash to another employee on more than one occasion in amounts in excess of $1000 without getting the receipts within 24 hours as specified. To compound the matter you allowed that condition to exist for more than 120 days with (sic) reporting the condition to anyone. When you did report the occurrence, you reported it to the HR (human resources) Generalist not the administrator or other person in your line of authority. A review of Resident Funds Account activity revealed checks were written and cashed out of petty cash for the following residents on these dates in these amounts: R10 - 7/6/23 - $3000; R11 - 7/6/23 - $2000; R12 - 7/6/23 - $2000. On 8/14/24 at 8:35 a.m., ASM (administrative staff member) #1, the administrator, was asked to provide evidence of an investigation related to these petty cash withdrawals, including documentation of who handled the cash, how much cash was exchanged among employees, copies of receipts, witness statements, resident interviews, and other staff interviews. ASM #1 was also asked to provide evidence that the facility reported the allegation of the misappropriation of resident funds, and that the employees involved (OSMs #1 and #2) were suspended pending the results of the investigation. On 8/14/24 at 10:29 a.m., OSM #1 was interviewed. She stated ASM #4, the administrator in July 2023, and OSM #2 instructed her that she needed to do a spend down for several residents because they had too much money in their account for Medicaid. She stated she could not recall all of the names of the residents for whom she received this instruction. She stated OSM #2 wrote one big check which was cashed by ASM #4. She stated the cash was given to her in an envelope, and she could not recall whether or not she verified the amount of cash she received, or whether or not she signed any sort of receipt for the large amount of cash. She stated: I think it was around $9000. She continued: I did the spend down. I went to Wal Mart, Ross, and lots of other places. She stated she bought televisions, hygiene products, hair products, nail care products, clothes, and accessories. She stated when she returned to the facility, she gave the receipts to OSM #2, but did not keep any copies for herself. She stated she had a witness to her providing the receipts immediately to OSM #2. She stated she now realizes she should have kept the copies. She stated approximately six months later, OSM #2 went to her and asked for all the receipts from the July 2023 spend down. OSM #1 stated she had already turned in all receipts to OSM #2, and did not have copies as back up. She stated she believes at the time OSM #2 asked again for the receipts, OSM #2 had already completed Medicaid renewals on some of the residents included in the July 2023 spend down. She stated Medicaid would not have renewed any resident's payment if receipts were not provided for the spend down. She also stated she actually overspent for some of the residents, and was personally reimbursed for these charges in cash immediately after the July 2023 spend down. OSM #1 stated she was never suspended from work pending an investigation of these events. On 8/14/24 at 10:45 a.m., ASM #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. ASM #1 stated if anyone is suspected of misappropriating resident property or funds, it becomes a part of the facility's abuse and neglect protocol. He stated the allegation should be reported to proper authorities, and an investigation should be started. He stated the employee who is the alleged perpetrator should be suspended pending the outcome of the investigation. Once the investigation has been thoroughly completed, the facility's policy guides the outcome for the employee and affected residents. ASM #1 and ASM #2 were informed of concerns regarding a lack of reporting, a lack of an investigation, and a lack of the facility's following its own policy. On 8/14/24 at 11:18 a.m., ASM #2 stated they had identified the witness to the receipt exchange as OSM #3, the admissions and marketing director. On 8/14/24 at 11:21 a.m., OSM #3 was interviewed. She stated she remembered seeing OSM #1 copying a large amount of receipts. OSM #3 had been in line at the copier behind OSM #1 as she copied the receipts and remembered remarking to OSM #1 about how long it was going to take her to get everything copied. She said OSM #2 walked into the area where OSM #1 was making the copies and said something to the effect of: Hurry up and give me the receipts. OSM #3 stated: I feel like there were receipts there for everything. There was a lot of stuff bought for the residents. It was spread out all over everywhere. When asked if she knew of any evidence that this was true, she stated she did not have evidence, but was only going by what she could see. On 8/14/24 at 12:19 p.m., ASM #3, the administrator in the facility in December 2023, was interviewed. He stated he was not working in the facility in July 2023 when the alleged spend down occurred, and only became aware of a problem when an internal complaint was filed through the corporate compliance line. He stated the complaint was about OSM #1 not providing receipts for purchases made out of resident personal funds accounts. He stated OSM #1 was adamant that she had provided some of the receipts, and had made copies of all of them. However, OSM #1's vehicle with some of the receipts and all of the copies was repossessed shortly after the shopping had occurred in July 2023 and OSM #1 had no way to retrieve the original receipts or the copies. He stated OSM #2 was equally adamant that most of the receipts had never been returned. He stated he was unclear about what happened to any leftover cash that would have been owed back to various resident funds accounts. He stated he did not remember any such records. He stated OSM #1 recreated, as best she could, lists of what she had bought for each resident in the spend down. He stated he took the list and went room to room for each resident to verify that what was on the list had made it into the residents' rooms. He stated: I didn't find anything in terms of misappropriation. It didn't appear like there was misappropriation. The value was approximately the value of the money attributed to each resident's account. When asked the location of documentation of the efforts he had made, he stated he could not recall for sure what, if any documentation he had made. He stated OSM #2 told him that she had initially reported this concern to ASM #4, who had not done anything about it. When asked if he had interviewed any residents or other staff members, he stated he had not. When asked if he had reported this allegation of possible misappropriation of resident property to the state agency or other agencies, he stated: Overall it appeared to me that the money taken from the PFAs was properly spent to buy things for residents. He stated it was more of an internal process problem than a concern about misappropriation of funds. He stated: What was presented to me was that someone purchased goods and did not turn in receipts. I did not take this to be an allegation of misappropriation of money. I understand now that it might be taken that way. When asked why, if he was not concerned about the possibility of misappropriation of funds, he needed to go room to room to verify what had been purchased, he did not answer. On 8/14/24 at 1:00 p.m., ASM #1 was asked if this allegation had been thoroughly investigated. He stated: We always go by facts. If I am doing an investigation, I get witness statements, and I would have documentation of everything I did. I would have a statement of my conclusion. Unfortunately there has been a large turnover of staff. I don't see those things here. On 8/14/24 at 1:35 p.m., ASM #2 stated she had heard from the corporate office staff. A corporate vice-president had called her and asked her to tell the surveyor that the corporate staff did not report this to the state because it was no misappropriation of funds. The staff members were disciplined because they did not follow internal policy; all items bought matched the money spent; the corporate office reconciled everything. When asked the possible consequences of staff not following the policy regarding cash disbursements from resident personal funds accounts, ASM #2 said: A misappropriation of the resident's money. When asked if she or ASM #1 had located any evidence of the corporate office's reconciliation of cash disbursed with items bought, she stated they had not. A review of the facility policy, Resident Abuse, revealed, in part: Misappropriation or resident property .means 'the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Investigation .Immediately upon report of an incident .the suspect(s) shall be segregated from the resident .An incident report shall be filed by the individual in charge who received the report .The facility shall report to the state agency and one or more law enforcement entities any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. No further information was provided prior to exit.

Based on staff interview and facility document review, the facility staff failed to report an allegation of misappropriation of resident property to the state agency for two of thirteen residents in the survey sample, Residents #11 and #12. The findings include: For Residents #11 (R11) and #12 (R12), the facility staff failed to investigate an allegation of staff misappropriation of resident property to the state agency between July and November 2023. On 8/13/24, OSM (other staff member) #1's (the director of social services) employee folder was reviewed. This review revealed an Employee Progressive Action Memorandum dated 11/28/23. This document contained, in part, the following information: Employee Name [OSM #1] .Supervisor Name [ASM #3] .Date 11/28/23 .Type of Violation Category 2 Violation .The offenses are considered improper conduct subject to progressive discipline up to, and including, termination .You failed to follow the .protocol for processing, dispersing and record keeping for the Residents Trust Accounts .You were given funds in excess of $9,000 and tasked with purchasing items for residents .policy requires that receipts for all purchases are turned in within 24 hours. You failed to insure receipts were provided for purchases you made .policy requires that a list of items to be purchased and an estimated value be given to the Business Office Prior to receiving any funds. You also failed to make these estimates prior to taking money .Outcome of Violation .Step 3: 3rd Disciplinary Action .You must follow the .policy of providing a list of items to be purchased when requesting funds from the resident trust accounts. You must turn in receipts for money spent within 24 hours of receiving funds. If you are unable to complete shopping within 24 hours you must turn in receipts you have and account for the balance of the money drawn daily until shopping is completed. Violations of handling Resident Trust Funds could be considered level 1 violations resulting in immediate termination. On 8/13/24, OSM (other staff member) #2's (the former business office manager) employee folder was reviewed. This review revealed an Employee Progressive Action Memorandum dated 11/28/23. This document contained, in part, the following information: Employee Name [OSM #1] .Supervisor Name [ASM #3] .Date 11/28/23 .Type of Violation Category 2 Violation .The offenses are considered improper conduct subject to progressive discipline up to, and including, termination .You failed to follow the .protocol for processing, dispersing and record keeping for the Residents Trust Accounts .You knowing (sic) dispensed cash to another employee on more than one occasion in amounts in excess of $1000 without getting the receipts within 24 hours as specified. To compound the matter you allowed that condition to exist for more than 120 days with (sic) reporting the condition to anyone. When you did report the occurrence, you reported it to the HR (human resources) Generalist not the administrator or other person in your line of authority. A review of Resident Funds Account activity revealed checks were written and cashed out of petty cash for the following residents on these dates in these amounts: R11 - 7/6/23 - $2000; R12 - 7/6/23 - $2000. On 8/14/24 at 8:35 a.m., ASM (administrative staff member) #1, the administrator, was asked to provide evidence of an investigation related to these petty cash withdrawals, including documentation of who handled the cash, how much cash was exchanged among employees, copies of receipts, witness statements, resident interviews, and other staff interviews. On 8/14/24 at 10:29 a.m., OSM #1 was interviewed. She stated ASM #4, the administrator in July 2023, and OSM #2 instructed her that she needed to do a spend down for several residents because they had too much money in their account for Medicaid. She stated she could not recall all of the names of the residents for whom she received this instruction. She stated OSM #2 wrote one big check which was cashed by ASM #4. She stated the cash was given to her in an envelope, and she could not recall whether or not she verified the amount of cash she received, or whether or not she signed any sort of receipt for the large amount of cash. She stated: I think it was around $9000. She continued: I did the spend down. I went to Wal Mart, Ross, and lots of other places. She stated she bought televisions, hygiene products, hair products, nail care products, clothes, and accessories. She stated when she returned to the facility, she gave the receipts to OSM #2, but did not keep any copies for herself. She stated she had a witness to her providing the receipts immediately to OSM #2. She stated she now realizes she should have kept the copies. She stated approximately six months later, OSM #2 went to her and asked for all the receipts from the July 2023 spend down. OSM #1 stated she had already turned in all receipts to OSM #2, and did not have copies as back up. She stated she believes at the time OSM #2 asked again for the receipts, OSM #2 had already completed Medicaid renewals on some of the residents included in the July 2023 spend down. She stated Medicaid would not have renewed any resident's payment if receipts were not provided for the spend down. She also stated she actually overspent for some of the residents, and was personally reimbursed for these charges in cash immediately after the July 2023 spend down. OSM #1 stated she was never suspended from work pending an investigation of these events. On 8/14/24 at 10:45 a.m., ASM #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. ASM #1 stated if anyone is suspected of misappropriating resident property or funds, it becomes a part of the facility's abuse and neglect protocol. He stated the allegation should be reported to proper authorities, and an investigation should be started. He stated the employee who is the alleged perpetrator should be suspended pending the outcome of the investigation. Once the investigation has been thoroughly completed, the facility's policy guides the outcome for the employee and affected residents. ASM #1 and ASM #2 were informed of concerns regarding a lack of reporting, a lack of an investigation, and a lack of the facility's following its own policy. On 8/14/24 at 11:18 a.m., ASM #2 stated they had identified the witness to the receipt exchange as OSM #3, the admissions and marketing director. On 8/14/24 at 11:21 a.m., OSM #3 was interviewed. She stated she remembered seeing OSM #1 copying a large amount of receipts. OSM #3 had been in line at the copier behind OSM #1 as she copied the receipts and remembered remarking to OSM #1 about how long it was going to take her to get everything copied. She said OSM #2 walked into the area where OSM #1 was making the copies and said something to the effect of: Hurry up and give me the receipts. OSM #3 stated: I feel like there were receipts there for everything. There was a lot of stuff bought for the residents. It was spread out all over everywhere. When asked if she knew of any evidence that this was true, she stated she did not have evidence, but was only going by what she could see. On 8/14/24 at 12:19 p.m., ASM #3, the administrator in the facility in December 2023, was interviewed. He stated he was not working in the facility in July 2023 when the alleged spend down occurred, and only became aware of a problem when an internal complaint was filed through the corporate compliance line. He stated the complaint was about OSM #1 not providing receipts for purchases made out of resident personal funds accounts. He stated OSM #1 was adamant that she had provided some of the receipts, and had made copies of all of them. However, OSM #1's vehicle with some of the receipts and all of the copies was repossessed shortly after the shopping had occurred in July 2023 and OSM #1 had no way to retrieve the original receipts or the copies. He stated OSM #2 was equally adamant that most of the receipts had never been returned. He stated he was unclear about what happened to any leftover cash that would have been owed back to various resident funds accounts. He stated he did not remember any such records. He stated OSM #1 recreated, as best she could, lists of what she had bought for each resident in the spend down. He stated he took the list and went room to room for each resident to verify that what was on the list had made it into the residents' rooms. He stated: I didn't find anything in terms of misappropriation. It didn't appear like there was misappropriation. The value was approximately the value of the money attributed to each resident's account. When asked the location of documentation of the efforts he had made, he stated he could not recall for sure what, if any documentation he had made. He stated OSM #2 told him that she had initially reported this concern to ASM #4, who had not done anything about it. When asked if he had interviewed any residents or other staff members, he stated he had not. When asked if he had reported this allegation of possible misappropriation of resident property to the state agency or other agencies, he stated: Overall it appeared to me that the money taken from the PFAs was properly spent to buy things for residents. He stated it was more of an internal process problem than a concern about misappropriation of funds. He stated: What was presented to me was that someone purchased goods and did not turn in receipts. I did not take this to be an allegation of misappropriation of money. I understand now that it might be taken that way. When asked why, if he was not concerned about the possibility of misappropriation of funds, he needed to go room to room to verify what had been purchased, he did not answer. On 8/14/24 at 1:00 p.m., ASM #1 was asked if this allegation had been thoroughly investigated. He stated: We always go by facts. If I am doing an investigation, I get witness statements, and I would have documentation of everything I did. I would have a statement of my conclusion. Unfortunately there has been a large turnover of staff. I don't see those things here. On 8/14/24 at 1:35 p.m., ASM #2 stated she had heard from the corporate office staff. A corporate vice-president had called her and asked her to tell the surveyor that the corporate staff did not report this to the state because it was no misappropriation of funds. The staff members were disciplined because they did not follow internal policy; all items bought matched the money spent; the corporate office reconciled everything. When asked the possible consequences of staff not following the policy regarding cash disbursements from resident personal funds accounts, ASM #2 said: A misappropriation of the resident's money. When asked if she or ASM #1 had located any evidence of the corporate office's reconciliation of cash disbursed with items bought, she stated they had not. A review of the facility policy, Resident Abuse, revealed, in part: Misappropriation or resident property .means 'the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Investigation .Immediately upon report of an incident .the suspect(s) shall be segregated from the resident .An incident report shall be filed by the individual in charge who received the report .The Abuse Coordinator and/or Director of Nursing shall take written statements from the victim, the suspect(s), and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. Any suspect(s), once he/she has (have) been identified will be suspended pending the investigation. No further information was provided prior to exit.

Based on staff interview and facility document review, it was determined the facility staff failed to maintain infection control tracking logs for two of the three months requested. The findings include: Upon entrance on 12/11/2023 at 9:15 a.m. a request was made for the infection control tracking logs for October, November, and December 2023. On 12/11/2023 at approximately 11:00 a.m. ASM (administrative staff member) #2, the director of nursing, provided a copy of the October 2023 infection control logs. She also provided a copy of a list from the pharmacy that documented what antibiotics were prescribed, but not the full documentation of a tracking log. She stated she could not find the November logs and the December logs have not been started. The facility policy, Infection Control Surveillance documented in part, 1. The Infection Control Committee (ICC) directs the infection control program and maintains minutes of all activities. The scope of surveillance includes: a. Establishing baseline nosocomial infection rates. B. Review of microbiological reports. C. Review resident infections to determine whether an infection is nosocomial, using the CDC (centers for disease control) guidelines. D. i. Review and analysis of surveillance data to include: i. Infections due to unusual pathogens. ii. Clusters of infections. iii. Unusual epidemics. iv. Nosocomial infection rate exceeds the baseline. v. Infections, populations, procedure or policies which are: a. high risk. b. high volume. c. problem prone. 2. Surveillance sampling of staff or the environment for infective agents is not done unless approved by the ICC an in accordance with applicable regulations. Analysis of surveillance data should include: A. Date of onset. B. Body site. C. Geographic location. D. Appropriate culture information. 3. The surveillance worksheet will be used as a tool to determine trends. ASM (administrative staff member) #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was obtained prior to exit.

Based on staff interview. facility document review, and clinical record review, it was determined the facility staff failed to notify the physician/nurse practitioner when medications were not available or administered for three of 13 residents in the survey sample, Residents #1, #10, and #11. The findings include: 1. For Resident #1, the facility staff failed to notify the physician/nurse practitioner (NP) when Toprol XL and Meloxicam were not available administration. The physician order dated, 8/22/2023, documented, Mobic (Meloxicam) Oral tablet 15 mg (milligrams); give 1 tablet by mouth one time a day for pain. The November 2023 MAR (medication administration record) documented the above order. On the following dates at the 9:00 a.m. dose, a 7 was documented, a 7 indicated, other/see nurse note: 11/2/2023 11/3/2023 11/6/2023 11/7/2022 11/8/2023 The nurse's note for 11/2/2023, documented in part, Awaiting pharmacy delivery, not in back up box. The nurse's note for 11/3/2023, documented in part, Reordered - pharmacy notified. The nurse's note for 11/6/2023, there was no nurse's note for this missed dose. The nurse's note dated, 11/7/2023, documented in part, pharmacy was notified of not being delivered. The nurse's note dated, 11/8/2023, documented in part, pharmacy was notified several times - no delivery at this time. The physician order dated, 11/15/2023, documented in part, Mobic Oral Tablet 15 mg; Give 1 tablet by mouth one time a day for back pain. The November MAR documented the above order. On 11/16/2023 and 11/17/2023 for the 9:00 a.m. dose, a 7 was documented. The nurse's note dated, 11/16/2023, documented in part, Not available at this time. The nurse's note dated, 11/17/2023, documented in part, Medication on order from Pharmacy. The physician order dated, 4/19/2023, documented, Toprol XL Oral Tablet Extended Release 24 hour 50 mg (Metoprolol Succinate); Give 1 tablet by mouth one time a day for HTN (high blood pressure). The November MAR documented the above order. On 11/2/2023, 11/14/2023, 11/16/2023, and 11/17/2023, there was documented a 7for the 9:00 a.m. doses of Toprol XL. The nurse's notes dated, 11/2/2023, documented in part, Awaiting pharmacy delivery, not available in back up box. The nurse's note dated, 11/14/2023, documented in part, Medication on order from Pharmacy. The nurse's note dated, 11/16/2023, documented in part, On order from Pharmacy. The nurse's note dated, 11/17/2023, documented in part, Medication on order from Pharmacy. An interview was conducted with LPN (licensed practical nurse) #2, on 12/12/2023 at 2:25 p.m. When asked the steps a nurse takes when a medication is not available at the scheduled time of administration, LPN #2 stated you first look in the bottom of the cart to see if the medication is there, where extra medication is stored. If not there, the nurse should go to the backup box. If not there the nurse should call the pharmacy to see if it's been sent and the status of it. If you still can't administer the medication, the nurse should notify the doctor and the resident and/or responsible party. LPN #2 was asked where all the steps they have taken are documented, LPN #2 stated, in the progress notes. The facility policy, Medication Administration documented in part, 2. If a dose of regularly scheduled medications is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled does time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initiated and circled. An explanatory note is entered on the reverse side of the record provided for PRN (as needed) documentation. If two consecutive doses of a vital mediation are withheld or refuse, the physician is notified. ASM #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was obtained prior to exit. 2. For Resident #10, the facility staff failed to notify the physician/NP when a dose of Trulicity not administered. The physician order dated, 10/5/2023, documented, Trulicity Subcutaneous Solution Pen-injector (2) 1.5 MG/0.5ML (milligrams per milliliter) (Dulaglutide); inject 0.5 ml subcutaneously one time a day every Mon (Monday) for DM (diabetes mellitus). The October MAR documented the above order. On 10/16/2023 a 5 was documented in the box for the administration of the Trulicity. A 5 indicated, LOA (leave of absence). Review of the nurse's note failed to evidence documentation of the reason the medications was not given. Nor documentation of the physician and/or nurse practitioner being notified that is wasn't given. The resident had a physician order dated, 10/5/2023, documented in part, Resident has dialysis Mon, Wed, Fri, pick up is 9:15 a.m. An interview was conducted with RN #1 on 12/12/2023 at 3:19 p.m. When asked if a medication is not given due to the resident going to dialysis, and it's a weekly medication, what steps should the nurse take, RN #1 stated first I would see what the medication is if it can be given later but mostly call the physician and follow their orders. It could have been given once the resident got back from dialysis since it's only a weekly medication. RN #1 stated if she had seen that order, she would have called the physician and scheduled it around the resident's dialysis schedule, but the nurse should have called the physician or nurse practitioner and told them it wasn't given. ASM (administrative staff member) #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was provided prior to exit. 3. For Resident #11, the facility staff failed to notify the physician/NP when medications were not given on 10/27/2023. Review of the October 2023 MAR (medication administration record) failed to evidence the following medications were administered on 10/27/2023 at 9:00 p.m.: -Hydrocortisone External gel 1%; apply to bilateral hands and leg topically two time a day for rash/itching for 7 days. -Keflex Oral Capsule (antibiotic) 500 mg (milligram); give 1 capsule by mouth two times a day for cellulitis lower legs for 5 days. -Lotrimin AF external cream 1%; apply to plantar of B. feet topically two times a day for tinea pedis (fungal rash) for 7 days. -Tylenol Extra Strength Oral tablet - 500 mg; give 2 tablets by mouth two times day for pain. Review of the physician orders documented the above orders. The nurse's notes were reviewed and failed to evidence any documentation as to why the medications were not administered or the notification to the physician that the medications were not given. An interview was conducted with LPN (licensed practical nurse) #2 on 12/12/2023 at 2:25 p.m. LPN #2 was shown the above MAR. When asked what do the blanks on 10/27/2023 indicate, LPN #2 stated it means the medications were not given. LPN #2 was asked if it was found that the medications were not given, should the nurse do anything, LPN #2 stated the nurse should notify the physician that the medications were not given. ASM (administrative staff member) #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the administration of medications for three of 13 residents in the survey sample, Residents #11, #2, and #7. The findings include: 1. For Resident #11, the facility staff failed to administer the physician ordered medications on 10/27/2023. Review of the October 2023 MAR (medication administration record) failed to evidence the following medications were administered on 10/27/2023 at 9:00 p.m.: -Hydrocortisone External gel 1%; apply to bilateral hands and leg topically two time a day for rash/itching for 7 days. -Keflex Oral Capsule (antibiotic) 500 mg (milligram); give 1 capsule by mouth two times a day for cellulitis lower legs for 5 days. -Lotrimin AF external cream 1%; apply to plantar of B. feet topically two times a day for tinea pedis (fungal rash) for 7 days. -Tylenol Extra Strength Oral tablet - 500 mg; give 2 tablets by mouth two times day for pain. Review of the physician orders documented the above orders. The nurse's notes were reviewed and failed to evidence any documentation as to why the medications were not administered or notification to the physician that the medications were not given. An interview was conducted with LPN (licensed practical nurse) #2 on 12/12/2023 at 2:25 p.m. LPN #2 was shown the above MAR. When asked what do the blanks on 10/27/2023 indicate, LPN #2 stated it means the medications were not given. When asked if she was working that evening, LPN #2 stated she was working the other two medication carts on that evening. The previous interim director of nursing (DON) was supposed to work on the other two carts that evening. A situation with an employee came up and the DON had to deal with that. She stated she did the best she could but never got down to some of the residents, as she was trying to get her scheduled work done. An interview was conducted with ASM #2, the interim director of nursing, on 12/12/2023 at 3:58 p.m. When asked what blanks on the MAR indicated, ASM #2 stated they weren't given. The facility policy, Medication Administration documented in part, Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices and only by legally authorized to do so .Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. ASM #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was obtained prior to exit. 2. For Resident #2, the facility staff failed to administer the physician ordered medications on 10/27/2023. Review of the October 2023 MAR (medication administration record) failed to evidence the following medications were administered on 10/27/2023 at 9:00 p.m.: -Atorvastatin Calcium Oral Tablet - high cholesterol - 40 mg; Give 1 tablet by mouth at bedtime for hyperlipidemia. -Loratadine Oral Tablet 10 mg; Give 1 tablet one time a day for allergies. -Trazadone HCL Oral tablet - 50 mg; Give 1 tablet by mouth at bedtime for depression. -Buspirone HCL Oral tablet 10 mg - Give 1 tablet by mouth two times a day for anxiety. -Famotidine Oral tablet 20 mg; Give 1 tablet by mouth two times a day for GERD (gastroesophageal reflux disease). -Furosemide Oral tablet 40 mg; Give 1 tablet by mouth two times a day for CHF (congestive heart failure). -Levetiracetam Oral tablet 750 mg; Give 1 tablet by mouth two times a day for Seizure disorder. -Magnesium Oxide Tablet; Give 400 mg by mouth two times a day for GERD. -Potassium Chloride ER (extended release) Oral Tablet 20 mEq (milliequivalents); give 1 tablet by mouth two times a day for hypokalemia. -Tylenol Extra Strength Tablet 500 mg; Give 2 tablets by mouth two times a day for pain until 10/30/2023. -Baclofen Oral Tablet 10 mg; Give 1 tablet by mouth every 8 hours for muscle spasms. -Glucophage Oral Tablet 500 mg; Give 1 tablet by mouth three times a day for DM (diabetes mellitus). -Ipratropium Bromide Solution 0.02%; Give 1 vial by mouth three times a day for SOB (shortness of breath). -Sodium Bicarbonate Oral tablet 650 mg; give 1 tablet by mouth four times a day for GERD. -Sucralfate Oral tablet 1 GM (gram); Give 1 tablet four times a day for GERD. Review of the physician orders documented the above orders. The nurse's notes were reviewed and failed to evidence any documentation as to why the medications were not administered or notification to the physician that the medications were not given. An interview was conducted with LPN (licensed practical nurse) #2 on 12/12/2023 at 2:25 p.m. LPN #2 was shown the above MAR. When asked what do the blanks on 10/27/2023 indicate, LPN #2 stated it means the medications were not given. When asked if she was working that evening, LPN #2 stated she was working the other two medication carts on that evening. The previous interim director of nursing (DON) was supposed to work on the other two carts that evening. A situation with an employee came up and the DON had to deal with that. She stated she did the best she could but never got down to some of the residents, as she was trying to get her scheduled work done. An interview was conducted with ASM #2, the interim director of nursing, on 12/12/2023 at 3:58 p.m. When asked what blanks on the MAR indicated, ASM #2 stated they weren't given. ASM #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was provided prior to exit. 3. For Resident #7, the facility staff failed to administer the physician ordered medications on 10/27/2023. Review of the October 2023 MAR (medication administration record) failed to evidence the following medications were administered on 10/27/2023 at 9:00 p.m.: -Donepezil HCL Oral Tablet 10 mg; Give 2 tablets by mouth at bedtime for dementia. -Melatonin Oral Tablet (used for sleep) 3 mg; Give 1 tablet by mouth at bedtime for anemia. -Carvedilol Oral tablet 25 mg; give 1 tablet by mouth two times a day for high blood pressure. -Depakote Oral Tablet Delayed Release 125 mg; give 1 tablet by mouth two times a day for MMD (myotonic muscular dystrophy) -Eliquis Oral Tablet 2.5 mg; give 1 tablet by mouth two times a day for ASHD (arteriosclerotic heart disease). -Memantine HCL Oral Tablet 10 mg; Give 1 tablet by mouth two times a day related to dementia. -Olanzapine Oral Tablet 2.5 mg; Give 1 tablet by mouth two times a day related to anxiety. -Tramadol HCL Oral Tablet 50 mg; Give 1 tablet by mouth every 12 hours for pain. -Gabapentin Oral Capsule 300 mg; Give 1 capsule by mouth three times a day for chronic pain. -Trazadone HCL Oral Tablet 50 mg; Give 1 tablet by mouth three times a day for anxiety and dementia. Review of the physician orders documented the above orders. The nurse's notes were reviewed and failed to evidence any documentation as to why the medications were not administered or notification to the physician that the medications were not given. An interview was conducted with LPN (licensed practical nurse) #2 on 12/12/2023 at 2:25 p.m. LPN #2 was shown the above MAR. When asked what do the blanks on 10/27/2023 indicate, LPN #2 stated it means the medications were not given. When asked if she was working that evening, LPN #2 stated she was working the other two medication carts on that evening. The previous interim director of nursing (DON) was supposed to work on the other two carts that evening. A situation with an employee came up and the DON had to deal with that. LPN #2 stated she did the best she could but never got down to some of the residents, as she was trying to get her scheduled work done. An interview was conducted with ASM #2, the interim director of nursing, on 12/12/2023 at 3:58 p.m. When asked what blanks on the MAR indicated, ASM #2 stated they weren't given. ASM #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide pharmacy services for one of 13 residents in the survey sample, Resident #1. The findings include: For Resident #1, the facility staff failed to ensure two medications were available for administration, Meloxicam (used for pain) and Toprol XL (used for high blood pressure). The physician order dated, 8/22/2023, documented, Mobic (Meloxicam) Oral tablet 15 mg (milligrams); give 1 tablet by mouth one time a day for pain. The November 2023 MAR (medication administration record) documented the above order. On the following dates at the 9:00 a.m. dose, a 7 was documented, a 7 indicated, other/see nurse note: 11/2/2023 11/3/2023 11/6/2023 11/7/2022 11/8/2023 The nurse's note for 11/2/2023, documented in part, Awaiting pharmacy delivery, not in back up box. The nurse's note for 11/3/2023, documented in part, Reordered - pharmacy notified. The nurse's note dated, 11/4/2023, documented, This nurse outreached (name of pharmacy) to request a RF (refill) on Meloxicam and Metoprolol but the pharmacy states they are unable to do so. Meloxicam cannot be RF until 11/16 and Metoprolol on 11/22. Placed in MD (medical doctor) book for review. The nurse's note for 11/6/2023, there was no nurse's note for this missed dose. The nurse's note dated, 11/7/2023, documented in part, pharmacy was notified of not being delivered. The nurse's note dated, 11/8/2023, documented in part, pharmacy was notified several times - no delivery at this time. The physician order dated, 11/15/2023, documented in part, Mobic Oral Tablet 15 mg; Give 1 tablet by mouth one time a day for back pain. The November MAR documented the above order. on 11/16/2023 and 11/17/2023 for the 9:00 a.m. dose, a 7 was documented. The nurse's note dated, 11/16/2023, documented in part, Not available at this time. The nurse's note dated, 11/17/2023, documented in part, Medication on order from Pharmacy. The physician order dated, 4/19/2023, documented, Toprol XL Oral Tablet Extended Release 24 hour 50 mg (Metoprolol Succinate); Give 1 tablet by mouth one time a day for HTN (high blood pressure). The November MAR documented the above order. On 11/2/2023, 11/14/2023, 11/16/2023, and 11/17/2023, there was documented a 7 for the 9:00 a.m. doses of Toprol XL. The nurse's notes dated, 11/2/2023, documented in part, Awaiting pharmacy delivery, not available in back up box. The nurse's note dated, 11/14/2023, documented in part, Medication on order from Pharmacy. The nurse's note dated, 11/16/2023, documented in part, On order from Pharmacy. The nurse's note dated, 11/17/2023, documented in part, Medication on order from Pharmacy. The list of the contents of the backup pharmacy box failed to evidence the two medications. An interview was conducted with LPN (licensed practical nurse) #2, on 12/12/2023 at 2:25 p.m. When asked the steps a nurse takes when a medication is not available at the scheduled time of administration, LPN #2 stated you first look in the bottom of the cart to see if the medication is there, where extra medication is stored. If not there, the nurse should go to the backup box. If not there the nurse should call the pharmacy to see if it's been sent and the status of it. If you still can't administer the medication, the nurse should notify the doctor and the resident and/or responsible party. LPN #2 was asked where all the steps they have taken are documented, LPN #2 stated, in the progress notes. The facility policy, Provider Pharmacy Requirements, documented in part, 4. The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to: a. Assisting the nursing care center, as necessary, in determining the appropriate acquisition, receipt, dispensing and administration of all medications and biologicals to meet the medication needs of the resident and the nursing care center. b. Accurately dispensing prescriptions based on authorized prescriber orders. ASM #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was obtained prior to exit.

Based on resident interview, staff interview and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of 13 residents in the survey sample, Resident #3. The findings include: For Resident #3, the facility staff failed to document accuracy of a podiatrist visit. The nurse's note dated 11/1/2023 at 4:53 p.m. documented, Resident received routine podiatry care on 10/31/23. A request was made for the copy of the podiatry note dated, 10/31/2023 on 12/12/2023 at 11:14 a.m. An interview was conducted with OSM (other staff member) #1 on 12/12/2023 at 12:32 p.m. OSM #1 informed this writer that Resident #3 was not seen by the podiatrist on 10/31/2023. The resident was scheduled to be seen on 11/15/2023 but due to COVID-19, the resident was not seen. OSM #1 stated the resident has not been seen by the podiatrist since September of 2023. When asked if this documentation is accurate in this resident's medical record, OSM #1 stated she doesn't know why the documentation is in (Resident #3)'s medical record. ASM #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure two of 13 residents were free of significant medication errors, Residents #7 and Resident #10. The findings include: 1. For Resident #7, the facility staff failed to administer Lantus Insulin on 10/27/2023 and the resident's blood sugar was elevated the next morning. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 10/7/2023, the resident scored a five out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. In Section N - Medications, the resident was coded as receiving insulin injections for seven days of the look back period. The physician order dated, 8/17/2023, documented, Lantus Subcutaneous Solution (1) 100 UNIT/ML (milliliters); Inject 34 units subcutaneously two times a day for diabetes. The October 2023 MAR (medication administration record) documented the above order. The place for the 10/27/2023 dose at 9:00 p.m. was blank on the MAR. The MAR documented the resident's blood sugar on 10/28/2023 at 324. Review of the MAR documented the resident's morning blood sugars from 110 to 299. The comprehensive care plan dated, 7/3/2023, documented in part, Focus: Resident is at risk for hyper/hypoglycemic episodes due to diagnosis of DM (diabetes mellitus). Insulin dependent. The Interventions documented in part, Administer medications per order observing affect. An interview was conducted with LPN (licensed practical nurse) #2 on 12/12/2023 at 2:25 p.m. An interview was conducted with LPN (licensed practical nurse) #2, who worked the wing Resident #7 resided on, on 10/27/2023. She stated the interim director of nursing was going to work the floor that evening, but something came up with one of the employees and she didn't get to give all of the scheduled medications. LPN #2 stated she tried to give some of the medications that night, but she was busy with her assignment too. An interview was conducted with RN (registered nurse) #1, on 12/12/2023 at 3:19 p.m. When asked what blanks on the MAR indicated, RN #1 stated, it wasn't given. The facility policy, Medication Administration - General Guidelines, documented in part, Policy: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so .The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. ASM (administrative staff member) #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was provided prior to exit, (1) Lantus is used to treat diabetes. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a600027.html. 2. For Resident #10, the facility failed to administer Trulicity injection on 10/16/2023. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 10/11/2023, the resident was coded as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. In Section N - Medications, the resident was coded as receiving insulin injections for seven days of the look back period. The physician order dated, 10/5/2023, documented, Trulicity Subcutaneous Solution Pen-injector (2) 1.5 MG/0.5ML (milligrams per milliliter) (Dulaglutide); inject 0.5 ml subcutaneously one time a day every Mon (Monday) for DM (diabetes mellitus). The October MAR documented the above order. On 10/16/2023 a 5 was documented in the box for the administration of the Trulicity. A 5 indicated, LOA (leave of absence). Review of the nurse's note failed to evidence documentation of the reason the medications was not given, nor documentation of the physician and/or nurse practitioner being notified that is wasn't given. The resident had a physician order dated, 10/5/2023, documented in part, Resident has dialysis Mon, Wed, Fri, pick up is 9:15 a.m. The comprehensive care plan dated, 10/6/2023, documented in part, Focus: I am a diabetic placing resident at risk for hypo/hyperglycemia episodes. Resident is receiving insulin and diet as treatment. The Interventions documented in part, Diabetic medications as ordered by physician. An interview was conducted with RN #1 on 12/12/2023 at 3:19 p.m. When asked if a medication is not given due to the resident going to dialysis, and it's a weekly medication, what steps should the nurse take, RN #1 stated first I would see what the medication is, if it can be given later but mostly call the physician and follow their orders. It could have been given once the resident got back from dialysis since it's only a weekly medication. RN #1 stated if she had seen that order, she would have called the physician and scheduled it around the resident's dialysis schedule, but the nurse should have called the physician or nurse practitioner and told them it wasn't given. ASM (administrative staff member) #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was provided prior to exit. (2) Dulaglutide injection is used with a diet and exercise program to control blood sugar levels in adults and children [AGE] years of age or older with type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood). This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a614047.html.

Based on observation, resident interview, staff interview and facility document review, it was determined the facility staff failed to implement a physician order for supervision of a resident when the resident signs himself out of the building, for one of 13 residents in the survey sample, Resident #12. The findings include: For Resident #12 (R12), the physician orders revealed an order for the resident to be supervised at all times when he signs himself out of the building, however no supervision was observed to occur on two occasions. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 10/3/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. Resident #12 was coded as being able to self-propel his wheelchair 150 feet and can walk 150 feet. The resident was not coded as having any behaviors. The resident was not coded as having had any falls since the previous assessment. The physician order dated 11/28/2023, documented, For patient safety - need supervision at all times when he signs himself out of the building. A request was made for the resident sign-out logs for October, November, and December. The only logs presented were the October and November. ASM (administrative staff member) #1 stated they could not locate the sign out logs for December. The October and November logs only documented R12's name once for each month. An interview was conducted with Resident #12 on 12/12/2023 at 3:51 p.m. When asked if he still goes outside to the property line to smoke, R12 stated he still goes out with the other residents that smoke. When asked if a staff member goes outside with him, R12 stated no. R12 was asked if he still walked into the town, R12 stated he didn't because it was too cold now. An interview was conducted with ASM #2, the interim director of nursing, on 12/12/2023 at 3:58 p.m. The order above was reviewed with ASM #2. When asked what the order entails, ASM #2 stated, it means he should be monitored. The comprehensive care plan dated, 7/4/2023, and last revised on 12/4/2023, documented in part, Focus: Resident is at risk for falls, related to: history of falls, use of medication, complicated by seizure disorder, required walked for independent ambulation. The Interventions documented in part, 12/4/2023: Re-educate resident of the danger of signing out to go to downtown alone and drinking. Resident #12 was observed self-propelling in the wheelchair outside the front door and went to the side of the property line on 12/12/2023 at 5:06 p.m., and 12/13/2023 at 10:46 a.m. No other person was with him. An interview was conducted with ASM #5, the nurse practitioner that wrote the above order, on 12/12/2023 at 11:07 a.m. When asked why she wrote the order, ASM #5 stated the resident has been falling a lot lately and some are in the parking lot. ASM #5 was asked who she felt was the expected person to go outside with him, a staff member? ASM #5 stated he should have a responsible person. When asked if it could be another resident, ASM #5 stated no, just a person that is responsible. An interview was conducted with ASM #2, the interim director of nursing, on 12/12/2023 at 3:58 p.m. The order above was reviewed with ASM #2. When asked what the order entails, ASM #2 stated, it means he should be monitored. A policy on resident safety was requested and none was provided prior to exit. ASM #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was obtained prior to exit.

Based on observation, resident interview, staff interview, and clinical record review, it was determined the facility staff failed to review and revise the care plan for one of 13 residents in the survey sample, Resident #12. The findings include: For Resident #12, the facility staff failed to revise the care plan for a physician order to monitor the resident when the resident signs himself out of the building. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 10/3/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. Resident #12 was coded as being able to self-propel his wheelchair 150 feet and can walk 150 feet. The resident was not coded as having any behaviors. The resident was not coded as having had any falls since the previous assessment. The comprehensive care plan dated, 7/4/2023, and last revised on 12/4/2023, documented in part, Focus: Resident is at risk for falls, related to: history of falls, use of medication, complicated by seizure disorder, required walked for independent ambulation. The Interventions documented in part, 12/4/2023: Re-educate resident of the danger of signing out to go to downtown alone and drinking. The physician order dated 11/28/2023, documented, For patient safety - need supervision at all times when he signs himself out of the building. A request was made for the resident sign-out logs for October, November, and December 2023. The only logs presented were for October and November. ASM (administrative staff member) #1 stated they could not locate the sign out logs for December. The October and November logs only documented R12's name once for each month. An interview was conducted with ASM #5, the nurse practitioner that wrote the above order, on 12/12/2023 at 11:07 a.m. When asked why she wrote the order, ASM #5 stated the resident has been falling a lot lately and some are in the parking lot. ASM #5 was asked who she felt is the expected person to go outside with him, a staff member? ASM #5 stated he should have a responsible person. When asked if it could be another resident, ASM #5 stated no, just a person that is responsible. An interview was conducted with Resident #12 on 12/12/2023 at 3:51 p.m. When asked if he still goes outside to the property line to smoke, R12 stated he still goes out with the other residents that smoke. When asked if a staff member goes outside with him, R12 stated no. R12 was asked if he still walked into the town, R12 stated he didn't because it was too cold now. An interview was conducted with RN (registered nurse) #1, on 12/12/2023 at 3:19 p.m. When asked the purpose of the care plan, RN #1 stated it so that everyone know how to take care of that resident, what special utensils, devices needed and why residents are on medications. RN #1 was asked if the physician wrote an order for supervision of a resident when they sign themselves out of the building, should that be on the care plan, RN #1 stated, yes. The facility policy, Care Plan documented in part, An interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis. ASM #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was obtained prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for three of 13 residents in the survey sample, Residents #7, #11, and #10. The findings include: 1. For Resident #7, the facility staff failed to implement the comprehensive care plan for administering medications per the physician orders. The comprehensive care plan documented, in part, the following: Focus: Resident at risk for hyper/hypoglycemic episodes due to diagnosis of DM (diabetes mellitus). Insulin dependent. Interventions: Administer medications per order observing affect. Focus: Resident is taking two anticoagulant and at risk for side effects/complications Interventions: Administer medication per order. Focus: Resident is taking an antidepressant for depression and anti-manic for Chronic pain. Interventions: Administer anti manic medication per order observing effect. Administer antidepressant per order observing effect. Medicate for pain as order observing effect. Focus: Resident is taking an antipsychotic medication placing resident at risk for side effects. Interventions: Administer medications per order observing effect. Focus: Resident is at risk for cardiac disease due to ASHD (arteriosclerotic heart disease), high blood pressure .Taking antihypertensive medications daily. Interventions: Administer antihypertensive medications per order. Review of the October 2023 MAR (medication administration record) failed to evidence the following medications were administered on 10/27/2023 at 9:00 p.m.: -Donepezil HCL Oral Tablet 10 mg; Give 2 tablets by mouth at bedtime for dementia. -Melatonin Oral Tablet (used for sleep) 3 mg; Give 1 tablet by mouth at bedtime for anemia. -Carvedilol Oral tablet 25 mg; give 1 tablet by mouth two times a day for high blood pressure. -Depakote Oral Tablet Delayed Release 125 mg; give 1 tablet by mouth two times a day for MMD (myotonic muscular dystrophy) -Eliquis Oral Tablet 2.5 mg; give 1 tablet by mouth two times a day for ASHD (arteriosclerotic heart disease). -Memantine HCL Oral Tablet 10 mg; Give 1 tablet by mouth two times a day related to dementia. -Olanzapine Oral Tablet 2.5 mg; Give 1 tablet by mouth two times a day related to anxiety. -Tramadol HCL Oral Tablet 50 mg; Give 1 tablet by mouth every 12 hours for pain. -Gabapentin Oral Capsule 300 mg; Give 1 capsule by mouth three times a day for chronic pain. -Trazadone HCL Oral Tablet 50 mg; Give 1 tablet by mouth three times a day for anxiety and dementia. An interview was conducted with RN (registered nurse) #1, on 12/12/2023 at 3:19 p.m. When asked the purpose of the care plan, RN #1 stated it so that everyone know how to take care of that resident, what special utensils, devices needed and why residents are on medications. RN #1 was asked if medications were not given, per the physician order, and it's written on the care plan, is that following the care plan, RN #1 stated, no. The facility policy, Care Plan documented in part, All staff must be familiar with each resident's Care Plan and all approaches must be implemented. ASM #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was provided prior to exit. 2. For Resident #11, the facility staff failed to implement the comprehensive care plan for administering medications per the physician orders. The comprehensive care plan documented, in part, the following: Focus: Altered skin integrity non pressure related to: per family my skin is fragile and I have a history of skin tears. Interventions: Treatments as ordered. Focus: I have increased pain in my right knee during therapy. Interventions: Medicate for pain as ordered by physician and follow up for effectiveness. Review of the October 2023 MAR (medication administration record) failed to evidence the following medications were administered on 10/27/2023 at 9:00 p.m.: -Hydrocortisone External gel 1%; apply to bilateral hands and leg topically two time a day for rash/itching for 7 days. -Keflex Oral Capsule (antibiotic) 500 mg (milligram); give 1 capsule by mouth two times a day for cellulitis lower legs for 5 days. -Lotrimin AF external cream 1%; apply to plantar of B. feet topically two times a day for tinea pedis (fungal rash) for 7 days. -Tylenol Extra Strength Oral tablet - 500 mg; give 2 tablets by mouth two times day for pain. An interview was conducted with RN (registered nurse) #1, on 12/12/2023 at 3:19 p.m. When asked the purpose of the care plan, RN #1 stated it so that everyone know how to take care of that resident, what special utensils, devices needed and why residents are on medications. RN #1 was asked if medications were not given, per the physician order, and it's written on the care plan, is that following the care plan, RN #1 stated, no. ASM #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was provided prior to exit. 3. For Resident #10, the facility staff failed to implement the comprehensive care plan for administering medications per the physician orders. The comprehensive care plan documented in part, the following: Focus: I am a diabetic placing resident at risk for hypo/hyperglycemia episodes. Resident is receiving insulin and diet as treatment. Interventions: Diabetic medications as ordered by physician. The physician order dated, 10/5/2023, documented, Trulicity Subcutaneous Solution Pen-injector (2) 1.5 MG/0.5ML (milligrams per milliliter) (Dulaglutide); inject 0.5 ml subcutaneously one time a day every Mon (Monday) for DM (diabetes mellitus). The October MAR documented the above order. On 10/16/2023 a 5 was documented in the box for the administration of the Trulicity. A 5 indicated, LOA (leave of absence). Review of the nurse's note failed to evidence documentation of the reason the medications was not given, nor documentation of the physician and/or nurse practitioner being notified that is wasn't given. An interview was conducted with RN (registered nurse) #1, on 12/12/2023 at 3:19 p.m. When asked the purpose of the care plan, RN #1 stated it so that everyone know how to take care of that resident, what special utensils, devices needed and why residents are on medications. RN #1 was asked if medications were not given, per the physician order, and it's written on the care plan, is that following the care plan, RN #1 stated, no. ASM #1, the interim administrator, ASM #2, the interim director of nursing, ASM #3, the regional clinical director and ASM #4 the interim assistant director of nursing, were made aware of the above findings on 12/12/2023 at 4:45 p.m. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to complete smoking assessments for four of 35 residents in the survey sample, Residents #76, #38, #67, and #307. The findings include: 1. For Resident #76 (R76), the facility staff failed to complete a safe smoking assessment. During the entrance conference on 6/27/2023 at approximately 10:20 a.m. a request was made for the list of smokers. ASM (administrative staff member) #1, the executive director, presented a list of residents that smoke but stated they are a non-smoking facility. ASM #1 stated when he came, he found out that residents were going outside to smoke. He then asked where the residents keep their cigarettes and lighters and found out the residents were keeping them in their rooms. He immediately removed them from the resident rooms, and they are kept by the staff, locked up. ASM #1 stated they were in the process of assessing the residents to see if they were capable of navigating outside to smoke. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 5/3/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as only requiring supervision after set up assistance if needed. An interview was conducted with R76 on 6/27/2023 at approximately 1:30 p.m. When asked if he goes out to smoke, R76 stated he goes out about three times a day for smoking. He does go out other times just to walk. R76 was asked who keeps his cigarettes, R76 stated they are kept in the social workers office during the week, but the nurses have them on the weekends and after the social worker goes home. When asked where he smokes as this is a non-smoking facility, R76 stated he walks to the end of the building and goes across the road where the telephone poles are, that's not the facility property. R76 also stated he walks up behind the building, through the path in the woods to an open field just to get away from the facility. R76 stated he also walks in the town and goes to the store a few blocks away. When asked if he signs out if he is going smoking outside, R76 stated that he doesn't bother to sign out now because they give me my cigarettes, so they know where I'm going. An interview was conducted with ASM #1 on 6/27/2023 at 4:11 p.m. When asked if residents were assessed for safe smoking, ASM #1 stated he didn't believe so. Review of the clinical record failed to evidence a smoking assessment for R76. The comprehensive care plan dated, revised on 11/22/2022 failed to evidence a care plan for being a smoker. There was no evidence that R76 had any accidents, burns, etc. while smoking. A document in the admission packet, Non-Smoking Policy documented, Smoking (including the use of e-cigarettes) is prohibited for everyone on the property operated by the Center, including residents, employees, visitors, volunteers, consultants, contractors, and government representatives. This policy applies to: All areas of the interior of the Facility and any outbuildings on the property. Parking lots and common outdoor areas within the boundaries of the facility. The facility may have specific Residents who are allowed to smoke because there were admitted prior to the implementation of this non-smoking policy. Violations of the Facility's smoking policy may result in your involuntary discharge from the facility. THIS NON-SMOKING POLICY EFFECTIVE MAY 9, 2017. Resident #76 signed this document on 1/26/2022. The South Resident Sign Out documents contained 15 pages, that were not labeled with a date. The sheets for May 2023 did not have any sheets prior to 5/3/2023. R76 signed out on 5/3/2023 six times, 5/4/2023 seven times, 5/8/2023 two times. Unable to tell dates until 5/11/2023 when the resident signed out three times. May 12, 2023 the resident signed out four times. There were no papers dated 5/13/2023. On 5/14/2023 R76 signed out two times. On 5/15/2023, the resident signed out three times. There was nothing for 5/16/2023. On 5/17/2023 R76 signed out five times. Nothing documented for 5/18/2023. A sheet dated 5/6/2023 through 5/22/2023 failed to evidence documentation of R76 signing out. R76 signed out twice on 5/19/2023. R76 signed out once on 5/20/2023, 5/21/2023 and 5/22/2023. Then the papers jump to 5/26/2023 where R76 signed out twice. Documentation on 5/27/2023, R76 signed out twice. On 5/28/2023, the resident signed out once. There was no documentation for 5/29/2023, that R76 signed out. R76 signed out once on 5/30/2023. On 5/31/2023 the resident signed out once. For the month of June 2023, R76 signed out once on 6/1/2023 and 6/2/2023. There was no dated documentation of R76 signing out until 6/7/2023 when he signed out once. On June 8, 2023, R76 did not sign out. There was no dated documentation for 6/9/2023. R76 signed out twice on 6/10/2023. There is no documentation for 6/11/2023. On 6/12/2023, R76 signed out once. There was no documentation for 6/13/2023. On 6/14/2023, the resident signed out once. There was no documentation for 6/15/2023 or 6/16/2023. There was no further documentation in the book. An interview was conducted with LPN (licensed practical nurse) #2 on 6/28/2023 at 1:35 p.m. When asked if there were any residents that smoke, LPN #2 stated, I don't know about this, but they sneak across the road. The nurses took everything away from them. They (nurses) locked them up in a cart that is not used. When asked who gives them their cigarettes, LPN #2 stated, They have to asked up for them. LPN #2 was asked who watches them go off the property, LPN #2 stated an aide is supposed to. The residents are supposed to be alert and oriented and sign out in the book. LPN #2 stated there is a book up front the resident have to sign out in. LPN #2 stated this has only been recently. The residents had already signed the no smoking policy, it needs to be stopped all together. LPN #2 stated, We weren't aware of it. When asked if she had any cigarettes for R76, LPN #2 stated she had not be asked by them for any cigarettes from her today. LPN #2 was asked for the residents that do smoke, has a smoking assessment been completed, LPN #2 stated she had never done a smoking assessment. When asked the purpose of the smoking assessment, LPN #2 stated it's to review their medications, if the resident has COPD (chronic obstructive pulmonary disease), if they are on oxygen, it is a danger. LPN #2 was asked if the smoking assessment reviewed the ability of the resident to light a cigarette, if they have ashes or burn holes in their clothing, LPN #2 stated she hadn't done one. An interview was conducted with ASM #1, and ASM #5, the regional vice president of operations, on 6/28/2023 at 2:08 p.m. When asked what prompted taking the cigarettes away from residents, ASM #1 stated he was told about it when he was updating the survey readiness book. ASM #1 was asked what he was told, ASM #1 stated he was told the residents were going off property to smoke. This is a smoke-building. ASM #1 stated last Friday, 6/23/2023, he asked where the cigarettes and lighters were kept and was told the residents had them in their rooms. ASM #1 stated he immediately took them away. They are stored in social services Monday through Friday and nursing has them locked up on the weekend, holidays and after social services goes home. When asked if the residents have been assessed for safe smoking, ASM #1 stated, a smoking assessment in not done, there is nothing in (name of computer program). An interview was conducted with ASM #4, the regional clinical consultant, and ASM #5, on 6/28/2023 at 2:54 p.m. ASM #5 stated that the residents are signing out, and going off property, they are responsible for their safety. They are on LOA (leave of absence). There would be no need to do a smoking assessment or care plan it. When asked if a resident doesn't sign out, ASM #5 stated he didn't know. At 4:11 p.m. ASM #5 stated that if a resident doesn't sign out then the resident will be educated on the process. Then if they still don't sign out, we would have to take each individual case and work through the process of education and if needed transfer out. The facility policy, FACILITY NON-SMOKING POLICY documented in part, It is the policy of the facility to promote a healthier environment by becoming a non-smoking facility. The facility will have smoking residents that will be grandfathered in but new admission will be made aware upon admission that the facility is a non-smoking facility. This policy applies to all smoking and tobacco related products including but not limited to: Cigarettes, cigars, E-Cigarettes, Vaporizers (aka Vapes), hookahs and pipes .While the facility leadership will attempt to accommodate those current residents who desire to smoke, the primary obligation is to the safety of the facility population as a whole. Therefore, any resident or visitor who does not comply with rules regarding smoking will be asked to restrict or forfeit smoking or visiting privileges. IF the smoking infraction or lack of compliance is serious enough, it will warrant discharge in accordance with state and federal law. Anytime the administrator or designee determines there is a reasonable suspicion of a violation of the smoking policy, such as a resident retaining their smoking materials or having others bring in smoking materials that are not retained according to policy, a room search may be conducted of all involved persons and areas .All residents must be supervised while smoking by a facility staff member .Smoking is prohibited to ALL staff while on facility property. ASM #1, ASM #2, the interim director of nursing, ASM #4 and ASM #5 were made aware of the above concern on 6/28/2023 at 5:30 p.m. No further information was provided prior to exit. 2. For Resident #38 (R38), the facility staff failed to complete a safe smoking assessment. On the most recent MDS assessment, a quarterly assessment, with an ARD of 5/10/2023, the resident scored a 15 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as requiring supervision with set up help only for transfers, walking in the room and moving on and off the unit. R38 was discharged from the facility on 6/14/2023 and readmitted on [DATE]. During the entrance conference on 6/27/2023 at approximately 10:20 a.m. a request was made for the list of smokers. ASM (administrative staff member) #1, the executive director, presented a list of residents that smoke but stated they are a non-smoking facility. ASM #1 stated when he came, he found out that residents were going outside to smoke. He then asked where the residents keep their cigarettes and lighters and found out the residents were keeping them in their rooms. He immediately removed them from the resident rooms and they are kept by the staff, locked up. ASM #1 stated they were in the process of assessing the residents to see if they were capable of navigating outside to smoke. Review of the clinical record failed to evidence a smoking assessment for R38. The care plan dated 6/28/2023 failed to evidence documentation related to smoking. There was no evidence that R38 had any accidents, burns, etc. while smoking. A document in the admission packet, Non-Smoking Policy documented, Smoking (including the use of e-cigarettes) is prohibited for everyone on the property operated by the Center, including residents, employees, visitors, volunteers, consultants, contractors, and government representatives. This policy applies to: All areas of the interior of the Facility and any outbuildings on the property. Parking lots and common outdoor areas within the boundaries of the facility. The facility may have specific Residents who are allowed to smoke because there were admitted prior to the implementation of this non-smoking policy. Violations of the Facility's smoking policy may result in your involuntary discharge from the facility. THIS NON-SMOKING POLICY EFFECTIVE MAY 9, 2017. Resident #38 signed this document on 6/23/2023. An interview was conducted with ASM #1 on 6/27/2023 at 4:11 p.m. When asked if residents were assessed for safe smoking, ASM #1 stated he didn't believe so. An interview was conducted with LPN (licensed practical nurse) #2 on 6/28/2023 at 1:35 p.m. When asked if there were any residents that smoke, LPN #2 stated, I don't know about this, but they sneak across the road. The nurses took everything away from the. They (nurses) locked them up in a cart that is not used. When asked who gives them their cigarettes, LPN #2 stated, They have to asked up for them. LPN #2 was asked who watches them go off the property, LPN #2 stated an aide is supposed to. The residents are supposed to be alert and oriented and sign out in the book. LPN #2 stated there is a book up front the resident have to sign out in. LPN #2 stated this has only been recently. The residents had already signed the no smoking policy, it needs to be stopped all together. LPN #2 stated, We weren't aware of it. When asked if she had any cigarettes for R38, LPN #2 stated she had not been asked by them for any cigarettes from her today. LPN #2 was asked for the residents that do smoke, has a smoking assessment been completed, LPN #2 stated she had never done a smoking assessment. When asked the purpose of the smoking assessment, LPN #2 stated it's to review their medications, if the resident has COPD (chronic obstructive pulmonary disease), if they are on oxygen, it is a danger. LPN #2 was asked if the smoking assessment reviewed the ability of the resident to light a cigarette, if they have ashes or burn holes in their clothing, LPN #2 stated she hadn't done one. An interview was conducted with ASM #1, and ASM #5, the regional vice president of operations, on 6/28/2023 at 2:08 p.m. When asked what prompted taking the cigarettes away from residents, ASM #1 stated he was told about it when he was updating the survey readiness book. ASM #1 was asked what he was told, ASM #1 stated he was told the residents were going off property to smoke. This is a smoke-building. ASM #1 stated last Friday, 6/23/2023, he asked where the cigarettes and lighters were kept and was told the residents had them in their rooms. ASM #1 stated he immediately took them away. They are stored in social services Monday through Friday and nursing has them locked up on the weekend, holidays and after social services goes home. When asked if the residents have been assessed for safe smoking, ASM #1 stated, a smoking assessment in not done, there is nothing in (name of computer program). An interview was conducted with ASM #4, the regional clinical consultant, and ASM #5, on 6/28/2023 at 2:54 p.m. ASM #5 stated that the residents are signing out, and going off property, they are responsible for their safety. They are on LOA (leave of absence). There would be no need to do a smoking assessment or care plan it. ASM #1, ASM #2, the interim director of nursing, ASM #4 and ASM #5 were made aware of the above concern on 6/28/2023 at 5:30 p.m. No further information was provided prior to exit. 29125 3. For Resident #67, the facility staff failed to complete a safe smoking assessment. On 6/26/23 at approximately 11:30 AM, the facility staff provided a list of residents who smoked. Resident #67 was on the list. On 6/27/23 at 4:45 PM in an interview conducted with Resident #67, he stated that he smokes about one small sized cigar a week. He stated that staff are to store his cigars and lighter and that he is to obtain them from the staff and then he walks up to the store about two blocks away to get a cup of coffee and sits on a bench drinking his coffee and smoking his cigar off campus. A review of the clinical record failed to reveal any evidence that a safe smoking assessment was completed for Resident #67. There was no evidence that Resident #67 had any accidents, burns, etc. while smoking. On 6/28/23 at 1:35 PM, an interview was conducted with LPN #2 (Licensed Practical Nurse). When asked if any of the residents on her unit smokes, she stated, Yes. I didn't know about it but apparently they sneak across the road (off campus but in eyesight of the facility) and smoke. She stated that the Administration confiscated everything from the residents that they could find (smoking materials) because the residents had signed a no smoking policy. She stated that the smoking materials are locked up in a cart and that residents will ask for the smoking materials but they have to leave the property to smoke. When asked if, for the residents who do smoke, has smoking assessments been completed on them, she stated. No. When asked what was the purpose of a smoking assessment, she stated that some residents may have medication related issues, be on oxygen, have COPD (chronic obstructive pulmonary disease), and to ensure they can light their own cigarette and put it out. On 6/28/23 at 2:08 PM an interview was conducted with ASM #1 (Administrative Staff Member) the Executive Director. He stated that he was new to the facility as of the week prior to this survey, and on Friday (6/23/23) he had identified that this was a concern and started addressing it. He stated that so far, he had addressed the accessibility of the smoking materials by having them locked up and residents have to ask for them, go off campus to smoke, and return the materials upon return to the facility. He stated that the concern would be residents who were not cognitively intact potentially getting access to a lighter or cigarette. When asked about residents being assessed for safe smoking, he stated that they were not because 1) there is no smoking assessment form in the electronic health record system that could be utilized because the facility was supposed to be a smoke-free facility, and 2) that when the residents leave the facility property to smoke and are cognitively intact, they are responsible for their own safety offsite. A review of the comprehensive care plan failed to reveal any evidence that Resident #67 was care planned for smoking related concerns and interventions. No further information was provided by the end of the survey. 31753 4. For Resident #307 (R307), the facility staff failed to complete a safe smoking assessment. On 6/27/23 at approximately 10:30 a.m., an interview was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 stated the facility was a non-smoking facility but there were some residents who walked off the property to smoke. ASM #1 stated these residents were deemed physically safe to walk off the property and were required to sign themselves out, but smoking assessments had not been completed. ASM #1 further stated these residents had to obtain their cigarettes and lighters from the nurses or social services employees. ASM #1 provided a list of the residents who went off the property to smoke and R307's name was on the list. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/19/23, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact. On 6/27/23 at 4:45 p.m., an interview was conducted with R307. R307 stated he obtains his smoking materials at the nurses' station, signs himself out, and walks off the property once or twice a day to smoke. A review of R307's clinical record failed to reveal a safe smoking assessment to ensure the resident could safely, independently smoke. On 6/28/23 at 418 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated a smoking assessment should be completed for residents who leave the property to smoke. RN #1 stated this should be done for the residents' safety and to ensure the residents can safely hold a cigarette, light a cigarette, and to ensure the residents know to not wear oxygen while smoking. On 6/29/23 at 11:43 a.m., ASM #1 and ASM #2 (the interim Director of Nursing) were made aware of the above concern.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for 7 of 35 residents in the survey sample; Residents #67, #40, 76, #45, #54, #51, and #2. The findings include: 1. For Resident #67, the facility staff failed to develop a comprehensive care plan related to smoking. On 6/26/23 at approximately 11:30 AM, the facility staff provided a list of residents who smoked. Resident #67 was on the list. On 6/27/23 at 4:45 PM in an interview conducted with Resident #67, he stated that he smokes about one small sized cigar a week. He stated that staff are to store his cigars and lighter and that he is to obtain them from the staff and then he walks up to the store about two blocks away to get a cup of coffee and sits on a bench drinking his coffee and smoking his cigar off campus. The clinical record documented the resident as not being a smoker as follows: 1. The most recent Quarterly Data Collection Tool dated 11/21/22 documented, Does the resident smoke? The box for No was marked. 2. A physician's progress note dated 4/21/23 documented, (-) (negative) smoker . A review of the comprehensive care plan failed to reveal any evidence that Resident #67 was care planned for smoking related concerns and interventions. On 6/28/23 at 4:18 PM, an interview was conducted with RN #1 (Registered Nurse). When asked what was the purpose of the care plan, she stated that it is what the staff go by to provide resident preferences, resident needs, etc. When asked if a resident who goes off property to smoke should have a care plan, she stated that they should have a care plan for smokers even though it is a non-smoking facility, they should be care planned that they leave to smoke. She stated there should be a care plan for residents who freely leaves the facility frequently. The facility policy, Care Plan Preparation was reviewed. This policy documented, A care plan direct's the patient's nursing care from admission to discharge. This written action plan is based on nursing diagnoses that have been formulated after reviewing assessment findings, and it embodies the components of the nursing process: assessment, diagnosis, planning, implementation and evaluation . On 6/29/23 at 9:20 AM, ASM #1 (Administrative Staff Member) the Executive Director, and ASM #4 the Regional Clinical Consultant, were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #40, the facility staff failed to develop a comprehensive care plan for the use of siderails. On 6/28/23 at 8:35 AM, Resident #40 was observed in bed, with the head of his bed elevated and the siderails were up on both sides. A review of the clinical record revealed that on 4/14/23, the therapy department had assessed Resident #40 for the use of siderails and determined that they were necessary for the resident for increased safety and independence for bed mobility. A review of the clinical record revealed the comprehensive care plan. The care plan did not address the use of the siderails. On 6/28/23 at 4:18 PM, an interview was conducted with RN #1 (Registered Nurse). When asked what was the purpose of the care plan, she stated that it is what the staff go by to provide resident preferences, resident needs, etc. When asked if a resident had siderails, should they be on the care plan, she stated, Definitely. She stated the siderails are to help residents assist themselves with positioning, like rolling over, to help them not roll off the bed. When asked why should they be on the care plan, she stated that staff need to know the resident is needing the assistance of siderails and they need to be used. The facility policy, Care Plan Preparation was reviewed. This policy documented, A care plan direct's the patient's nursing care from admission to discharge. This written action plan is based on nursing diagnoses that have been formulated after reviewing assessment findings, and it embodies the components of the nursing process: assessment, diagnosis, planning, implementation and evaluation . On 6/29/23 at 9:20 AM, ASM #1 (Administrative Staff Member) the Executive Director, and ASM #4 the Regional Clinical Consultant, were made aware of the findings. No further information was provided by the end of the survey. 27660 3. For Resident #76 (R76), the facility staff failed to develop a care plan to address the resident's smoking. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 5/3/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as only requiring supervision after set up assistance if needed. An interview was conducted with R76 on 6/27/2023 at approximately 1:30 p.m. When asked if he goes out to smoke, R76 stated he goes out about three times a day for smoking and does go out other times just to walk. R76 was asked who keeps his cigarettes, R76 stated they are kept in the social workers office during the week, but the nurses have them on the weekends and after the social worker goes home. When asked where he smokes since this is a non-smoking facility, R76 stated he walks to the end of the building and goes across the road where the telephone poles are, that's not the facility property. R76 also stated he walks up behind the building, through the path in the woods to an open field just to get away from the facility. R76 stated he also walks in the town and goes to the store a few blocks away. When asked if he signs out if he is going smoking outside, R76 stated that he doesn't bother to sign out now because they give me my cigarettes, so they know where I'm going. The comprehensive care plan, revised on 11/22/2022, failed to evidence a care plan for being a smoker. An interview was conducted with RN (registered nurse) #1, a unit manager, on 6/28/2023 at 4:30 p.m. When asked the purpose of the care plan, RN #1 stated it's a disciplinary team effort to see what is good for the resident. That's what the staff go by to care for the resident. It should contain the resident's preferences, likes and dislikes, and how to care for them. RN #1 was asked if a resident should be care planned if they independently goes off the property, RN #1 stated, yes, if they are going out frequently. When asked if they had knowledge the resident is smoking and going off property to do so, even though the facility is a non-smoking facility, should that be care planned, RN #1 stated, The residents even sign a paper that says they can't smoke. I would want it care planned. ASM (administrative staff member) #1, the executive director, ASM #2, the interim director of nursing, ASM #4, regional clinical consultant, and ASM #5, the regional vice president of operations, were made aware of the above concern on 6/28/2023 at 5:30 p.m. No further information was provided prior to exit. 4. For Resident #45, the facility staff failed to implement the comprehensive care plan for communicating with the dialysis center each time the resident went to dialysis. The comprehensive care plan dated, 12/12/2022, documented in part, Focus: Alteration in Kidney Function due to end stage renal disease (ESRD) with dialysis on M - W - F. The Interventions documented in part, Written communication form with review of weights and any change of condition between dialysis provider and living center. The physician order dated, 5/17/2023 documented, Dialysis (name, address and phone number of dialysis center) MWF (Monday/Wednesday/Friday) one tine a day every Mon, Wed, Fri related to end stage renal disease. Chair time 12:45 p.m. until 17:00 p.m. (5:00 p.m.). The review of the clinical record failed to evidence communication with the dialysis center on the following dates: May 2023: 5/17/2023, 5/19/2023, 5/26/2023, 5/29/2023 and 5/31/2023. June 2023: 6/2/2023, 6/5/2023, 6/7/2023, 6/9/2023, 6/12/2023, 6/14/2023, 6/16/2023, 6/19/2023, 6/23/2023, and 6/26/2023. An interview was conducted with LPN (licensed practical nurse) #5 on 6/28/2023 at 5:32 p.m. When asked the process for resident going to dialysis, LPN #5 stated a paper goes with the resident, it is filled out by the nurse here [at the facility] and then dialysis fills it out, sometimes, and sends it back. When asked how the paper is taken to the dialysis center, LPN #5 stated, it is put in an envelope and sent with the resident. An interview was conducted with RN (registered nurse) #1, a unit manager, on 6/28/2023 at 4:30 p.m. When asked the purpose of the care plan, RN #1 stated it's a disciplinary team effort to see what is good for the resident. That's what the staff go by to care for the resident. It should contain the resident's preferences, likes and dislikes, and how to care for them. ASM (administrative staff member) #1, the executive director, ASM #2, the interim director of nursing, ASM #4, regional clinical consultant, and ASM #5, the regional vice president of operations, were made aware of the above concern on 6/29/2023 at 11:43 a.m. No further information was provided prior to exit. 31753 5. For Resident #54 (R54), the facility staff failed to develop a care plan for the resident's diagnosis of PTSD (post-traumatic stress disorder). R54 was admitted to the facility on [DATE] with a diagnosis of PTSD. A review of R54's comprehensive care plan dated 2/2/22 failed to reveal a care plan to address PTSD. On 6/28/23 at 4:18 p.m., an interview was conducted with RN (registered nurse) #1 who stated a care plan for PTSD should be developed, reflect the resident's behaviors, and document interventions to address the behaviors. On 6/29/23 at 11:43 a.m., ASM (administrative staff member) #1 (the Executive Director) and ASM #2 (the interim Director of Nursing) were made aware of the above concern. 6. For Resident #51 (R51), the facility staff failed to implement the resident's comprehensive care plan for cardiovascular medication administration on 6/12/23 and 6/13/23. R51's comprehensive care plan dated 4/22/19 documented, Impaired Cardiovascular status related to: Hypertension, Peripheral Vascular Disease (PVD), HLD (hyperlipidemia), A-fib (atrial fibrillation), hx (history) of cva (cerebrovascular accident) and hemiplegia (paralysis). Interventions: medications as ordered by physician . A review of R51's clinical record revealed a physician's order dated 12/3/19 for Pradaxa (1) 150 mg (milligrams) two times a day for atrial fibrillation. A review of R51's June 2023 MAR (medication administration record) revealed the same physician's order for Pradaxa. On 6/12/23 and 6/13/23, the MAR documented the code, 7=Other/See Nurse Notes. Nurses' notes dated 6/12/23 and 6/13/23 documented, Medication on order from pharmacy. Further review of nurses' notes and the June 2023 MAR failed to reveal documentation that Pradaxa was administered to R51 on 6/12/23 and 6/13/23. On 6/28/23 at 4:18 p.m., an interview was conducted with RN (registered nurse) #1 who stated the purpose of the care plan is to direct staff how to care for residents. RN #1 stated medications should be ordered from the pharmacy when there are seven pills remaining. RN #1 stated if a medication is not available for administration, then she checks the bottom of medication cart, where extra medications are stored, and if the medication is not there, then she checks the backup medication supply box and calls the pharmacy. On 6/29/23 at 9:38 a.m., another interview was conducted with RN #1. RN #1 stated nurses need to give medications as ordered, and nurses have access to residents' care plans. On 6/29/23 at 11:43 a.m., ASM (administrative staff member) #1 (the Executive Director) and ASM #2 (the interim Director of Nursing) were made aware of the above concern. Reference: (1) Dabigatran (Pradaxa) is also used to help prevent strokes or serious blood clots in adults who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body, and possibly causing strokes) without heart valve disease. If you have atrial fibrillation and are taking dabigatran to help prevent strokes or serious blood clots, you are at a higher risk of having a stroke after you stop taking this medication. Do not stop taking dabigatran without talking to your doctor. Continue to take dabigatran even if you feel well. Be sure to refill your prescription before you run out of medication so that you will not miss any doses of dabigatran. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a610024.html 7. For Resident #2 (R2), the facility staff failed to implement the resident's comprehensive care plan for anti-anxiety medication administration on 6/17/23. R2's comprehensive care plan dated 7/10/19 documented, Potential for drug related complications associated with use of psychotropic medications related to: prescribed Anti-Depressant medication, anti-anxiety medication. Interventions: provide medications as ordered by physician . A review of R2's clinical record revealed a physician's order dated 3/4/22 for buspirone (1) 10 mg (milligrams) one time a day for anxiety disorder. A review of R2's June 2023 MAR (medication administration record) revealed the same physician's order for buspirone. On 6/17/23, the MAR documented the code, 7=Other/See Nurse Notes. A nurse's note dated 6/17/23 documented, Medication on order. Further review of nurses' notes and the June 2023 MAR failed to reveal documentation that buspirone was administered to R2 on 6/17/23. On 6/28/23 at 4:18 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the purpose of the care plan is to direct staff how to care for residents. RN #1 stated medications should be ordered from the pharmacy when there are seven pills remaining. RN #1 stated if a medication is not available for administration, then she checks the bottom of medication cart, where extra medications are stored and if the medication is not there, then she checks the backup medication supply box and calls the pharmacy. On 6/29/23 at 9:38 a.m., another interview was conducted with RN #1. RN #1 stated nurses need to give medications as ordered, and nurses have access to residents' care plans. On 6/29/23 at 11:43 a.m., ASM (administrative staff member) #1 (the Executive Director) and ASM #2 (the interim Director of Nursing) were made aware of the above concern. Reference: (1) Buspirone is used to treat anxiety. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a688005.html

Based on staff interview, facility document review and clinical record review it was determined the facility staff failed to notify the Office of the State Long-Term Care Ombudsman and the resident and/or responsible party of a transfer to the hospital for four of 35 residents in the survey sample, Residents #45, #102, #43, and #89. The findings include: 1. For Resident #45 (R45), the facility staff failed to notify the ombudsman of transfers to the hospital on 3/11/2023 and 4/12/2023. The nurse's note dated, 3/11/2023 at 9:45 p.m. documented, Contacted (Name of Hospital) for an update on resident, admitted with PNE (pneumonia) and low H&H (hemoglobin and hematocrit) need transfusion. There was no further documentation related to the 3/11/2023 transfer to the hospital. The nurse's note dated 4/8/2023 at 6:41 p.m. documented in part, FSBS (fingerstick blood sugar) is 516. Awaiting return call and orders from on call services. The nurse's note dated 4/12/2023 at 3:54 p.m. documented in part, Resident returned from (initials of hospital). There was no further documentation related to the 4/9/2023 transfer to the hospital. On 6/28/2023 a request was made for documentation that the ombudsman was notified of the transfer. On 6/28/2023 at 5:21 p.m. ASM (administrative staff member) #1, the executive director, and ASM #2, the interim director of nursing, stated they had no evidence of notification to the ombudsman. The facility policy, Transfer a Resident to a Hospital Policy documented in part, 9. Send a copy of Bed Hold Policy and Involuntary Transfer form with the resident .Please note: Notification of Involuntary Transfers from the facility must be sent to the Ombudsman. Coordinate with local Ombudsman to determine communication frequency. (Must be at least monthly). ASM #1, ASM #2, ASM #4, the regional clinical consultant, and ASM #5, regional vice president of operations, were made aware of the above findings on 6/28/2023 at 5:30 p.m. No further information was provided prior to exit. 29843 2. For Resident #120 (R102), the facility staff failed to evidence the ombudsman, resident, or the resident's responsible party was notified of the transfer to the hospital on 05/26/2023. The facility's nursing progress noted for (R102) dated 05/27/2023 documented, Per Social Worker information, resident was admitted at (Name of Hospital). Review of the EHR (electronic health record) for (R102) failed to evidence written notification of transfer was provided to the ombudsman, (R102) or (R102's) representative for the transfer on 05/26/2023. On 06/28/32 at approximately 5:00 p.m., an interview was conducted with ASM (administrative staff member) #2, the interim director of nursing. When asked to describe the procedure of notifying the resident, resident's representative and ombudsman when a resident is transferred to the hospital ASM #2 stated that she did not know what the facility's policy was. On 06/28/2023 at approximately 5:50 p.m., ASM #1, executive director and ASM #2, were made aware of the above findings. No further information was provided prior to exit. 29125 3. For Resident #43, the facility staff failed to evidence that written notification was provided to Resident #43's responsible party and the ombudsman for a hospital transfer on 5/14/23. A review of the clinical record revealed the following: A nurse's note dated 5/14/23 documented, (Name of) NP advised to send resident out to ED (emergency department) for suspected GI (gastrointestinal) bleed. A nurse's note dated 5/15/23 documented, (Name of family member) was notified of resident's transport out to (name of hospital) for possible GI bleed last night on the 14th of May. He called this morning asking for an update on the resident. Update was given. There was no documentation to evidence that the resident's responsible party and the ombudsman was provided with written notification of the hospital transfer on 5/14/23. On 06/28/23 at approximately 5:00 p.m., an interview was conducted with ASM #2 (Administrative Staff Member), the interim Director of Nursing. When asked to describe the procedure of notifying the resident, resident's representative and ombudsman when a resident is transferred to the hospital ASM #2 stated that she did not know what the facility's policy was. When asked about evidence of a written notice to the resident's responsible party and the ombudsman, she stated, We don't have it. 4. For Resident #89, the facility staff failed to evidence that written notification was provided to Resident #89's responsible party and the ombudsman for hospital transfers on 4/5/23 and 5/17/23. A review of the clinical record revealed the following: A. For the hospital transfer on 4/5/23: A nurse's note dated 4/5/23 documented, Critical labs value called to facility. NP (Nurse Practitioner) notified. gave verbal order to send to ER (emergency room ) for further evaluation. Emergency contact notified. DON (Director of Nursing) notified, Admin (Administrator) notified. 911 called to transport resident to ER. A nurse's note dated 4/5/23 documented, Residents family called about the 911 send out due to elevated and critical lab results. There was no documentation to evidence that the resident's responsible party and the ombudsman was provided with written notification of the hospital transfer on 4/5/23. On 06/28/23 at approximately 5:00 p.m., an interview was conducted with ASM #2 (Administrative Staff Member), the interim Director of Nursing. When asked to describe the procedure of notifying the resident, resident's representative and ombudsman when a resident is transferred to the hospital ASM #2 stated that she did not know what the facility's policy was. When asked about evidence of a written notice to the resident's responsible party and the ombudsman, she stated, We don't have it. No further information was provided by the end of the survey. B. For the hospital transfer on 5/17/23: A nurse's note dated 5/17/23 documented, CNA (Certified Nursing Assistant) reported that res had been reported to have vomited, then started with labored respirations On call notified, O2 (oxygen) placed & (and) ordered to send to ED (emergency department), res (resident) (family member) also notified There was no documentation to evidence that the resident's responsible party and the ombudsman was provided with written notification of the hospital transfer on 5/17/23. On 06/28/23 at approximately 5:00 p.m., an interview was conducted with ASM #2 (Administrative Staff Member), the interim Director of Nursing. When asked to describe the procedure of notifying the resident, resident's representative and ombudsman when a resident is transferred to the hospital ASM #2 stated that she did not know what the facility's policy was. When asked about evidence of a written notice to the resident's responsible party and the ombudsman, she stated, We don't have it. No further information was provided by the end of the survey.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence the required documents were sent with residents upon transfer to the hospital for four of 35 residents, Residents #45, #102, #43 and #89. The findings include: 1. For Resident #45 (R45), the facility staff failed to evidence the required documents were sent with the resident upon transfer to the hospital on 3/11/2023 and 4/9/2023. The nurse's note dated, 3/11/2023 at 9:45 p.m. documented, Contacted (Name of Hospital) for an update on resident, admitted with PNE (pneumonia) and low H&H (hemoglobin and hematocrit) need transfusion. There was no further documentation related to the 3/11/2023 transfer to the hospital. The nurse's note dated 4/8/2023 at 6:41 p.m. documented in part, FSBS (fingerstick blood sugar) is 516. Awaiting return call and orders from on call services. The nurse's note dated 4/12/2023 at 3:54 p.m. documented in part, Resident returned from (initials of hospital). There was no further documentation related to the 4/9/2023 transfer to the hospital. On 6/28/2023 at 5:21 p.m. ASM (administrative staff member) #1, the executive director, and ASM #2, the interim director of nursing, stated the had no documentation of what was sent to the hospital on 3/11/2023 and 4/9/2023. An interview was conducted with RN (registered nurse) #1 on 6/29/2023. When asked the process for when a resident goes to the hospital, RN #1 stated., the nurse should provide the transfer out packet, that includes the resident medication list, four or five pages of information regarding the resident, and a face sheet. RN #1 was asked if the care plan goals are sent with the resident, RN #1 stated she didn't believe that was in the packet. When asked where what is sent to the hospital is documented, RN #1 stated the only thing they were told to copy is the transfer out form. The facility policy, Transfer a Resident to a Hospital Policy: When the transfer of a resident is imminent, based on medical necessity, the primary nurse will report on the Nurse) to promote continuity of care. Procedure Emergency Transfer: 1. Call the physician and obtain an order to transfer the resident. 2. Call the ambulance 3. Complete the Interact Facility Transfer Form. 4. Print two copies of the resident's chart via PCC (see attached instructions) A. One copy for EMS and one for the hospital. 5. Place printed content into 2 transfer envelopes .13. Write discharge note. Include: A. Notification of family. B. Reason or transfer. ASM #1, ASM #2, ASM #4, the regional clinical consultant and ASM #5, regional vice president of operations, were made aware of the above findings on 6/28/2023 at 5:30 p.m. No further information was provided prior to exit. 29843 2. For Resident #102 (R102), the facility staff failed to evidence required documentation was provided to the receiving facility for a transfer to the hospital on 05/26/2023. The facility's nursing progress noted for (R102) dated 05/27/2023 documented, Per Social Worker information, resident was admitted at (Name of Hospital). Review of the EHR (electronic health record) failed to evidence documentation of required information provided to the hospital on 05/27/2023 for (R102). On 06/28/32 at approximately 5:00 p.m., an interview was conducted with ASM (administrative staff member) #2, the interim director of nursing. When asked to describe the procedure when a resident is transferred to the hospital ASM #2 stated that the resident's face sheet, care plan goals, medication list and transfer paperwork are sent to the hospital. When asked about the documentation for (R102's) transfer on 05/26/2023 she stated that she could not locate it. On 06/28/2023 at approximately 5:50 p.m., ASM #1, executive director and ASM #2, were made aware of the above findings. No further information was provided prior to exit. 29125 3. For Resident #43, the facility staff failed to evidence required documentation was provided to the receiving facility upon a hospital transfer on 5/14/23 . A review of the clinical record revealed the following: A nurse's note dated 5/14/23 documented, Nurse aide (name) reported resident has had two episodes of thick black liquid stool in large amounts. NP (Nurse Practitioner) (name) was notified, awaiting further instructions. A second nurse's note dated 5/14/23 documented, (Name of) NP advised to send resident out to ED (emergency department) for suspected GI (gastrointestinal) bleed. A nurse's note dated 5/16/23 documented, S/P (status post) return from ER (emergency room ), dx (diagnosis) internal hemorrhoids. No c/o (complaints of) pain or discomfort. No acute distress. Resting in bed with eyes closed and call bell in reach. A physician's progress note dated 5/16/23 documented, Asked to see patient following recent ER visit. Patient was sent to the ER from this facility related to dark stools. Patient evaluated in the ER determined black stools related to iron supplementation. Stool was tested in ER and found to be negative for blood. There was no documentation in the clinical record that evidenced documentation was sent to the hospital, including but not limited to: (1) Contact information of the practitioner responsible for the care of the resident. (2) Resident representative information including contact information. (3) Advance Directive information. (4) All special instructions or precautions for ongoing care, as appropriate. (5) Comprehensive care plan goals. (6) All other necessary information, including a copy of the resident's discharge summary. (7) Any other documentation, as applicable, to ensure a safe and effective transition of care. On 06/28/23 at approximately 5:00 p.m., an interview was conducted with ASM (Administrative Staff Member) #2, the interim Director of Nursing. When asked to describe the procedure when a resident is transferred to the hospital ASM #2 stated that the resident's face sheet, care plan goals, medication list and transfer paperwork are sent to the hospital. When asked about evidence of what documentation was sent for Resident #43, she stated, We don't have it. No further information was provided by the end of the survey. 4. For Resident #89, the facility staff failed to evidence what required documentation was provided to the receiving facility upon hospital transfers on 4/5/23, 5/17/23 and 6/20/23. A review of the clinical record revealed the following: A. For the hospital transfer on 4/5/23: A nurse's note dated 4/5/23 documented, Critical labs value called to facility. NP (Nurse Practitioner) notified. gave verbal order to send to ER (emergency room ) for further evaluation. Emergency contact notified. DON (Director of Nursing) notified, Admin (Administrator) notified. 911 called to transport resident to ER. A nurse's note dated 4/5/23 documented, Resident returned to facility on stretcher via Ambulance with 2 staff. Alert and awake. (Name of doctor) on call paged to be notified of resident return and new orders as well. (Name of doctor) called back and was made aware (name of family member), also notified of resident return. B. For the hospital transfer on 5/17/23: A nurse's note dated 5/17/23 documented, CNA (Certified Nursing Assistant) reported that res had been reported to have vomited, then started with labored respirations On call notified, O2 (oxygen) placed & (and) ordered to send to ED (emergency department), res (resident) (family member) also notified C. For the hospital transfer on 6/20/23: A nurse's note dated 6/20/23 documented, Resident had a fall at 0415 (4:15 AM) this morning incurred multiple skin tears on right and left forearms. Hours later resident had complaint of hip pain. NP (nurse practitioner) notified , DON (Director of Nursing) notified and resident was sent vis (sic) 911 for evaluation and to rule out possible hip fracture. (Family member) notified and will be meeting resident there at (name of hospital). A nurse's note dated 6/20/23 documented, Resident is returning to facility via (family member). No fractures and is doing well. For all three hospital visits, there was no documentation to evidence required documentation was sent to the hospital, including but not limited to: (1) Contact information of the practitioner responsible for the care of the resident. (2) Resident representative information including contact information. (3) Advance Directive information. (4) All special instructions or precautions for ongoing care, as appropriate. (5) Comprehensive care plan goals. (6) All other necessary information, including a copy of the resident's discharge summary. (7) Any other documentation, as applicable, to ensure a safe and effective transition of care. On 06/28/23 at approximately 5:00 p.m., an interview was conducted with ASM (Administrative Staff Member) #2, the interim Director of Nursing. When asked to describe the procedure when a resident is transferred to the hospital ASM #2 stated that the resident's face sheet, care plan goals, medication list and transfer paperwork are sent to the hospital. When asked about evidence of what documentation was sent for Resident #89, she stated, We don't have it. No further information was provided by the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician of a possible need to alter treatment for two of 35 residents in the survey sample, Residents #51 and #2. The findings include: 1. For Resident #51 (R51), the facility staff failed to notify the physician when the medication Pradaxa (1) was not administered on 6/12/23 and 6/13/23. A review of R51's clinical record revealed a physician's order dated 12/3/19 for Pradaxa 150 mg (milligrams) two times a day for atrial fibrillation. A review of R51's June 2023 MAR (medication administration record) revealed the same physician's order for Pradaxa. On 6/12/23 and 6/13/23, the MAR documented the code, 7=Other/See Nurse Notes. Nurses' notes dated 6/12/23 and 6/13/23 documented, Medication on order from pharmacy. Further review of nurses' notes and the June 2023 MAR failed to reveal documentation that Pradaxa was administered to R51 on 6/12/23 and 6/13/23, and failed to reveal documentation that R51's physician was notified. On 6/28/23 at 4:18 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the physician should absolutely be notified when a medication is not administered so the physician can adjust treatment. On 6/29/23 at 11:43 a.m., ASM (administrative staff member) #1 (the Executive Director) and ASM #2 (the interim Director of Nursing) were made aware of the above concern. The facility staff did not provide a policy regarding physician notification. Reference: (1) Dabigatran (Pradaxa) is also used to help prevent strokes or serious blood clots in adults who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body, and possibly causing strokes) without heart valve disease. If you have atrial fibrillation and are taking dabigatran to help prevent strokes or serious blood clots, you are at a higher risk of having a stroke after you stop taking this medication. Do not stop taking dabigatran without talking to your doctor. Continue to take dabigatran even if you feel well. Be sure to refill your prescription before you run out of medication so that you will not miss any doses of dabigatran. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a610024.html 2. For Resident #2 (R2), the facility staff failed to notify the physician when the medication buspirone was not administered on 6/17/23. A review of R2's clinical record revealed a physician's order dated 3/4/22 for buspirone 10 mg (milligrams) one time a day for anxiety disorder. A review of R2's June 2023 MAR (medication administration record) revealed the same physician's order for buspirone. On 6/17/23, the MAR documented the code, 7=Other/See Nurse Notes. A nurse's note dated 6/17/23 documented, Medication on order. Further review of nurses' notes and the June 2023 MAR failed to reveal documentation that buspirone was administered to R2 on 6/17/23 and failed to reveal documentation that R2's physician was notified. On 6/28/23 at 4:18 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the physician should absolutely be notified when a medication is not administered so the physician can adjust treatment. On 6/29/23 at 11:43 a.m., ASM (administrative staff member) #1 (the Executive Director) and ASM #2 (the interim Director of Nursing) were made aware of the above concern. Reference: (1) Buspirone is used to treat anxiety. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a688005.html

Based on staff interview, facility document review, and clinical record review, the facility staff failed to conduct a periodic review of advance directives with residents and/or their RRs (resident representatives) to determine if they wished to make changes to their existing advance directives or maintain them as written, for two of 35 residents in the survey sample, Residents #36 and #2. The findings include: 1. For Resident #36 (R36), the facility staff failed to conduct a periodic review of the resident's advance directives (1). R36 was admitted to the facility on [DATE]. A review of R36's clinical record revealed medical power of attorney and durable power of attorney documents dated 3/15/2015. Further review of R36's clinical record failed to reveal a periodic review of all aspects of advance directives was conducted with R36 or the resident's representative. On 6/28/23 at 3:41 p.m., an interview was conducted with OSM (other staff member) #3 (the director of social services). OSM #3 stated she holds an advance directive discussion with residents and/or their representatives upon admission and during quarterly care plan meetings. OSM #3 stated the discussion consists of if the residents want cardiopulmonary resuscitation, artificial means of nutrition/hydration and artificial respiration. OSM #3 stated she does not document the discussions held in quarterly care plan meetings unless there are changes. On 6/29/23 at 11:43 a.m., ASM (administrative staff member) #1 (the Executive Director) and ASM #2 (the interim Director of Nursing) were made aware of the above concern. The facility policy titled, Advance Directive-Admissions/Social Services documented, 5. Advanced Directives will be reviewed at least annually . Reference: (1) What kind of medical care would you want if you were too ill or hurt to express your wishes? Advance directives are legal documents that allow you to spell out your decisions about end-of-life care ahead of time. They give you a way to tell your wishes to family, friends, and health care professionals and to avoid confusion later on. A living will tells which treatments you want if you are dying or permanently unconscious. You can accept or refuse medical care. You might want to include instructions on The use of dialysis and breathing machines If you want to be resuscitated if your breathing or heartbeat stops Tube feeding Organ or tissue donation A durable power of attorney for health care is a document that names your health care proxy. Your proxy is someone you trust to make health decisions for you if you are unable to do so. This information was obtained from the website: https://medlineplus.gov/advancedirectives.html 2. For Resident #2 (R2), the facility staff failed to conduct a periodic review of the resident's advance directives (1). R2 was admitted to the facility on [DATE]. A review of R2's clinical record revealed an advance medical directive form dated 2013 (the day and month was illegible). Further review of R2's clinical record failed to reveal a periodic review of all aspects of advance directives was conducted with R2 or the resident's representative. On 6/28/23 at 3:41 p.m., an interview was conducted with OSM (other staff member) #3 (the director of social services). OSM #3 stated she holds an advance directive discussion with residents and/or their representatives upon admission and during quarterly care plan meetings. OSM #3 stated the discussion consists of if the residents want cardiopulmonary resuscitation, artificial means of nutrition/hydration and artificial respiration. OSM #3 stated she does not document the discussions held in quarterly care plan meetings unless there are changes. On 6/29/23 at 11:43 a.m., ASM (administrative staff member) #1 (the Executive Director) and ASM #2 (the interim Director of Nursing) were made aware of the above concern.

Based on family interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to invite the responsible party to the care plan meeting for one of 35 residents in the survey sample, Resident #100. The findings include: For Resident #100 (R100) the facility staff failed to invite the family member/responsible party, to the care plan meeting held on 6/6/2023. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 6/5/2023, the resident scored a three out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. An interview was conducted on 6/27/2023 at approximately 1:00 p.m. with the family member/responsible party of R100. The family member stated she was told she would have monthly meetings with the facility regarding her father's plan of care, but she hadn't had any and her father had been there since 5/26/2023. The progress note dated, 6/6/2023 at 1:15 p.m. documented, Care plan meeting conducted with patient. There were no concerns addressed. An interview was conducted with OSM (other staff member) #3, the director of social services, on 6/28/2023 at 3:34 p.m. When asked who sends the invitations for the care plan meetings, OSM #3 stated initially they were sent through the mail but she felt that wasn't efficient, so she's been calling the families to invite them. When asked if she called R100's family member to invite them to the care plan meeting held on 6/6/2023, OSM #3 stated, she thought she did. A request was made for the documentation of the call. OSM #3 was asked if a care plan meeting should be held with a resident with a BIMS of three, OSM #3 stated, Now that I think about it, I did the care plan with (R100). I should have had her with R100 for the care plan meeting. The facility policy, Family Notification, documented in part, It is the policy of this facility to: 1. Keep families informed. 2. Keep families involved. ASM (administrative staff member) #1, the executive director, ASM #2, the interim director of nursing, ASM #4, the regional clinical consultant and ASM #5, regional vice president of operations, were made aware of the above findings on 6/28/2023 at 5:30 p.m. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to inform a resident/resident representative of the risks and benefits of medication treatment for one of 35 residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to inform the resident/resident representative of the risks and benefits for the use of the anti-psychotic medication Seroquel (1). R5 was readmitted to the facility on [DATE] with a diagnosis of schizoaffective disorder and a physician's order for Seroquel 50 mg (milligrams) in the morning and 25 mg in the evening. A review of R5's clinical record failed to reveal that the facility staff informed the resident or the resident's representative of the risks and benefits for the use of Seroquel. On 6/29/23 at 9:38 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that any time anti-psychotic medication is initiated, the staff should ask the resident or resident representative to sign a consent form. RN #1 stated the form contains information such as the name of the medication, the reason the medication is prescribed, and the side effects that are associated with the medication. Further review of R5's clinical record revealed a consent to use antipsychotic medication form that documented consent for the use of Seroquel; however, the form did not evidence R5, or the resident's representative was made aware of the reason the medication was prescribed or the risks and benefits. The sections to document the reason for the medication and acknowledgment that R5 or the resident's representative was made aware of potential side effects of the medication were blank. On 6/29/23 at 11:43 a.m., ASM (administrative staff member) #1 (the Executive Director) and ASM #2 (the interim Director of Nursing) were made aware of the above concern. The facility policy titled, Chemical Restraint failed to document information regarding the above concern. Reference: (1) Seroquel is used to treat schizophrenia. Side effects include but are not limited to fainting, falling, seizures, uncontrollable movements, fast or irregular heartbeat, confusion, hives, blisters and difficulty breathing or swallowing. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a698019.html

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care and services to prevent and/or treat pressure injuries for two of 21 residents in the survey sample, Residents #3 and #13, resulting in harm for Resident #3. The findings include: 1. For Resident #3, the facility staff failed to prevent an avoidable pressure injury from developing and being found at an advanced stage. The facility staff also failed to transcribe and implement the wound physician's treatment order dated 12/15/22. Resident #3 subsequently went to the hospital for surgical debridement (1) and had findings consistent of osteomyelitis (2). A Braden Scale for Predicting Pressure Sore Risk document dated 11/22/22 scored the resident as a 17 - Low Risk for developing pressure injuries. A weekly skin assessment dated [DATE] revealed no findings, documenting, Skin clear, no change of condition assessed. A Change of Condition note dated 12/12/22 at 9:41 PM documented, Situation: 5 cm (centimeters) circular pressure wound, Black in color noted by CNA (certified nursing assistant.) Response: Foam dressing applied. Resident positioned on side to relieve pressure. An Initial Pressure Injury report dated 12/12/22 at 12:13 PM documented, Site: Left buttock. Type: Pressure. Length: 5 cm (centimeters) .Stage III .Is there drainage? No. Is there tunneling or undermining present? No. Describe Current Treatment Plan: Clean with wound cleanser and apply foam boarder dressing QD (everyday) . A review of the physician's orders revealed one dated 12/12/22 for Cleanse coccyx wound with wound cleanser, pat dry, apply foam dressing QD (everyday), and PRN (as needed) every evening shift for Pressure wound. There was no documentation between the 12/6/22 skin assessment and the 12/12/22 identification of the wound, to indicate that any skin breakdown was identified and treated before becoming an advanced stage wound, or that preventative measures were in place. A review of the wound care physician's progress notes revealed that the wound care physician first evaluated the resident's wound on 12/15/22 and documented, .Unstageable necrosis 6 x 4 x not measurable .Thick adherent devitalized necrotic tissue - 100% Dressing treatment plan: Santyl apply once daily for 30 days; Gauze island w/ bdr (with border) apply once daily for 30 days . Further review of the clinical record revealed that this treatment plan order was not transcribed and implemented. A review of the December 2022 TAR (Treatment Administration Record) revealed that the initial treatment (foam dressing) that was started on 12/12/22 was administered each day through 12/23/22, except for 12/17/22, however, the new treatment should have been ordered and implemented, per the above wound care physician's note dated 12/15/22. Further review of the clinical record revealed a second wound physician progress note dated 12/23/22, one week after the above note of 12/15/22. This note documented, .Stage 4 (3) .5 x 6.5 x 0.1 .Thick adherent devitalized necrotic tissue - 100% Wound progress: Improved .Dressing treatment plan: Santyl apply once daily for 22 days; Gauze island w/ bdr (with border) apply once daily for 22 days Additional Note: Post-debridement assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level, which had been obscured by necrosis (4) prior to this point. This wound has now revealed itself to be a Stage 4 pressure injury. This is not a wound deterioration. A nurse practitioner note dated 12/23/22 documented, .Stage 4 sacral wound, acute, possibly infected .New recommendations given for management but family wants pt (patient) to go to the ER (emergency room .) . A review of the hospital record, dated 12/26/22 documented, .Date of Operation: 12/24/22 .Operative Procedure: INCISIONAL DEBRIDEMENT & IRRIGATION OF SACRAL WOUND, INCLUDING SKIN, SUB Q FAT, AND BONE - Wound Class: Dirty or Infected .Findings: Extensive necrotic tissue involving skin subcutaneous fat muscle and bone, stage 4 sacral decub, purulent drainage . As part of the hospital record, a 12/25/22 radiology exam documented, .Large posterior decubitus ulcer with components extending into the gluteus maximus muscle bilaterally with greatest involvement on the left. Marrow changes in the S4, S5, and proximal coccyx, adjacent to the ulceration, suggesting osteomyelitis. Abscess collection along the inferior medial aspect of the left gluteus maximus measuring 3 cm in greatest dimension Also, as part of the hospital record was an MRI exam dated 12/25/22 that documented, .There is a large decubitus ulcer in the midline measuring 10.2 cm in width by 2.6 cm in depth by 7.8 cm in craniocaudad dimension findings consistent with osteomyelitis . A review of the comprehensive care plan revealed one dated 11/17/22 and most recently revised on 12/22/22, documented, at risk for skin breakdown r/t Assistance required in bed mobility current tx for unstag ulcer. Interventions that were in place prior to the wound, all dated 11/17/22, included: Complete Braden Scale. Conduct weekly skin inspection. Moisturize skin with lotion as needed. Turning and repositioning schedule per assessment. Interventions added after the wound developed included: For residents who are ambulatory, encourage activity as tolerated (added 12/15/22). Provide pressure reduction/relieving mattress (added 12/15/22). Treatments as ordered (added 12/15/22). Weekly Wound assessment (added 12/15/22). On 3/28/23 at 11:37 AM, an interview was conducted with ASM #3 (Administrative Staff Member) the Regional Clinical Consultant, who provided information regarding the resident's pressure injury. When asked if it was a concern that the wound was not identified until an advanced stage, she stated that it was, and should have been identified before reaching an advanced stage. When asked if there was a concern that the Santyl treatment ordered by the wound care physician on 12/15/22 was not transcribed and implemented, she stated that it was. On 3/29/23 at 10:23 AM, an interview was conducted with RN #1 (Registered Nurse). When asked what it means if a wound treatment is not signed off as being done, she stated that if it isn't charted it isn't done. When asked if the wound physician writes a treatment plan on his wound evaluation notes, what is to be done with that, she stated that it should be transcribed as an order and implemented. When asked what systems are in place to prevent pressure injuries, she stated that residents who are not able to turn themselves should be turned every two hours and that during incontinent care, staff should apply barrier cream to the resident. RN #1 stated the main thing is to keep residents off the pressure points and to keep them clean and dry; and that skin assessments are done weekly and that this assessment is a head to toe assessment. When asked about identifying wounds at the earliest possible time, before it becomes an advanced stage, RN #1 stated that the aides are trained to identify if something is new or different with a resident's skin and should be identifying these changes during bathing and incontinent care. The aides cannot identify what a wound is or the stage, but can identify if something wasn't there before, but is now, that the nurse should be notified, or if something looks different than it did before, they should notify the nurse, and the aides should be looking for this every time they provide care to a resident. She stated that if residents are being turned and repositioned, provided bathing and frequent incontinent care, that wounds could and should be identified early and treatment initiated before a wound becomes an advanced stage. It would be rare for a wound to not be identified at an early stage if the skin is being monitored as it should be. On 3/29/23 at 11:33 AM, ASM #1 the Administrator, ASM #2 the Director of Nursing, ASM #3 the Regional Clinical Consultant, and ASM #4 the Regional VP of Operations, were notified of the findings and the concern for harm. ASM #3 stated that the facility had no further information regarding this pressure injury. References: (1) Debridement: This is a type of debridement where devitalized tissue (slough, necrotic, or eschar) in the presence of underlying infection is removed using sharp instruments such as a scalpel, Metzenbaum, and curettes, among others. This can be done bedside, in the office or wound care center, or the operating room, depending on the adequacy of anesthesia and the ability to control perioperative complications like bleeding. https://www.ncbi.nlm.nih.gov/books/NBK507882/ (2) Osteomyelitis: Osteomyelitis is an infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue. Infections can also begin in the bone itself if an injury exposes the bone to germs. https://www.mayoclinic.org/diseases-conditions/osteomyelitis/symptoms-causes/syc-20375913 (3) Stage 4: full thickness ulcer with the involvement of the muscle or bone. https://www.ncbi.nlm.nih.gov/books/NBK532897/#:~:text=Stage%201%3A%20just%20erythema%20of,of%20the%20muscle%20or%20bone (4) Necrosis: Necrosis is the medical term for the death of your body tissue. When the cells in your tissues die, it can affect many different areas of your body, including your bones, skin and organs. Necrosis can occur because of illness, infection, injury, disease or lack of blood flow to your tissues. https://my.clevelandclinic.org/health/diseases/23959-necrosis#:~:text=Necrosis%20is%20the%20medical%20term,Questions%20216.444.2538 2. For Resident #13, the facility staff failed to provide care and services to treat pressure injuries. A review of the clinical record revealed that Resident #13 had a history of pressure injuries. A left ischial stage 3 pressure injury which was being treated with negative pressure wound therapy (wound vac) upon admission on 4/13/22, an unavoidable stage 4 sacral wound that developed on or about 5/20/22, an unavoidable right lower back stage 3 wound that develop on or about 8/25/22 (at which time the left ischial wound was determined to be resolved), and an unavoidable re-emergence of the left ischial wound on or about 1/12/23. First left ischial wound: A review of the nurse's notes, physicians' orders and TAR revealed the following: A review of the clinical record revealed that the resident was admitted on [DATE] with a wound vac to a pressure injury. A physician's order dated 4/13/22 documented Change wound Vac. 3 x weekly to under left ischial. Ensure proper seal and suctioning at all times. 125 mmhg (millimeters of mercury) negative pressure every day shift every Mon, Wed, Fri (Monday, Wednesday, Friday) for Wound. The resident was readmitted to the hospital on 4/14/22 and this order was subsequently discontinued on 4/19/22. Further review of the clinical record revealed that the resident was readmitted on [DATE]. A nurse's note dated 4/22/22 documented, Wound [name of wound care physician] into see this resident for the 2 pressure wounds. Left ischium improved. Size: 2.3x2.5x3.6cm (centimeters). Moderate serous. 15% slough and 85% granulated tissue Wound vac intact and draining properly. No s/s distress or discomfort. Will continue to monitor. A nurse's note dated 4/24/22 documented, .wound vac that is attached & functioning properly to left ischium A nurse's note dated 4/29/22 documented, Wound vac intact and draining properly Further review of the clinical record revealed a physician's order dated 4/29/22 that documented, Change wound Vac. 3 x weekly to under left ischial. Ensure proper seal and suctioning at all times. 125 mmhg negative pressure every day shift every Mon, Wed, Fri. This order was set with a start date of 5/2/22. This order was discontinued on 5/9/22. A review of the physician's orders failed to reveal any evidence that an order was in place for this treatment from the time of readmission on 4/21/22 through 4/29/22 when the above order was written. A review of the treatment administration record (TAR) for April and May 2022 revealed that the wound vac was not included as an order to be followed upon the resident's readmission on 4/21/22 through 4/29/22. Based on the notes that documented the presence of the wound vac from the time of readmission on 4/21/22, the resident was receiving wound vac therapy at times, but without an order, and therefore, the use of the wound vac therapy was not evidenced on the treatment administration record from the readmission on 4/21/22 through 4/29/22. Therefore, there was no evidence other than the sporadic nurses' note, that the treatment was provided daily, and that the required settings of 125 mmhg was implemented, and that the three times a week associated dressing change for wound vac dressings was completed. Therefore, the facility could not evidence that the wound vac therapy, if provided, was provided in accordance with standards of wound vac therapy to include machine settings and dressing changes. Sacral stage 4 wound: A review of the physician's orders and TAR revealed the following: On 5/20/22, the wound physician ordered calcium alginate, dressing, daily, to the sacral wound. This order was discontinued on 10/17/22. A review of the TAR from May 2022 through October 2022 revealed this treatment was not provided on 8/1/22, 8/9/22, 9/24/22, 10/1/22, 10/5/22, and 10/10/22. On 8/25/22, an order was written for calcium alginate and Santyl, daily. This order was discontinued on 11/10/22. A review of the TAR from August 2022 through November 2022 revealed this treatment was not provided on 9/24/22, 10/1/22, 10/5/22, 10/10/22, 10/20/22, 10/22/22, 10/23/22, 11/5/22, and 11/6/22. On 11/10/22, an order was written for collagen sheet with silver alginate cream, daily. This order was discontinued on 3/17/23. A review of the TAR from November 2022 through March 2023 revealed this treatment was not provided on 11/30/22, 12/3/22, 12/12/22, 12/25/22, 1/9/23, 1/17/23, 1/31/23, 2/9/23, and 2/11/23. On 3/17/23 an order was written for collagen sheet and cover with gauze island with border, daily. A review of the March 2023 TAR revealed this treatment was not provided on 3/19/23, 3/20/23, and 3/26/23. Lower right back wound: A review of the physician's orders and TAR revealed the following: On 8/25/22, an order was written for calcium and alginate. This order was discontinued on 11/10/22. A review of the TAR from August 2022 through November 2022 revealed this treatment was not provided on 9/24/22, 10/5/22, 10/10/22, 10/22/22, 10/23/22, 11/5/22, and 11/6/22. On 11/22/22 an order was written for collagen with silver sheet, daily. This order was discontinued on 3/17/23. A review of the TAR from November 2022 through March 2023 revealed this treatment was not provided on 11/30/22, 12/3/22, 12/12/22, 1/9/23, 1/17/23, 1/31/23, 2/9/23, and 2/11/23. On 3/17/23 an order was written for collagen with silver sheet and cover with boarder gauze, daily. A review of the TAR for March 2023 revealed this treatment was not provided on 3/19/23, 3/20/23, and 3/26/23. Re-emerged left ischial wound: On 1/12/23 an order was written by the wound physician on the wound evaluation notes for alginate calcium with silver, to be done daily. This order was not transcribed and not implemented. The wound physician documented on 1/19/23 on the weekly wound evaluation note to discontinue this order. On 1/19/23 an order was written for alginate calcium and Santyl, daily. This order was discontinued on 3/17/23. A review of the TAR for January 2023 through March 2023 revealed this treatment was not done on 1/31/23, 2/9/23, and 2/11/23. On 3/17/23 an order was written for alginate calcium and island gauze with border. A review of the TAR for March 2023 revealed this treatment was not provided on 3/19/23, 3/20/23, and 3/26/23. On 3/29/23 at 10:23 AM, an interview was conducted with RN #1 (Registered Nurse). When asked what it means if a wound treatment is not signed off as being done, she stated that if it isn't charted it isn't done. On 3/29/23 at 11:33 AM, ASM #1 the Administrator, ASM #2 the Director of Nursing, ASM #3 the Regional Clinical Consultant, and ASM #4 the Regional VP of Operations, were notified of the findings. No further information was provided.

Based on staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to provide CPR (cardiopulmonary resuscitation) on a resident who was a full code for one of three residents in the survey sample, Resident #1. The facility staff failed to initiate and perform (cardiopulmonary resuscitation) CPR for Resident #1 after the resident was found without a pulse or respirations and the resident subsequently expirred in the facility on [DATE]. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent complete minimum data set, a quarterly assessment, with an assessment reference date of [DATE] coded the resident as having 15 out of 15 on the brief interview for mental status indicating the resident was cognitively intact to make daily decisions. The resident was coded as requiring set up assistance from staff for activities of daily living. Review of the resident's care plan initiated on [DATE] documented, Focus. My code status is Full code (administer cardiopulmonary resuscitation -- CPR). Interventions CPR will be performed as ordered. Review of the facility's form titled, DNR (do not resuscitate)/CPR Status Order Form dated [DATE] evidenced documentation that the resident requested CPR to be initiated in the case of respiratory or [MEDICAL CONDITION]. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. The record documented no advance directives or physician order [REDACTED]. Review of the nurse's notes dated [DATE] at 5:50 a.m., documented no evidence that CPR was initiated or provided to Resident #1 or that Emergency Medical Services (EMS) was called. On [DATE] at 11:50 a.m., the facility investigation for Resident #1 was requested from ASM (administrative staff member) #1, the executive director. ASM #1 brought in the investigation, which included the plan of correction and stated, The nurse called the DON (director of nursing) who was home sick. The DON said to call the family; she did not tell them to do CPR. Both were suspended because they didn't follow policy and procedure. I let the DON go but let the nurse come back because she was following what the DON said to do. On [DATE] the facility's investigation of the events, surrounding Resident #1's death on [DATE] was reviewed. The investigation indicated RN (registered nurse) #1 failed to initiate and perform CPR for Resident #1 on [DATE]. Their investigation included in part, the following documentation of events documented by the facility's administrator: At approximately 5:40 a.m. on [DATE]: RN #1 was notified by CNA (certified nursing assistant) #1 that there was something wrong with Resident #1; RN #1 entered the room found resident lying across the bed with eyes fixed with cold extremities, blue nail beds and RN #1 was unable to auscultate heart or breath sounds; did not initiate CRP (sic) and resident was full code; RN #1 notified LPN (licensed practical nurse) #1, the supervisor and the nurse practitioner; LPN #1 entered room and observed resident; LPN #1 left room to verify code status; LPN #1 called director of nursing (DON) to verify protocol; DON stated that (LPN #1) informed her at 5:45am that (Resident #1) had expired. She also stated that he (Resident #1) was found unresponsive and cool to the touch without vital signs this morning; DON stated to call family and pronounce death. An interview statement was obtain from CNA (certified nursing assistant) #1 on [DATE] at 2:25 p.m. CNA #1, stated that around 5:40 to 5:50 a.m. The lab (laboratory) staff said something was wrong with him (Resident #1). I went over and shook him and I knew something was wrong he (Resident #1) was dead cold. I put my hand over his mouth and couldn't feel any breath and I ran to get the vital sign machine (automatic machine that measures blood pressure, pulse, temperature and oxygen saturation). When I ran down the hall I saw the nurse (RN (registered nurse) #1) and said (name of Resident #1) might have passed away and she said 'What?' CNA #1 stated, I was running down the hall with the vital sign machine and the nurse, she was right behind me. I asked the nurse if he was a DNR (do not resuscitate) or a full resuscitation. I got no response. CNA #1 stated, I checked his blood pressure but there wasn't one. When asked if he put the blood pressure cuff on the resident's arm, CNA #1 stated he did. When asked if he was able to straighten the resident's arm, CNA #1 stated, Yes. An interview was conducted on [DATE] at 8:32 a.m. with RN (registered nurse) #1, the resident's nurse. When asked if she had seen the resident the night of [DATE], RN #1 stated, That night I saw him. I was back there once that night. When asked if she assessed the resident, RN #1 stated, He had his curtain pulled, he had a [MEDICAL CONDITION] machine and I could hear it running but when we found him that morning the [MEDICAL CONDITION] was on the floor running. When asked if she had put the [MEDICAL CONDITION] on the resident, RN #1 stated the resident did that independently. When asked if she had actually seen the resident, RN #1 stated she had not. When asked what occurred next, RN #1 stated, I had started my med (medication) pass. It was a lab morning so the lab lady was there and he (Resident #1) was going to have blood drawn. All of a sudden (CNA #1) came running up the hall and said, 'there's something wrong with (Resident #1)' and then the lab lady said there was something wrong with (Resident #1). When asked what she did next, RN #1 stated she went into the resident's room and determined the resident had been dead and had been dead for several hours. RN #1 stated she ran to get her stethoscope and returned to the room. She was not able to hear heart or lung sounds and instead of starting CPR, she called the supervisor. When asked if she knew how to determine the resident's code status, RN #1 stated she could check the chart. When asked why she did not check the chart, RN #1 didn't have an answer. RN #1 stated, It was a mistake. I didn't know the policies. When asked if she had been educated on the CPR policy at the time of the incident, RN #1 stated, No. When asked if a nurse needed a policy to initiate CPR on a full code RN #1 stated no. An interview was conducted on [DATE] at 8:55 a.m. with LPN (licensed practical nurse) #1, the supervisor on [DATE]. LPN #1 stated that RN #1 had called her to check on the resident. I got to the room and he was cold. They (RN #1 and CNA#1) had the vital sign machine in there and he didn't have any BP (blood pressure), pulse. LPN #1 stated she checked the code status and determined the resident was a full code. LPN #1 stated we weren't sure what to do if the resident was cold and blue so she called the director of nursing for guidance. When asked what would normally occur if a resident was found dead, LPN #1 stated, Normally somebody would have called a code (that a resident needed CPR), she (RN #1) would have initiated CPR. I would have grabbed the crash cart and then it would have been both of us. Looking back on it, it was poor judgement. Review of the nurse's notes dated [DATE] at 5:50 a.m. documented, Upon entering room, resident lying horizontally across bed without pulse or breath sounds. Could not auscultate heart sounds or breathe sounds. Pronounced at 0550 am (a.m.) NP (nurse practitioner) on call notified and emergency contacts called and messages left. Review of the nurses' notes and clinical record failed to reveal any documented evidence that the resident was cold or blue. A telephone interview was conducted on [DATE] at 11:30 a.m. with RN #2, the facility director of nursing (DON) on [DATE]. When asked what occurred the morning of [DATE], RN #2 stated, I got the phone call around 5:40 that morning. I was home very sick. (LPN #1) told me that (Resident #1) had passed. That his arms were blue and he had been gone for some time. She asked me what time she would use for time of death. I told her to check the heart sounds and asked if there was an RN in the building. She said yes (RN #1) was here. I told her to call the family. I don't recall speaking about code status. I don't recall telling them to call 911. When asked if that would be what would normally occur, RN #2 stated that staff would do CPR until relieved by EMS (emergency medical services). The nurse practitioner, who was covering the facility on [DATE], for another nurse practitioner, was not available for interview during the survey. Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR) documented, POLICY: Cardiopulmonary Resuscitation (CPR) is initiated to support the ventilation and circulation function until: aid arrives and the resident is place on advanced life support systems; he/she is stimulated to function on his/her own; and/or he/she is pronounce dead. 1. Cardiopulmonary resuscitation is initiated on all residents except those with a no code order and appropriate documentation. 2. Cardiopulmonary resuscitation is performed only by individual certified in CPR. 3. All licensed nurse are to be certified in CPR and must be re-certified as needed. The facility implemented a plan of correction effective on [DATE] regarding the failure to perform CPR on [DATE]. The plan of correction included the following interventions. 1. Statements obtained and investigation completed. (Completed [DATE]) 2. Audit of current in-house resident code status. (Completed [DATE]) 3. Completed verification of current staff CPR certification. 4. Reeducation (sic) for current staff of policy and procedures for the code blue process. 5. AD H[NAME] (when necessary) meeting with administrator, medical director and adon (assistant director of nursing) (sic) held on [DATE] for review and discussion of corrective action for incident. (Completed [DATE]) 6. Audits of any code blues to be evaluated during the monthly and quarterly QAPI (quality assurance and performance improvement) meeting. On [DATE] at approximately 10:45 a.m., entrance to the facility a list of all residents who were a full code and had expired in the facility was requested from ASM #1, the executive director. On [DATE] at 11:10 a.m., a list of residents was received. The list documented two additional residents who were full codes and had expired. Review of the records documented the residents had received CPR as ordered. Review of the [DATE] in service attendance documented, SUBJECT Code initiation & CPR. It was documented that eleven nurses had attended the inservice. When asked if all nurses had been educated on CPR as documented in the plan of correction, ASM #1 stated, Yes. ASM #2 stated, I know, I was here until 3:30 in the morning and I educated, (name of RN #1, LPN #1 and another nurse who's name she could not recall.). An interview was conducted on [DATE] at 2:25 p.m. with LPN #2. When asked what staff were to do if they found without a heartbeat or respirations, LPN #2 stated, First check the vital signs. Check the code status. If they're a full code immediately start CPR. When asked what staff did if the resident felt cold and was blue, LPN #2 stated, Exactly the same thing. We immediately start CPR. An interview was conducted on [DATE] at 10:05 a.m. with LPN #3. When asked what staff were to do if they found without a heartbeat or respirations, LPN #3 stated, Look at the chart. If you're at the cart (medication cart) you can go into their record it says if they're a full code or DNR. When asked what staff did if the resident was found to be cold and blue, LPN #3 stated, Start a code blue. LPN #3 stated, They're a full code. Someone starts it (CPR) and we continue the code until the EMT (emergency medical technicians) get here. No further information was provided prior to exit. COMPLAINT DEFICIENCY According to Fundamentals of Nursing 6th edition, 2005; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 1126. Cardiopulmonary resuscitation. [MEDICAL CONDITION] is characterized by an absence of pulse and respiration. If the nurse determines that a client has [MEDICAL CONDITION], cardiopulmonary resuscitation (CPR) must be initiated. CPR is a basic emergency procedure of artificial respiration and manual external cardiac massage . The purpose of CPR is to circulate [MEDICATION NAME] blood to the brain to prevent permanent tissue damage (AHA, 2001).

Based on observation, staff interview, facility document review, clinical record review and in the course of complaint investigation, it was determined that the facility staff failed to provide care and services for a feeding tube for one of 22 residents in the survey sample, Resident #21. Resident #21 was admitted to the facility with a feeding tube on 10/20/16. The facility staff failed to clean the resident's feeding tube site during the resident's stay until 10/26/16 when the resident was transferred to the hospital and admitted [MEDICAL CONDITION] due to an infection of the feeding tube site, resulting in harm. The findings include: Resident #21 was admitted to the facility on [DATE]. Resident #21's [DIAGNOSES REDACTED]. Resident #21's five day Medicare MDS (minimum data set) assessment with an ARD (assessment reference date) of 10/26/16 coded the resident's cognitive skills for daily decision making as modified independence- some difficulty in new situations only. Section G coded Resident #21 as totally dependent on two or more staff with transfers and bathing, totally dependent on one staff with locomotion and requiring extensive assistance of one staff with personal hygiene. Section K documented Resident #21 had a feeding tube (1). Review of Resident #21's admission clinical health status assessment failed to reveal documentation regarding a feeding tube. The admitting nurse's note documented, Resident has a [DEVICE] (type of feeding tube) in place. Resident receives nepro (nutrition) q (every) 8 hours via tube. Resident received 150 cc (cubic centimeters) free water flushes x (times) 4 a day . Resident #21's clinical record failed to reveal skin assessments. Resident #21's comprehensive care plan initiated on 10/20/16 failed to reveal documentation regarding the cleaning of the resident's feeding tube site. Review of Resident #21's physician's orders [REDACTED]. Resident #21's October 2016 MAR (medication administration record)/TAR (treatment administration record) revealed physician's orders [REDACTED]. Nurses' notes during Resident #21's stay revealed documentation regarding feeding tube patency, flushes and feedings but failed to reveal documentation regarding the cleaning of the resident's feeding tube site until 10/26/16 when the resident was sent to the hospital. A nurse's note dated 10/26/16 documented, Situation: Elevated Temp (temperature) and B/P (blood pressure) with PEG tube (type of feeding tube) drainage .Assessment: Upon assessment resident alert and oriented x (times) 2, lethargic, able to voice needs and concerns, easily redirected, pleasant with staff, denied SOB (shortness of breath), total assist with ADL's (activities of daily living) and transfers, PEG tube has brown drainage around site, site cleansed and adherent dressing applied, Elevated B/P 160/84 with increased Temp of 100.4, c/o (complained of) slight discomfort to ABD (abdomen) where PEG located, resident receives Glucerna (nutrition) 1.5 mL (milliliters) runs at 84ml/Hr (hour) 6a-6p and continues with [MEDICAL TREATMENT] (2), resident emesis (vomit) x 1 this shift, breath sounds with crackles in upper lobes, active bowel sounds x4 quads (quadrants), pupils PERRLA (pupils equal, round, reactive to light and accommodation). Response: MD (medical doctor) aware and notified with new orders for CBC (complete blood count) (3), UA (urinalysis) C&S (Culture and sensitivity) (4), [MEDICATION NAME] (5) 40 mg (milligrams) Q (every) Day, wound nurse to eval (evaluate) PEG site, order for dressing changes, and CXR (chest x-ray) 2 views to assess the ABD wall around site to check for ABD abscess, Family aware of condition and requested to be sent 911, MD called back and notified of request, care plan revised and reviewed. A nursing home to hospital transfer form that documented a telephone report was called into the hospital on [DATE], and also documented, Reason(s) for transfer: Other- PEG tube site infected with increased temp and elevated blood pressure . An emergency department physician's note dated 10/26/16 documented, (Name of Resident #21) is a 50 y.o. (year old) male who presents with a feeding tube problem. Family states he had this placed 2 weeks ago. He is currently residing at (name of facility). Family is very concerned about the care he is receiving there. His feeding tube was not cleaned until today. They report swelling around the insertion site as well as drainage. They also report abdominal pain, nausea, vomiting, and a fever .Physical Exam: Abdominal: Feeding tube in place. There is a 3x3 area of swelling around the tube. There is mild drainage coming from the insertion site .The patient presents to the Emergency Department with abdominal pain. Treatment has been initiated in the ER (emergency room ), but the patient has not had significant improvement in symptoms, appears ill enough and/or has illness/findings/co-morbidities that make admission for IV (intravenous) medications, possible surgical consult, and further management the most appropriate disposition . The hospital history and physical dated 10/27/16 documented IV antibiotic medications were initiated in the ED and continued. The history and physical further documented, Assessment and Plan: [MEDICAL CONDITION] with leukocytosis (6) with fever and [MEDICAL CONDITION](7) with nausea due to PEG site infection/infectious myositis (8) . On 10/18/17 at 10:52 a.m. an interview was conducted with LPN (licensed practical nurse) #1 regarding the care that should be provided to residents with feeding tubes. LPN #1 stated the tube should be checked for placement, should be flushed in between each medication and observed for signs/symptoms of infection. LPN #1 was asked if the feeding tube site should be cleaned. LPN #1 stated, That should be done every shift and as needed. LPN #1 was asked if the cleaning of the feeding tube site should be documented. LPN #1 stated there usually is documentation such as verification of feeding tube placement and documentation that the site was cleaned on the TAR and nurses have to sign off the completion of those tasks. On 10/18/17 at 1:47 p.m. an interview was conducted with LPN #3 regarding the care that should be provided to residents with feeding tubes. LPN #3 stated usually the physician will write specific treatment orders. When asked if the feeding tube site should be cleaned, LPN #3 stated the area is usually cleaned with soap and water then patted dry. LPN #3 stated a majority of residents with feeding tubes have a drain sponge on the site that will be changed every shift or twice a day depending on what the physician requests. LPN #3 was asked if the cleaning of feeding tube sites is physician ordered or if it is just done as a nursing intervention. LPN #3 stated, No. There should be an order to clean the site. When asked what should be done if there isn't an order, LPN #3 stated, Talk to the nurse practitioner or physician. LPN #3 was asked where evidence of the cleaning of a resident's feeding tube site should be documented and stated, In the TAR. LPN #3 was asked if this process was in place in October 2016 and stated, Yeah. LPN #3 stated there was no guarantee that nurses were cleaning residents' feeding tube sites if there was no order and if this was not documented on the TAR or in the nurse's notes. LPN #3 stated CNAs (certified nursing assistants) were not allowed to clean feeding tube sites. On 10/18/17 at 4:01 p.m. ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above findings and the concern for harm. ASM #1 confirmed Resident #21 resided at the facility when the facility was owned by the previous company. A new company took ownership of the facility on 12/16/16. ASM #1 and ASM #2 were asked for a policy regarding the care of feeding tubes. The new company referenced Lippincott's Nursing Procedures for care of feeding tubes. Lippincott's Nursing Procedures sixth edition documented, Once daily, clean the [MEDICATION NAME] skin with mild soap and water or [MEDICATION NAME]-iodine solution, and let the skin air-dry for 20 minutes to avoid skin irritation . ASM #1 was asked when the new policies were effective and stated they were uploaded to the computer system for administration and staff use on 5/30/17. On 10/18/17 at 4:35 p.m. ASM #1 presented a tube feeding audit that was completed/reviewed by facility staff on 8/14/17. Also, ASM #1 stated the current medical director is affiliated with the local hospital and reviews/evaluates all re-hospitalization s. ASM #1 stated because of this process, the medical director would identify any concerns related to residents with feeding tubes. A Inservice Education document dated 6/22/17 documented the following: Subject covered: Tube feeding Care- See Attached. Monitor peg site for any signs and symptoms of infection and report any to MD (medical doctor). Reaction from Participants: Understanding. Summary and Conclusions: Will monitor tube feeding for compliance. The Inservice Education sheet further documented the signatures of staff and attached was a policy and procedure addressing Tube Feedings. Two residents with feeding tubes resided at the facility during the survey. Both residents' feeding tube sites were observed. The residents' clinical records were also reviewed and contained documentation that the feeding tube sites were cared for each day. No deficiencies regarding the care of current residents with feeding tubes were identified. No further information was presented prior to exit. COMPLAINT DEFICIENCY PAST-NON-COMPLIANCE (1) A feeding tube is a plastic tube placed into the stomach that delivers nutrition and medication. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/ 3.htm (2) When your kidneys are healthy, they clean your blood. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, you need treatment to replace the work your kidneys used to do. Unless you have a kidney transplant, you will need a treatment called [MEDICAL TREATMENT]. There are two main types of [MEDICAL TREATMENT]. Both types filter your blood to rid your body of harmful wastes, extra salt, and water . This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=[MEDICAL TREATMENT] (3) A CBC (complete blood count) is a blood test that can diagnose diseases and conditions. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=cbc (4) A UA C&S (urinalysis with culture and sensitivity) is a urine test that is completed to check for infection, kidney problems and diabetes. This information was obtained from the website: https://medlineplus.gov/urinalysis.html (5) Prescription [MEDICATION NAME] is used alone or with other medications to treat [MEDICAL CONDITION] reflux disease (GERD), a condition in which backward flow of acid from the stomach causes heartburn and possible injury of the esophagus (the tube between the throat and stomach) . This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 0.html