Every finding on record at San Saba Nursing & Rehabilitation

Based on interviews and record review, the facility failed to ensure resident's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 3 (Resident #300, Resident #29, and Resident #37) of 5 residents reviewed for immunizations. The facility failed to document in Resident #300's, #29's and #37's medical records for having had received education, whether by self or with responsible party, of the benefits, and potential side effects, of the influenza immunization and receipt of the of the pneumococcal immunization or having had not received the pneumococcal immunization due to medical contraindication or refusal. This failure could place residents at risk of contracting a viral illness, influenza and pneumococcal, or being informed of the benefits/risk which could cause respiratory complications and potential adverse health outcomes. Findings include: Resident #300 Review of Resident #300's face sheet dated 10/03/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Type 2 Diabetes Mellitus w/o complications, Constipation (unspecified), Hypothyroidism (unspecified), Hypo-osmolality & Hyponatremia, Hypokalemia, Essential (primary) Hypertension, Unspecified Atrial Fibrillation. Review of Resident #300's admission MDS assessment dated [DATE] reflected Resident #300 was assessed to have a BIMS score of 15 indicating cognition was intact. Review of Resident #300's comprehensive care plan dated 09/18/2024 reflected no entries regarding immunization status. Review of Resident #300's immunization records in the EMR reflected no pneumococcal vaccine record. Further review of record reflected Resident #300 was offered the influenza and pneumococcal vaccine and declined. The immunization record does not list a date. Resident #29 Review of Resident #29's face sheet dated 10/03/2024 reflected an [AGE] year-old male admitted to the facility on [DATE] with an initial admitted [DATE] with the following diagnoses Unspecified dislocation of left hip (subsequent encounter), Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, Type 2 diabetes mellitus (w/moderate non-proliferative), Diabetic retinopathy w/macular edema, right eye. Review of Resident #29's quarterly MDS assessment dated [DATE] reflected Resident #29 was assessed to have a BIMS score of 8 indicating moderate cognitive impairment. Review of Resident #29's comprehensive care plan dated 05/06/2024 reflected no entries regarding immunization status. Review of Resident #29's immunization records in the EMR reflected no pneumococcal vaccine record. Further review of record reflected Resident #29 was offered the influenza and pneumococcal vaccine and declined. The immunization record does not list a date. Review of Resident #37's face sheet dated 10/03/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Malignant neoplasm of unspecified part of unspecified bronchus or lung, secondary malignant and neoplasm or brain, muscle weakness (generalized), constipation (unspecified), depression (unspecified), Gastro-esophageal reflux disease w/o esophagitis, overactive bladder, unspecified protein calorie nutrition, anemia (unspecified), compression of brain, cerebral anemia. Review of Resident #37's admission MDS assessment dated [DATE] reflected Resident #37 was assessed to have a BIMS score of 5 indicating severe cognitive impairment. Review of Resident #37's comprehensive care plan dated 08/20/2024 reflected no entries regarding immunization status. Review of Resident #37's immunization records in the EMR reflected no pneumococcal vaccine record. Further review of record reflected Resident #37 was offered the influenza and pneumococcal vaccine and declined. The immunization record does not list a date. In an interview with the ADON on 10/03/2024 at 10:58 a.m. the ADON stated that Resident #300 refused consents for the pneumococcal vaccine, but resident records reflect she did receive the education. There was not documentation or record showing Resident #300 refusals of the vaccines. Resident #300 refused the influenza vaccine, but the signature page had not been uploaded to the residents' records. The ADON stated Resident #29 record showed a refusal for the pneumococcal vaccines but there was no record documenting the refusal. The ADON stated it was a verbal decline. The ADON stated Resident #37 has a prepared form that will be provided to the resident offering the influenza vaccine. Resident can decline or accept influenza. The ADON stated Resident # 37 gave a verbal refusal for the pneumococcal vaccine and no education was provided to the resident. The ADON stated moving forward she would make sure residents immunization history was recorded for what vaccines were administered and make sure if residents or family's refuse vaccines that education was provided. In an interview with the DON on 10/03/2024 at 12:03 p.m., the DON said, I would expect that they (residents) would be provided informed consent and the discussion be documented and placed in PCC (electronic medical record). Review of the facility's Infection Control Policy dated 03/2024 reflected It is the policy of this company that all residents will be offered the influenza immunization annually October 1 through March 31, unless the immunization is contraindicated, or the resident has already been immunized during this time period. Residents or the resident's representative will have the opportunity to refuse the immunization. The following must occur prior to administering the immunization: Provide a Vaccine Information Statement (VIS) to the resident and/or resident representative that corresponds to the influenza vaccine being administered to the recipient. The VIS will outline education, benefits and potential risks of the immunization. The facility will maintain documentation of influenza vaccinations or refusals of the influenza immunization in the Point Click Care clinical record and will include: That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindication or refusal. Pneumonia Vaccine: It is the policy of this company that all residents will be offered the pneumonia immunization unless the immunization is contraindicated, or the resident has already been immunized. The following must occur prior to administering the immunization: Provide a Vaccine Information Statement (VIS) to the resident and/or resident representative that corresponds to the pneumonia vaccine being administered to the recipient. The VIS will outline education, benefits, and potential risks of the immunization. The facility will maintain documentation of pneumonia vaccinations or refusals of the pneumonia immunization in the Point Click Care clinical record and will include: That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the pneumonia immunization or did not receive the pneumonia immunization due to medical contraindication or refusal.

Based on interview and record review, the facility failed to ensure a comprehensive, accurate, standardized reproducible assessment of the functional capacity was conducted initially and periodically for one (Resident #300) of five residents reviewed for comprehensive assessments. The facility failed to ensure Resident #300's comprehensive admission MDS was conducted within 14 days of admission. The due date was on 10/01/2024 and it was not completed. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided. Findings included: Review of Resident #300's face sheet dated 10/03/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Type 2 Diabetes Mellitus w/o complications, Constipation (unspecified), Hypothyroidism (unspecified), Hypo-osmolality & Hyponatremia, Hypokalemia, Essential (primary) Hypertension, Unspecified Atrial Fibrillation. Review of Resident #300's admission MDS assessment dated [DATE] reflected Resident #300 was assessed to have a BIMS score of 15 indicating cognition was intact. Interview on 10/03/24 at 10:18 AM with the Regional Reimbursement Nurse (RRN), stated that the MDS should have been completed on 10/01/2024 but as of today 10/03/2024 the MDS assessment was not completed. The RRN said the MDS should be completed within 14 days of admissions and (Resident #300's) MDS has not been completed per the 14-day rule. The RRN stated normally they're done the day after ARD but because the facility has not had a MDS coordinator since 09/19/2024 it has not been completed. The RRN stated she is responsible for making sure they were supposed to be completed during the new MDS hiring process. The RRN stated there would not be a consequence to the residents' care if it is not completed in time. Review of undated facility policy titled Policy for Resident Assessments revealed A comprehensive assessment will be completed within 14 days of admission and annually on each resident. The facility will utilize the Resident Assessment Instrument (RAI).

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of 16 residents (Resident #30) reviewed for quality of care. The facility failed to follow a physician order dated 07/11/23 to increase Resident #30's insulin from eight units to ten units. This failure could place residents at risk of uncontrolled blood sugar and kidney injury. Findings included: Review of the undated face sheet for Resident #30 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of vascular dementia, type II diabetes mellitus, and long term (current) use of insulin. Review of the annual MDS for Resident #30 dated 07/10/23 reflected a BIMS score of 11, indicating moderate cognitive impairment. It also reflected Resident #30 received insulin injections for seven of the seven days captured by the assessment. Review of the care plan for Resident #30 with a target date of 10/10/23 reflected the following: The resident has Diabetes Mellitus. The resident will be free from any s/sx of hyperglycemia through the review date. The resident will have no complications related to diabetes through the review date. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Fasting Serum Blood Sugar as ordered by doctor. Review of active physician orders for Resident #30 dated 06/16/23 reflected the following order: Levemir FlexTouch Solution Pen-injector 100 UNIT/ML (Insulin Detemir) Inject 8 unit subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA Review of the July 2023 MAR for Resident #30 reflected her fasting blood sugars ranged from 147 to 353 with a reading of 214 prior to the administration of insulin on 07/31/23. It reflected she was administered eight units during the AM medication shift (precise times not available) from 07/11/23 to 07/31/23. Review of laboratory results of a blood specimen taken from Resident #30 on 07/05/23 reflected her A1C result (a test that measures the amount of hemoglobin {red blood cells} with attached glucose {sugar} and reflects a three-month average for blood sugar levels) was 8.9, which was marked high. The normal reference range was denoted as 4.0-5.6. Review of nursing progress notes dated 7/11/2023 at 10:03 AM and documented by LVN A reflected the following: New order per (MD) to increase Levemir to 10 units QAM due to elevated A1C level. RP notified. During an interview on 08/01/23 at 10:52 AM, the MD stated the order should have been entered when he made it, but he had no reason to think it had a profound effect on Resident #30 in the short term. He stated he had examined Resident #30 that morning, and she was fine. He stated the A1C was an average, and her blood sugars had been up and down. He stated the changes to insulin dosage were part of a long-term plan to treat her diabetes, not an urgent or emergent response. During an interview on 08/02/23 at 11:50 AM, LVN A stated she had no idea why the order for Resident #30's increase in insulin did not get entered. She stated she had a regular process she always used: she entered the order in the EMR first, called the resident's responsible party, wrote a nursing progress note, and then she put it in the 24-hour communication book. LVN A stated she could not tell why she failed to get the order into the EMR but took all the other steps, because it was a few weeks back. LVN A stated her process was her own and not specifically how any of her nurse managers instructed her to proceed. LVN A stated a potential negative impact on the resident was her sugars could have stayed too high and caused kidney problems. During an interview on 08/02/23 at 12:01 PM, the DON stated her process for training staff to enter orders accurately and in a timely manner started with new staff being provided a guidebook for the facility's EMR. She stated she did one on one training with nurses to ensure they knew how to enter orders into the system. The DON stated the facility was small, and they also supported each other with a lot of internal communication. The DON stated she had a monitoring process to ensure the orders were properly entered, but the facility was short an overnight nurse, and the assistant DON, who usually did the oversight for that issue, had been working the overnight shift. The DON stated when she did a root cause analysis of the failure to enter Resident #30's new orders, she determined the usual process had been fragmented, because the assistant DON was doing someone else's job. The DON stated the other issue she determined was that LVN A was distracted during the process, which could happen often at the nurse's station. The DON stated a potential negative impact would be related to blood sugars, which were running high, and there could be some damage to be done. During an interview on 08/02/23 at 12:51 PM, the ADM stated her expectation on new orders for residents being implemented was that the nurse immediately entered the data in the EMR so the MAR would be updated, and the order be followed. The ADM stated her expectation after that was that nurse management, who included the DON, assistant DON, and MDS nurse would reconcile all new orders entered into the EMR and ensure they were entered correctly. The ADM stated in the case of the order to increase Resident #30's insulin, she did not know why it did not happen. The ADM stated LVN A might have been on autopilot for some unknown reason. The ADM stated LVN A was usually very thorough. The ADM stated there were textbook outcomes that could occur if insulin was not increased as ordered, but everyone was different, so she could not say what the outcome could have been for Resident #30. Review of undated facility policy titled Medication Orders reflected the following: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders are received only by licensed nurses or pharmacists. Mail the appropriate copy of the telephone / verbal order form to the prescriber. Procedure: Documentation of the medication order 1. Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the physician order sheet, or the telephone order sheets (if it is a verbal order) and the Medication Administration Record (MAR). 2. The following steps are initiated to complete documentation: $ Clarify the order $ Enter the orders on the medication order and receipt record $ Call (or fax) the medication order to the provider pharmacy $ Transcribe newly prescribed medications on the MAR or treatment record. When a new order changes the dosage of a previously prescribed medication, discontinue previous entry by writing ?DISCONTINUED on the MAR. Enter the new order on the MAR as a separate entry with arrows drawn to the start date. Specific Procedures for the four types of medication orders 1. NEW HANDWRITTEN ORDERS signed by the prescriber. The charge nurse on duty at the time the order is received, notes the order and enters it on the physician order sheet if not written there by the prescriber. If necessary, the order is clarified before the prescriber leaves the nursing station whenever possible.

Based on observation, interview and record review the facility failed to ensure that a resident representative had the right to exercise the resident's rights to the extent those rights are delegated to the representative for 1 of 4 Resident's (Resident #1) whose records were reviewed for resident rights. Facility transported Resident #1 to pharmacy that was 45 minutes away from the facility for COVID-19 vaccination without consulting or obtaining consent from her family member or representative. This deficient practice could result in the violation of the resident's rights. The findings were: Record review of Resident #1's face sheet, dated 10/13/22 reveled an [AGE] year-old female admitted to the facility on [DATE] with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's discharge record revealed Resident #1 discharged from the facility on 08/24/22. Record review of Resident #1's progress notes dated 08/24/22 at 8:42 AM documented by DON reflected that the DON spoke with the LVN who reported that Resident #1's FM N had requested to get Resident #1 COVID-19 vaccine early after Resident #1's admission to the facility. Record review of Resident #1's Medical POA revealed Resident #1's FM D was appointed as the POA and not FM N. Record review of Resident #1's medical records revealed there was no consent obtained for COVID-19 vaccination. Record review of Resident #1's care plan dated 08/19/22 reflected: The resident has impaired cognitive function/dementia or impaired thought processes Alzheimer's and will be able to communicate basic needs on a daily basis. Record review of Resident #1's MDS dated [DATE] had BIMS score of 3 which indicated Resident #1 has severely impaired cognition. Record review of Resident #1's immunization records reflected; resident received COVID-19 vaccination on 08/23/22 at outside pharmacy. An interview on 10/13/22 at 12:21 PM, CNA C stated she does help with transportation, and she does not talk to resident's family members. CNA C stated, on 8/19/22 the day Resident #1 had appointment to get vaccination, facility was so busy, and CNA C did not review the transportation for the day. CNA C stated she did transport Resident #1 on 8/23/22 to get her vaccination from an outside pharmacy. An interview on 10/13/22 at 12:32 PM, ADON stated who ever receives the appointment is responsible to place the transportation request into the computer. ADON stated she had placed Resident #1 appointment into the computer because the DON had asked her to. ADON stated DON informed that Resident #1 needed a vaccination and to see when the next clinic was. ADON stated she believes the transportation was busy on the 8/19/22 so Resident #1 did not go and made an accommodation to vaccine on 8/23/22. ADON stated she did not talk with Resident #1's family and stated, usually the charge nurse is responsible to talk to the family. An interview on 10/13/22 at 12:40 PM, the DON stated on Resident #1 admission, the LVN entered the info into the computer system was the one who received the family's interest in receiving the vaccination. The DON stated both the charge nurse and the ADON is responsible to talk to family members to inform of resident's appointments. The DON stated, we normally inform the 1st emergency contact person, but I am not sure if the 1st contact person for Resident #1 was notified which is the POA. An interview on 10/13/22 at 1:58 PM, LVN S stated she recalls Resident #1's FM N asking information about the vaccination upon admission day. LVN S stated FM N was requesting to get information about the vaccination and not requesting to give the vaccination to Resident #1. LVN S stated not having any conversation with Resident #1's POA regarding the vaccination. LVN S stated the charge nurse is responsible to contact the resident's POA to inform when residents have appointment. LVN S stated she did not make the appointment and not sure who made the appointment for Resident #1. An interview on 10/13/22 at 12:15PM, ADMN stated facility does not provide the vaccination at the facility but help with transportation of the residents to go to outside pharmacy to obtain vaccination. ADMN stated because facility is not providing the vaccination the facility does not need to obtain consent. ADMN stated Resident #1 was accompanied by CNA C. ADMN stated the nursing department sets up the transportation for the residents. The charge nurse starts the process and ADON or DON is in charge of the transportation for the residents. ADMN stated prior to her employment with the facility Resident #1 had been admitted to the facility and upon Resident #1's admission to the facility unknown family member had requested to get vaccine. ADMN stated the facility had appointment made at the nearby pharmacy for Resident #1 to get vaccination but for some reason Resident #1 did not get to go. Facility then got accommodation to get Resident #1 to get vaccinated at an outside pharmacy 45 minutes away from the facility. ADMN stated FM N knew Resident #1 was getting vaccination because FM N was present at the facility when Resident #1 was going out to receive vaccination. ADMN stated FM N is not the POA but is authorized for us to speak to in regard to resident care. ADMN stated FM N was listed as emergency contact person from the hospital records the facility received. Record review of facility's policy titled Resident Rights revised date 11/28/16 reflected: Exercise of Rights- The resident ha the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United states. Planning and implementing care- The resident has the right to be informed of, and participate in, his or her treatment, including: 1. The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

45830 Based on interview and record review, the facility failed to ensure resident assessments were accurately completed for four (Residents #1, #2, #3, and #4) of 12 residents reviewed for resident assessments. The MDS Case Manager failed to accurately code Section N (Medications) of the MDS assessment for medications received in a seven-day lookback period for Residents #1, #2, #3, and #4. This failure placed residents at risk of inadequate care due to inaccurate MDS assessments. Findings included: A record review of Resident #1's face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of dementia, major depressive disorder (depression), hypertension (high blood pressure), type 2 diabetes, malnutrition, hyperlipidemia (high cholesterol), dysphagia (difficulty swallowing), and hypothyroidism (underactive thyroid). A record review of Resident #1's care plan last revised on 6/07/2022 reflected she had a potential for uncontrolled pain related to disease process, muscle spasms, and chronic pain. Resident #1's intervention for pain reflected she was to receive analgesia (pain medication) as per orders. A record review of Resident #1's physician orders reflected an active order dated 3/18/2022 for Morphine concentrate (opioid medication) 5 mg/0.5 mL to be given by mouth every one hour as needed for pain. A record review of Resident #1's MAR dated March 2022 reflected she received Morphine concentrate 5 mg/0.5 mL on 3/22/2022. A record review of Section N (Medications) of Resident #1's MDS assessment dated [DATE] reflected she received opioid medication zero days during the seven-day lookback period from 3/17/2022-3/23/2022 . A review of Section C (Cognitive Patterns) of Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 8. A record review of Resident #2's face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Crohn's disease (chronic inflammation of digestive tract), malnutrition, major depressive disorder (depression), hypertension (high blood pressure), altered mental status (abnormal state of alertness or awareness), anxiety, anemia, hypothyroidism (underactive thyroid), hyperlipidemia (high cholesterol), atrial fibrillation (irregular heartbeat), arthritis (swelling and tenderness of joints), and dysphagia (difficulty swallowing). A record review of Resident #2's care plan last revised on 5/25/2022 reflected she was on pain medication therapy related to chronic pain syndrome, arthritis, kyphosis (hunchback), and intervertebral disc disorder with myelopathy lumbar region (nervous system disorder of the spine). Resident #2's intervention for pain reflected she was to be administered medication as ordered. A record review of Resident #2's physician orders reflected an active order dated 9/07/2021 for Norco tablet (opioid medication) 5-325 mg to be given by mouth two times a day for pain. A record review of Resident #2's MAR dated April 2022 reflected she received Norco tablet 5-325 mg twice a day from 4/07/2022-4/13/2022. A record review of Section N (Medications) of Resident #2's MDS assessment dated [DATE] reflected she received opioid medication zero days during the seven-day lookback period from 4/07/2022-4/13/2022 . A review of Section C (Cognitive Patterns) of Resident #2's MDS assessment dated [DATE] did not reflect a BIMS score. A record review of Resident #3's face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of type 2 diabetes, major depressive disorder (depression), chronic obstructive pulmonary disease (inflammatory lung disease), malnutrition, cirrhosis of liver (liver disease), chronic kidney disease, hyperlipidemia (high cholesterol), gastroesophageal reflux disease (acid reflux), osteoporosis (weak bones), and chronic pain syndrome. A record review of Resident #3's care plan last revised on 2/09/2022 reflected she had a potential for uncontrolled pain. Resident #2's intervention for pain reflected she was to be administered medications as per orders. A record review of Resident #3's physician orders reflected an active order dated 3/08/2022 for Acetaminophen-Codeine (opioid medication) tablet 300-30 mg to be given by mouth once a day for pain. A record review of Resident #3's MAR dated April 2022 reflected she received Acetaminophen-Codeine tablet 300-30 mg once a day from 4/10/2022-4/16/2022. A record review of Section N (Medications) of Resident #3's MDS assessment dated [DATE] reflected she received opioid medication zero days during the seven-day lookback period from 4/10/2022-4/16/2022 . A review of Section C (Cognitive Patterns) of Resident #3's MDS assessment dated [DATE] reflected a BIMS score of 12. A record review of Resident #4's face sheet reflected an [AGE] year-old female admitted on [DATE] with diagnoses of heart disease, chronic obstructive pulmonary disease (inflammatory lung disease), type 2 diabetes, dysphagia (difficulty swallowing), chronic kidney disease, major depressive disorder (depression), hypertension (high blood pressure), dilated cardiomyopathy (enlarged and weakened heart), malnutrition, hypothyroidism (underactive thyroid), hyperlipidemia (high cholesterol), urticaria (skin rash) and pruritus (skin irritation). A record review of Resident #4's care plan last revised on 5/20/2022 reflected she had potential/actual impairment to skin integrity related to allergies and fragile skin. Resident #4's intervention for skin impairment reflected she was to avoid scratching. A record review of Resident #4's physician orders reflected an active order dated 7/14/2021 for Hydroxyzine HCl (antianxiety medication) tablet 25 mg to be given by mouth every four hours as needed for itching. A record review of Resident #4's MAR dated March 2022 reflected she received Hydroxyzine HCl tablet 25 mg on 3/27/2022. A record review of Section N (Medications) of Resident #4's MDS assessment dated [DATE] reflected she received antianxiety medication zero days during the seven-day lookback period from 3/24/2022-3/30/2022 . A review of Section C (Cognitive Patterns) of Resident #4's MDS assessment dated [DATE] reflected a BIMS score of 8. During an interview on 6/07/2022 at 11:56 a.m., the MDS Case Manager stated she was responsible for completing the residents' MDS assessments. When asked what the process for completing assessments was, the MDS Case Manager stated she would go through the MAR, see which medications the resident had taken in the last seven days, and input that information in their MDS assessment. The MDS Case Manager stated the lookback period for completing MDS assessments was seven days. When asked what kind of medications she looked for in the MAR, the MDS Case Manager stated antianxiety and opioid medications. The MDS Case Manager stated the MDS Regional Coordinator monitored this process and ensured compliance. The MDS Case Manager stated the MDS Regional Coordinator would come in and check all the MDS Case Manager's MDS assessments. During an interview on 6/07/2022 at 1:20 p.m., the MDS Case Manager stated opioid medications should be coded in the MDS if the resident had taken that medication in the seven-day lookback period. The MDS Case Manager stated the MDS Regional Coordinator would come into the facility about once a month to oversee the process of completing MDS assessments-any issues in MDS assessments would be identified and corrected by the MDS Regional Coordinator. The MDS Case Manager stated when MDS assessments were completed, the DON would sign off on them. The MDS Case Manager stated she followed the RAI Manual for coding medications in MDS assessments . During an interview on 6/07/2022 at 1:45 p.m., the DON stated opioid medications should be documented in MDS assessments. The DON stated that MDS were used for financial reimbursement and if they were not accurately completed, it could affect reimbursement. The DON stated she signed off on all MDS assessments when they were complete. During an interview on 6/07/2022 at 1:58 p.m., the MDS Regional Coordinator stated he was required to visit the facility once a quarter and stated he was last in the facility on 5/03/2022. The MDS Regional Coordinator stated he would go through MDS assessments completed by the MDS Case Manager. The MDS Regional Coordinator stated opioid medications should be marked appropriately but they were not a reimbursable item. During an interview on 6/07/2022 at 2:00 p.m., the Administrator stated the facility did not have a specific policy regarding MDS assessments, but that the facility followed the RAI Manual . During an interview on 6/07/2022 at 2:04 p.m., the MDS Case Manager stated she was not sure whether Hydroxyzine was considered an antianxiety medication. A record review of CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 reflected the following: Steps for Assessment: Review the resident's medical record for documentation that any of these medications were received by the resident during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Coding Instructions: N0410A-H: Code medications according to the pharmacological classification, not how they are being used. N0410B, Antianxiety: Record the number of days an anxiolytic medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). N0410H, Opioid: Record the number of days an opioid medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Coding Tips and Special Populations: Code medications in Item N0410 according to the medication's therapeutic category and/or pharmacological classification, not how it is used. Medications that have more than one therapeutic category and/or pharmacological classification should be coded in all categories/classifications assigned to the medication, regardless of how it is being used. Code a medication even if it was given only once during the look-back period.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 staff (LVN A and MA B) reviewed for the following; 1. LVN A failed to don gloves when administering insulin by injection to Resident #1. 2. MA B failed to sanitize a blood pressure monitor between uses on Residents #1 and #2. 3. LVN A failed to change gloves and perform hand hygiene when moving from a contaminated to a clean body site on Resident #3. These failures affected residents by placing them at risk for spread of infection through cross-contamination of pathogens and illness. Findings included: 1. Review of face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the annual MDS for Resident #1 dated 1/12/2022 reflected a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan for Resident #1 dated 5/13/2021 reflected the following: The resident has Diabetes Mellitus. The resident will have no complications related to diabetes through the next review date. Check all of body for breaks in skin and treat promptly as ordered by doctor. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 2/2/2022 at 8:27 a.m., revealed Resident #1 was laying in his bed. LVN A entered the room and, without donning disposable gloves, lifted his shirt, and administered insulin in his abdomen using an injectable insulin pen. During an interview on 2/2/2022 at 8:49 a.m., LVN A stated she usually does not wear gloves during insulin administration. She stated usually when she dispenses medication, she only performs hand hygiene and does not don gloves, but if she had to touch a pill, she should wear gloves. She stated if she gave eyedrops or something like that, she would have used gloves because it would be an open area the eye. She stated she had not been told that if she touched a resident, she should wear gloves and did not think she had been trained to use gloves when injecting insulin. 2. Observation on 2/2/2022 at 8:20 a.m., revealed MA B passing medications to Resident #1. MA B did not clean the wrist cuff blood pressure monitor between Resident #2 and Resident #2. During an interview on 2/2/2022 at 8:30 a.m., MA B stated that she had been sanitizing the blood pressure cuff by rubbing alcohol-based hand rub on it (. She stated she could not recall being trained on what to do to sanitize the equipment and asked what she should have been doing. She stated she did have the purple-topped wipes in her medication cart but was not aware if they were safe to use on the blood pressure monitor or not. 3. Review of face sheet for Resident #3 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a quarterly MDS for Resident #3 dated 11/30/2021 reflected that she was coded at risk of pressure ulcers and required clinical assessment of her skin conditions. Review of care plan date unknown for Resident #3 reflected the following: The resident has an abrasion to right forearm. The resident's abrasion of the right forearm will be healed by review date. If skin tear occurs, treat per facility protocol and notify MD, family. Inform/instruct staff of causative factors and measures to prevent skin tears. Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 2/2/2022 at 8:45 a.m., revealed Resident #3 seated in her wheelchair in her room. She had a small abrasion on her right arm. LVN A donned gloves, sprayed the skin tear with normal saline, used a piece of gauze to catch the dripping liquid and then cleaned the abrasion. She then applied the [MEDICATION(S)] oil with her gloved fingertips and proceed to open the package of a clean bandage without changing gloves or performing hand hygiene, cut the clean bandage to form applied the bandage to the abrasion. During an interview on 2/2/2022 at 8:49 a.m., LVN A stated she had not been changing gloves between cleaning of the Resident #3's skin tear and the application of the new bandage, but she guessed she should. She stated that if it had been an ulcer then she would have. She stated she had been trained to change her gloves when going from a contaminated to a clean field, but she had not been doing it with this skin tear. During an interview on 2/2/2022 at 11:58 a.m., the DON stated the policy was that any time they provided patient care they should have worn gloves. She stated the staff were all trained on infection control at least every three months and a lot more since COVID started. She stated her expectation and the way the staff were trained is, if they were going to touch the resident or do any direct care , they should have worn gloves. She supposes it's nursing common sense if you're doing care or touching the resident. She stated she would not have expected them to use gloves if they were just walking in the room unless the resident was on isolation, but otherwise they should have. She stated that LVN A should have worn gloves while administering insulin to Resident #1 and when administering insulin to all residents who receive injectable insulin. She stated that injecting insulin into Resident #1 without gloves was not consistent with their policy and procedure. She stated it was especially important to use gloves, as they never knew if the injection site was going to bleed a little bit. She stated she did regular in-servicing for the staff, but she usually did not do routine monitoring and overnight of their compliance until they learned there was an issue like this situation with LVN A. She stated they also did monitoring and skills checks for all staff annual evaluations. She stated that anyone performing direct care should always change gloves and performed hand hygiene when going from a contaminated to a clean body site. She stated they should always take care of the dirty and then once they got all that done, they would not want to put more dirty on the clean. She stated she probably had not been specific on this in between anything you use between. She stated she did not know why LVN A was not using the correct procedure, but she felt LVN A needed more education and oversight. Regarding MA B not sanitizing the wrist blood pressure monitor, she stated the staff should all know to use the alcohol wipes (purple topped canister) to sanitize noncritical healthcare equipment between uses on different residents. She stated that MA B must have forgotten, but she must have also needed more education and reminders. She stated this requirement was in the facility's written policy. She stated these failures could cause transmission of infection among residents. During an interview on 2/2/2022 at 12:17 p.m., the ADM acknowledged the scenarios described above were not consistent with good infection control or with the facility policy and procedure. Review of in-services reflected Infection Control dated 1/7/2022 and included the following topics: 1) Contact precautions/Droplet; 2) Putting on/Taking off PPE; 3) Hand Hygiene; and 4) COVID policy. This in-service also contained the signatures of both LVN A and MA B. Review of facility policy titled Handwashing/Hand Hygiene and dated August 2019 reflected the following: Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care. Single use disposable gloves should be used: before aseptic procedures; when anticipating contact with blood or body fluid; and when in contact with the resident, or the equipment or environment of a resident, who is on contact precautions. Review of facility policy titled Skin Tears- Abrasions and Minor Breaks, Care of and dated 2013 reflected the following: Steps in the procedure 7. Put on clean gloves. Loosen tape and remove soiled dressing. 8. Pull glove over dressing and discard into plastic or biohazard bag. 9. Wash and dry your hands thoroughly. 10. Open dry/clean dressings by pulling corners of the exterior wrapping our touching only the exterior surface. 11. Label tape or dressing the date, time, and initials. Place on clean field. 12. Using clean technique, open other products (i.e. prescribed dressing; dry, clean gauze). 13. Wash and dry your hands thoroughly. 14. Put on clean gloves. Review of facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment and dated October 2018 reflected the following: Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to the current CDC recommendations for disinfection and the OSHA blood-borne pathogen standard. 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: C. Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical resident care items include bedpans, blood pressure cuffs, crutches and computers. Most non-critical reusable items can be decontaminated where they are used as opposed to being transported to a central processing location. Reusable items are cleaned and disinfected or sterilized between residence (e.g., stethoscopes, durable medical equipment). Durable medical equipment (DME) must be cleaned and disinfected before were used by another resident. Reusable resident care equipment will be decontaminated and/or sterilized between residence according to manufacture instructions. 5. Only equipment that is designated by usable should be used by more than one resident. 7. Intermediate and low-level disinfectants for non-critical items include: a period Apple or [MEDICATION(S)] alcohol; be sodium hypochlorite C. Phenolic germicidal detergents; D. [MEDICATION(S)] germicidal detergents; and E. quaternary ammonium germicidal detergents.

Based on observation, interview, and record review, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, for one (Resident # 9) of five residents reviewed for pharmacy services. The facility failed to ensure that Resident # 9's pain medication was labeled as ordered by the resident's physician. The label stated the medication was as needed but the physician ordered the medication to be given around the clock. This failure could affect residents on pain medication by putting them at risk for not receiving the appropriate amount. Findings include: Review of the fact sheet for Resident # 9 reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Minimum Data Sets document ((MDS) dated [DATE] for Resident # 9 reflected a BIMS score of 15 indicating no cognitive deficit. Review of the care plan problem for Resident # 9 labeled, 'Pain related to chronic pai[DIAGNOSES REDACTED]' reflected an approach of 'administer my routine pain medication per MD order'. Review of Resident # 9's Controlled Drug Record/Individual Patient's Narcotic Record reflected '[MEDICATION NAME]-[MEDICATION NAME] 10-325 mg, take 1 tablet by mouth every 6 hours as needed for pain'. Review of Resident # 9's medication blister pack of [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg reflected 36 tablets of with directions stating, 'take 1 tablet by mouth every 6 hours as needed for pain'; a red label beneath Resident # 9's name stated, 'Directions Changed REFER TO CHART'. Review of Resident # 9's Medication Administration Record [REDACTED]. Review of Resident # 9's Physician's Consolidated Orders dated 7/1/2019-7/31/2019; 6/1/2019-6/30/2019; 5/1/2019-5/31/2019; 4/1/2019-4/30/2019; 3/1/2019-3/31/2019; and 2/1/2019-2/28/2019 reflected prescriptions for '[MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) - tablet 10-325 mg oral every 6 hours; 2 AM, 8 AM, 2 PM, 8 PM' In an interview with LVN B on 8/12/19 at 10:45 AM, LVN B stated that no [MEDICATION NAME] scheduled medication blister pack nor Controlled Drug Record existed. LVN B then said Resident # 9's attending physician had changed the dosing of Resident # 9's [MEDICATION NAME] from 'as needed' to every 6 hours. She stated no one had gone back and changed Resident # 9's chart orders to indicate the medication was regularly scheduled instead of as needed, although at least two requests had been made to make this change. In an interview with the DON on 8/13/19 at 3:00 PM, the DON stated that issues regarding incorrect medication labeling would be a Pharmerica issue. Issues of this kind are written on a board in her office, and she would bring them forward daily until they are resolved. The DON said she did not remember this labeling issue but she would look for a fax that addressed the issue with the MD. She said she would have expected this issue to be corrected by now; she said staff nurses would know to follow up on it. In an interview with Pharmacy Representative on 8/19/19 at 10:05 AM, Pharmacy Representative stated the earliest entry Pharmerica had for a [MEDICATION NAME] prescription for Resident # 9 was dated 9/12/2018. At that time, Resident # 9's attending physician had prescribed [MEDICATION NAME]-[MEDICATION NAME] 10/325 mg one to two tablets every 6 hours as needed for pain. On 7/11/19 the prescription was changed to one tablet every six hours as needed for pain. Pharmacy Representative stated none of the triplicate prescriptions for [MEDICATION NAME] indicated that the medication was ever scheduled every six hours rather than every six hours as needed. Review of the facility's '10 Rights to Medication Administration' document reflected 1. Right patient; 2. Right medications; 3. Right dosage; 4. Right route; 5. Right time; 6. Right documentation Review of Medication Administration General Guidelines, Section 7.1 copyright 2007 by Pharmerica reflected under Medication Administration, item #1: Medication are administered in accordance with written orders of the prescriber'.

Based on interviews and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 2 (Residents #16 and #36) of 5 residents reviewed for PASRR: 1. The facility failed to refer Resident #16 for PASRR Level II determination when a [DIAGNOSES REDACTED]. 2. The facility failed to refer Resident #36 for PASRR Level II determination when a [DIAGNOSES REDACTED]. These failures could affect the 2 residents and had the potential to affect the other 15 residents with a documented psychiatric diagnosis, intellectual and/or developmental disability by placing them at risk for not receiving needed services. Findings Included: Resident #16's Annual MDS Assessment, dated 07/26/18, reflected a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His cognitive skills for daily decision making were moderately impaired. He ambulated using a wheelchair and required assistance for all ADLs. Resident #16's PASRR Level I Screening, dated 10/21/16, reflected a negative screening with no indicators of mental illness, intellectual disability, or developmental disability. Resident #16's physician orders, dated 08/01/18, reflected [MEDICATION NAME] 7.5mg for [MEDICAL CONDITION]. Resident #16 signed the facility psychoactive medication therapy consent form for [MEDICATION NAME] on 11/12/17. Resident #16's medication regimen review reflected a gradual dose reduction attempt for [MEDICATION NAME] on 5/11/18. Resident #16's care plan, updated 1/21/17, reflected use of antipsychotic drugs and listed monitoring for behaviors and risk of side effects from antipsychotic drug use in the care plan. Review of Resident #16's PASRR Screenings reflected no PASRR Screening Level II completed to address the mental illness diagnosis. Resident #36's initial MDS Assessment, dated 4/16/18, reflected a [AGE] year old female, admitted to the facility on [DATE]. She had no vision impairment, hearing or speech issues. She had severe cognitive impairment, her ability to recall was not assessed, and there is no behavioral history. Resident #36 required assistance for most ADLs. Her [DIAGNOSES REDACTED]. Resident #36's PASRR Level I Screening, dated 4/9/18, reflected a negative screening. There were no indicators for mental illness, intellectual disorder, or intellectual development disorder. Resident #36's physicians orders, dated 07/31/18, reflected [MEDICAL CONDITION] with delusions due to known physiological condition and major [MEDICAL CONDITION]. Resident #36 is ordered [MEDICATION NAME] for the [MEDICAL CONDITION] and [MEDICATION NAME] for the [MEDICAL CONDITION]. Resident #36's care plan, reviewed 08/9/18, reflected a cognitive impairment, some anxiety and agitation, and documented use of [MEDICAL CONDITION] medications. Also addressed in the care plan is Resident #36's [DIAGNOSES REDACTED]. Review of Resident #36's PASRR Screenings reflected no PASRR Screening Level II completed to address the mental illness diagnoses. In a phone interview on 8/10/18 at 10:30 AM, the MDS Coordinator stated that she started the position in (MONTH) of (YEAR). She also stated most PASRR screenings come with the resident upon admission from the previous facility. When she completes PASRR screenings, she contacts the prior facility, the resident's family and responsible party, and speaks with Hospice or Home Healthcare providers that come with the resident to get medical history on the resident. She has completed screenings but the screenings were negative. If a resident is identified with a new diagnosis, she stated that protocol was to contact the local mental health authority. When asked what she would do if PASRR screenings the facility received from prior facilities were incorrect, she stated that moving forward that was something she would make sure to keep up with. In an interview on 8/10/18 at 10:45 AM with the Administrator, she stated that her knowledge of PASRR screenings was that they were received from the hospital or previous facility and are entered electronically. The facility followed screenings received from the hospitals. It had not been the facility's practice to change the Level 1 Screening if they come from another provider. The Administrator also stated there was not a facility policy on PASRR screenings. Form CMS-672, Resident Census and Conditions of Residents, signed and dated by the Administrator on 08/07/18, reflected 15 residents that have a documented psychiatric [DIAGNOSES REDACTED].

Based on interviews and record review, the facility failed to ensure proper notification when changes in coverage were made to items and services covered by Medicare and/or by the Medicaid State plan by not providing an Advanced Beneficiary Notification to one (Resident #9) of three residents reviewed for skilled nursing facility beneficiary protection notifications. This failure could affect 36 residents currently receiving Medicare or Medicaid by placing them at risk for delayed medical care or services the resident is entitled to, a decreased quality of life, and/or poor quality of care. Findings included: Resident #9's MDS Assessment, dated 12/19/17, reflected a [AGE] year old female admitted to the facility on [DATE]. Resident #9's [DIAGNOSES REDACTED]. Her BIMS score was 12. She began occupational therapy on 12/12/17, physical therapy on 12/14/17, and speech therapy on 12/13/17. Record Review of Resident #9's notice of exclusions from medicare benefits, dated 02/21/18, reflected Resident #9 signed notification that the facility initiated termination of Medicare Part A for skilled nursing services because Resident #9 plateaued and services were no longer needed. Resident #9 elected to not receive services. During an interview with the Administrator on 08/09/18 at 3:00 PM, the Administrator confirmed Resident #9 was still in the facility and discharged from Part A services on 02/24/18 due to progress achieved with occupational and physical therapy. Resident #9 was stable and had reached a point in therapy where she plateaued. It was determined that she no longer needed the services. When asked why resident was given the advance beneficiary notice but not the notice of medicare non coverage, the Administrator stated she was not aware that there was a difference in either form and could not recall seeing a notice of medicare non coverage form in resident files. The Administrator then stated that she would check the file to make sure. During an interview, on 08/10/18 at 10:45 AM, the Administrator stated that the facility did not have a notice of medicare non coverage form signed for Resident #9. Form CMS-672, Resident Census and Conditions of Residents, signed and dated by the Administrator on 08/07/18, reflected there were 54 residents in the facility. Of the 54 residents, five residents had Medicare and 31 residents had Medicaid.

Based on interview and record review, the facility failed to provide basic life support, including CPR, for 1 of 4 residents reviewed for advanced directives (Resident #1). The facility did not initiate CPR for Resident #1 when she was found with no pulse. Resident #1 was a full code. Resident #1 was pronounced dead in the facility on [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility's need to complete training of all staff and monitor the plan of removal. This failure affected one resident who died on [DATE] and could place 25 residents who are documented as requesting full code status at risk of not being provided resuscitation, which could lead to death. Findings include: Review of face sheet reflected Resident #1 was an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan (last revised [DATE]) reflected interventions to address [MEDICAL CONDITION], cognitive impairment, gastro-[MEDICAL CONDITION] reflux disease, [MEDICAL CONDITIONS], hypertension, incontinence, activities of daily living, falls, catheter care, pain, skin integrity, pain and anticoagulation. The most recent Minimum (MDS) data set [DATE] reflected full code status. Review of the Resident #1's medical record (undated) reflected a green full code status sheet at the front of the chart. Review of the 'Go' list (Do CPR) (undated) maintained on the facility crash cart reflected 26 residents, including Resident #1. Review of progress notes dated [DATE] reflected CNA B made rounds and changed Resident #1's bedding at 2:00 a.m. A second progress note dated [DATE] revealed CNA B made rounds and had spoken with Resident #1 about her nails at 3:00 a.m. Resident #1 complained that she was cold so CNA B covered her with a blanket. A progress note dated [DATE] reflected LVN A entered Resident #1's room at 5:15 a.m. to administer [MEDICATION NAME] for [MEDICAL CONDITION] and found Resident #1 cold. The note indicated that LVN A felt for a pulse, called Resident #1's husband and the DON. A late entry note dated [DATE] for 5:16 a.m. reflected the DON spoke over the phone with LVN A, who informed the DON that Resident #1 had passed away and asked the DON to come to the facility to pronounce. At 6:15 a.m., the DON arrived and assessed Resident #1, who was determined to be unresponsive, no pulse, no respirations, pupils fixed, and cold to the touch with general cyanosis and rigor mortis present - pronounced dead at this time. The note also reflect at 6:20 a.m., the DON looked at Resident #1's chart and discovered the full code status. Interview on [DATE] at 1:00 p.m., DON stated LVN A called her on the phone about 5:15 a.m. and informed her that Resident #1 had passed and asked her to come into the facility to pronounce her dead. The DON stated she arrived and assessed Resident #1 and pronounced her dead. When she went to the nurses' station to enter her documentation in the chart, she discovered Resident #1 was a full code. The DON then spoke with LVN A and asked if LVN A had checked Resident #1's code status. LVN A reported she had asked LVN B to check for her and informed her Resident #1 was a full code. The DON asked if CPR had been initiated and LVN A replied no because she didn't have a pulse. A telephone interview on [DATE] at 3 p.m. LVN B stated she was passing morning medications about 5:15 a.m., when LVN A called her over to Resident #1's room to help her check Resident #1's pulse. LVN B went to the room and found Resident #1 cold and clammy, with vomit on her. LVN A asked LVN B if she knew if she was a full code or DNR, so LVN B went to the nurses' station to check status. LVN B returned to Resident #1's room and informed LVN A that Resident #1 was a full code. LVN B stated she recalled that LVN A asked CNA C to help clean up Resident #1 and heard LVN A say she was going to call the DON and Resident #1's husband. LVN B stated she returned to passing morning medications so she was uncertain what happened after this. LVN B stated there was no discussion about starting CPR or calling 911 or EMS. LVN B stated there was no discussion about calling the DON to clarify what to do. When asked why CPR was not started, LVN B stated because Resident #1 did not have a pulse. A telephone interview on [DATE] at 3:30 p.m. CNA C stated LVN A called her to come to Resident #1's room and help her check her pulse. CNA C stated Resident #1 was covered in vomit, even her bed linens were soiled. CNA C stated she was unable to find a pulse. CNA C reported LVN A had called LVN B to check if Resident #1 was a full code or DNR. LVN B returned and informed LVN A that Resident #1 was a full code. CNA C reported seeing LVN A heading to the nurses' station to call the DON and family. CNA C then began to clean up Resident #1. CNA C stated CPR was not started and EMS was not called. A telephone interview on [DATE] 11:20 a.m. LVN A stated at 8:30 p.m. Resident #1 c/o nausea so she gave her prn [MEDICATION NAME]. At 2 a.m., the aides told her that Resident #1 was good and they had just changed her bedding. At 3:00 a.m., CNA C went in to her room to answer the call light for Resident #1's roommate. While there, CNA C spoke with Resident #1 about her nails and covered her up because Resident #1 told her she was cold. At 5:10 a.m., LVN A went into Resident #1's room to give her her [MEDICATION NAME]. She found Resident #1 cold, ghost-like; shook her and called for her; looked at her eyes; but Resident #1 did not respond. LVN A called for LVN B for help and CNA C joined them in Resident #1's room. LVN A asked LVN B if she could check on Resident #1's code status and she informed her that Resident #1 was a full code. LVN A contacted the DON and told the DON that Resident #1 had passed (specifically that she was cold, clammy and not responding to voice/touch) and that she didn't know what to do. The DON told LVN A she was getting dressed and would be at the facility shortly. A telephone interview on [DATE] at 3:00 p.m., the facility doctor stated that an LVN should not be making the determination of death and he would expect the LVN to initiate CPR and activate the emergency response system by calling 911. Interview on [DATE] at 1:15 p.m., the Administrator stated if a resident is listed as a full code, then an LVN should start CPR and have another staff person call 911 and the DON. LVN A should have started CPR and had someone call 911 as soon as Resident #1 was identified as a full code. The Administrator added that an LVN does not have the authority to determine time of death. A Cardiopulmonary Resuscitation policy last revised (MONTH) (YEAR) indicated It is the policy of this facility to provide Cardiopulmonary Resuscitation to those residents who experience [MEDICAL CONDITION] and have made their desire for Cardiopulmonary Resuscitation known. The policy specifies if a resident has no pulse: perform external chest compressions .open the airway and deliver two rescue breaths . Once CPR is started do not discontinue unless qualified help arrives (paramedics) or a physician pronounces the resident dead and gives orders to discontinue CPR. An Abuse/Neglect Prohibition policy last revised (MONTH) (YEAR) indicated it is the policy of this facility to prohibit resident abuse, neglect in any form, misappropriation of resident property and exploitation, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse, neglect, misappropriation, or exploitation caused by another person. Neglect is defined as the failure of the facility, its employees or service providers to provide good s and services necessary to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The administrator was notified on [DATE] at 12:24 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The following Plan of Removal was submitted by the Administrator on [DATE]. The final Plan of Removal was accepted by the Survey Team on [DATE]. The facility's plan was as follows: The DON took statements from the nursing staff regarding the incident and immediately suspended both LVN A and LVN B for not initiating CPR on Resident #1. Statements were also obtained from C.N.A staff who had helped care for Resident #1 through the night. A self-report form was submitted to the state regarding the incident. Police Chief was called and notified of the initiation of investigation of potential neglect. An in-service was begun on [DATE] with all nursing staff by the DON on use of AED abuse and neglect, and advance directives: the ability to determine full code versus do not resuscitate (DNR) order. Met with family of Resident #1 and they are sad about her passing but not angry or upset at the facility regarding her passing. During the course of the investigation, the ADM and DON reviewed all CPR certifications and found that all 16 currently employed licensed nursing staff have current CPR certification. We initiated post training tests to include questioning regarding the determination of competencies of the training on [DATE]. These post training tests are being administered to individual employees by administrator and or DON to test competencies regarding the identification of code status, the process to follow for Full Code verses DNR, measure their level of comfort with the initiation and/or assisting with CPR, and to give them scenarios to ensure competencies have been successfully trained. Both C.N.A staff and licensed LVN/RN staff have been administered the post training. AED competencies were completed by the DON on [DATE] to all nursing staff. The nursing staff that is on leave during this time will be in serviced by either the Administrator or DON on abuse/neglect, use of AED, and advanced directives: the ability to determine full code versus do not resuscitate. The training and post test will be administered individually by either the DON or administrator prior to their next scheduled shift until all nursing employees have completed all competencies satisfactorily. If competencies are not satisfactorily completed, the employees will be monitored 1:1 with staff that has successfully demonstrated competencies until which time the employee can demonstrate competencies regarding the process and use of CPR for the residents in our care. An audit of all resident charts was performed on [DATE] by ADM, DON, and social worker to ensure correct code statuses were accurate and complete. Two lists are maintained on the crash cart. One list indicated all residents that are Full Code and the other all residents that are DNR. That list was audited for accuracy by the DON and ADON, and no discrepancies were found. New nursing employee orientation and training will be done with all new nursing employees to include the system of identification of code status and the process to follow once a situation arises. New nursing employee orientation and annual CPR training will be done with all nursing staff. In addition to our current system of orientation, we will add the post training survey to ensure competence in the areas of Advance directive acknowledgment and process to follow if the different scenarios are presented. Effective immediately, new employee licensed nursing staff will be required to present current CPR certification before being assigned to charge nurse duties. CPR certification will be required to be maintained by all licensed nursing staff during the duration of employment with the facility. DON will maintain CPR certifications with nurse license and will ensure that all licensed staff are current by looking 90 days ahead and requiring the nursing staff to maintain certification and licensure. Effective immediately, when creating a schedule for the following month, the DON and/or designee will ensure that all staff on the upcoming schedule are current with CPR certifications and licensures. On [DATE] at 5:15 p.m. this surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Interviews on [DATE] and [DATE] with 1 RN, 3 LVNs and 3 CNAs regarding the assessment and inservice they received on identification of code status, the process for Full Code versus DNR, and abuse. Each knew to look at either the resident's chart or the crash cart to identify code status. Staff were able to accurately explain the steps to take in the event they find a resident unresponsive - determine unresponsiveness, ask someone to call 911/DON/Physician, open the airway, check for breathing-perform rescue breathing, check for pulse-start chest compressions. Staff understood that CPR is to be continued until paramedics arrive. Staff interviewed stated they had previous experience running a full code and felt comfortable doing it. Review of 15 resident records indicated correct code status. Review of the undated Go list on the crash cart indicated it was updated to include all residents that are full code. Review of 24 personnel files indicated current CPR training. On [DATE] at 5:15 pm the Administrator was informed the IJ was removed. However the facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility requiring additional time to train all staff and monitor their plan of removal. The Administrator indicated on [DATE] there were 26 residents with full code status.

Based on interview and record review, the facility failed to ensure each resident was free from neglect for 1 of 4 residents reviewed for neglect (Resident #1). The facility did not initiate CPR for Resident #1 when she was found with no pulse. Resident #1 was a full code. Resident #1 was pronounced dead in the facility on [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility's need to complete training of all staff and monitor the plan of removal. This failure affected one resident who died on [DATE] and could place 25 residents who are documented as requesting full code status at risk of not being provided resuscitation, which could lead to death. Findings include: Review of face sheet reflected Resident #1 was an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan (last revised [DATE]) reflected interventions to address [MEDICAL CONDITION], cognitive impairment, gastro-[MEDICAL CONDITION] reflux disease, [MEDICAL CONDITIONS], hypertension, incontinence, activities of daily living, falls, catheter care, pain, skin integrity, pain and anticoagulation. The most recent Minimum (MDS) data set [DATE] reflected full code status. Review of the Resident #1's medical record (undated) reflected a green full code status sheet at the front of the chart. Review of the 'Go' list (Do CPR) (undated) maintained on the facility crash cart reflected 26 residents, including Resident #1. Review of progress notes dated [DATE] reflected CNA B made rounds and changed Resident #1's bedding at 2:00 a.m. A second progress note dated [DATE] revealed CNA B made rounds and had spoken with Resident #1 about her nails at 3:00 a.m. Resident #1 complained that she was cold so CNA B covered her with a blanket. A progress note dated [DATE] reflected LVN A entered Resident #1's room at 5:15 a.m. to administer [MEDICATION NAME] for [MEDICAL CONDITION] and found Resident #1 cold. The note indicated that LVN A felt for a pulse, called Resident #1's husband and the DON. A late entry note dated [DATE] for 5:16 a.m. reflected the DON spoke over the phone with LVN A, who informed the DON that Resident #1 had passed away and asked the DON to come to the facility to pronounce. At 6:15 a.m., the DON arrived and assessed Resident #1, who was determined to be unresponsive, no pulse, no respirations, pupils fixed, and cold to the touch with general cyanosis and rigor mortis present - pronounced dead at this time. The note also reflect at 6:20 a.m., the DON looked at Resident #1's chart and discovered the full code status. Interview on [DATE] at 1:00 p.m., DON stated LVN A called her on the phone about 5:15 a.m. and informed her that Resident #1 had passed and asked her to come into the facility to pronounce her dead. The DON stated she arrived and assessed Resident #1 and pronounced her dead. When she went to the nurses' station to enter her documentation in the chart, she discovered Resident #1 was a full code. The DON then spoke with LVN A and asked if LVN A had checked Resident #1's code status. LVN A reported she had asked LVN B to check for her and informed her Resident #1 was a full code. The DON asked if CPR had been initiated and LVN A replied no because she didn't have a pulse. A telephone interview on [DATE] at 3 p.m. LVN B stated she was passing morning medications about 5:15 a.m., when LVN A called her over to Resident #1's room to help her check Resident #1's pulse. LVN B went to the room and found Resident #1 cold and clammy, with vomit on her. LVN A asked LVN B if she knew if she was a full code or DNR, so LVN B went to the nurses' station to check status. LVN B returned to Resident #1's room and informed LVN A that Resident #1 was a full code. LVN B stated she recalled that LVN A asked CNA C to help clean up Resident #1 and heard LVN A say she was going to call the DON and Resident #1's husband. LVN B stated she returned to passing morning medications so she was uncertain what happened after this. LVN B stated there was no discussion about starting CPR or calling 911 or EMS. LVN B stated there was no discussion about calling the DON to clarify what to do. When asked why CPR was not started, LVN B stated because Resident #1 did not have a pulse. A telephone interview on [DATE] at 3:30 p.m. CNA C stated LVN A called her to come to Resident #1's room and help her check her pulse. CNA C stated Resident #1 was covered in vomit, even her bed linens were soiled. CNA C stated she was unable to find a pulse. CNA C reported LVN A had called LVN B to check if Resident #1 was a full code or DNR. LVN B returned and informed LVN A that Resident #1 was a full code. CNA C reported seeing LVN A heading to the nurses' station to call the DON and family. CNA C then began to clean up Resident #1. CNA C stated CPR was not started and EMS was not called. A telephone interview on [DATE] 11:20 a.m. LVN A stated at 8:30 p.m. Resident #1 c/o nausea so she gave her prn [MEDICATION NAME]. At 2 a.m., the aides told her that Resident #1 was good and they had just changed her bedding. At 3:00 a.m., CNA C went in to her room to answer the call light for Resident #1's roommate. While there, CNA C spoke with Resident #1 about her nails and covered her up because Resident #1 told her she was cold. At 5:10 a.m., LVN A went into Resident #1's room to give her her [MEDICATION NAME]. She found Resident #1 cold, ghost-like; shook her and called for her; looked at her eyes; but Resident #1 did not respond. LVN A called for LVN B for help and CNA C joined them in Resident #1's room. LVN A asked LVN B if she could check on Resident #1's code status and she informed her that Resident #1 was a full code. LVN A contacted the DON and told the DON that Resident #1 had passed (specifically that she was cold, clammy and not responding to voice/touch) and that she didn't know what to do. The DON told LVN A she was getting dressed and would be at the facility shortly. A telephone interview on [DATE] at 3:00 p.m., the facility doctor stated that an LVN should not be making the determination of death and he would expect the LVN to initiate CPR and activate the emergency response system by calling 911. Interview on [DATE] at 1:15 p.m., the Administrator stated if a resident is listed as a full code, then an LVN should start CPR and have another staff person call 911 and the DON. LVN A should have started CPR and had someone call 911 as soon as Resident #1 was identified as a full code. The Administrator added that an LVN does not have the authority to determine time of death. A Cardiopulmonary Resuscitation policy last revised (MONTH) (YEAR) indicated It is the policy of this facility to provide Cardiopulmonary Resuscitation to those residents who experience [MEDICAL CONDITION] and have made their desire for Cardiopulmonary Resuscitation known. The policy specifies if a resident has no pulse: perform external chest compressions .open the airway and deliver two rescue breaths . Once CPR is started do not discontinue unless qualified help arrives (paramedics) or a physician pronounces the resident dead and gives orders to discontinue CPR. An Abuse/Neglect Prohibition policy last revised (MONTH) (YEAR) indicated it is the policy of this facility to prohibit resident abuse, neglect in any form, misappropriation of resident property and exploitation, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse, neglect, misappropriation, or exploitation caused by another person. Neglect is defined as the failure of the facility, its employees or service providers to provide good s and services necessary to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The administrator was notified on [DATE] at 12:24 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The following Plan of Removal was submitted by the Administrator on [DATE]. The final Plan of Removal was accepted by the Survey Team on [DATE]. The facility's plan was as follows: The DON took statements from the nursing staff regarding the incident and immediately suspended both LVN A and LVN B for not initiating CPR on Resident #1. Statements were also obtained from C.N.A staff who had helped care for Resident #1 through the night. A self-report form was submitted to the state regarding the incident. Police Chief was called and notified of the initiation of investigation of potential neglect. An in-service was begun on [DATE] with all nursing staff by the DON on use of AED abuse and neglect, and advance directives: the ability to determine full code versus do not resuscitate (DNR) order. Met with family of Resident #1 and they are sad about her passing but not angry or upset at the facility regarding her passing. During the course of the investigation, the ADM and DON reviewed all CPR certifications and found that all 16 currently employed licensed nursing staff have current CPR certification. We initiated post training tests to include questioning regarding the determination of competencies of the training on [DATE]. These post training tests are being administered to individual employees by administrator and or DON to test competencies regarding the identification of code status, the process to follow for Full Code verses DNR, measure their level of comfort with the initiation and/or assisting with CPR, and to give them scenarios to ensure competencies have been successfully trained. Both C.N.A staff and licensed LVN/RN staff have been administered the post training. AED competencies were completed by the DON on [DATE] to all nursing staff. The nursing staff that is on leave during this time will be in serviced by either the Administrator or DON on abuse/neglect, use of AED, and advanced directives: the ability to determine full code versus do not resuscitate. The training and post test will be administered individually by either the DON or administrator prior to their next scheduled shift until all nursing employees have completed all competencies satisfactorily. If competencies are not satisfactorily completed, the employees will be monitored 1:1 with staff that has successfully demonstrated competencies until which time the employee can demonstrate competencies regarding the process and use of CPR for the residents in our care. An audit of all resident charts was performed on [DATE] by ADM, DON, and social worker to ensure correct code statuses were accurate and complete. Two lists are maintained on the crash cart. One list indicated all residents that are Full Code and the other all residents that are DNR. That list was audited for accuracy by the DON and ADON, and no discrepancies were found. New nursing employee orientation and training will be done with all new nursing employees to include the system of identification of code status and the process to follow once a situation arises. New nursing employee orientation and annual CPR training will be done with all nursing staff. In addition to our current system of orientation, we will add the post training survey to ensure competence in the areas of Advance directive acknowledgment and process to follow if the different scenarios are presented. Effective immediately, new employee licensed nursing staff will be required to present current CPR certification before being assigned to charge nurse duties. CPR certification will be required to be maintained by all licensed nursing staff during the duration of employment with the facility. DON will maintain CPR certifications with nurse license and will ensure that all licensed staff are current by looking 90 days ahead and requiring the nursing staff to maintain certification and licensure. Effective immediately, when creating a schedule for the following month, the DON and/or designee will ensure that all staff on the upcoming schedule are current with CPR certifications and licensures. On [DATE] at 5:15 p.m. this surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Interviews on [DATE] and [DATE] with 1 RN, 3 LVNs and 3 CNAs regarding the assessment and inservice they received on identification of code status, the process for Full Code versus DNR, and abuse. Each knew to look at either the resident's chart or the crash cart to identify code status. Staff were able to accurately explain the steps to take in the event they find a resident unresponsive - determine unresponsiveness, ask someone to call 911/DON/Physician, open the airway, check for breathing-perform rescue breathing, check for pulse-start chest compressions. Staff understood that CPR is to be continued until paramedics arrive. Staff interviewed stated they had previous experience running a full code and felt comfortable doing it. Review of 15 resident records indicated correct code status. Review of the undatedGo list on the crash cart indicated it was updated to include all residents that are full code. Review of 24 personnel files indicated current CPR training. On [DATE] at 5:15 pm the Administrator was informed the IJ was removed. However the facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility requiring additional time to train all staff and monitor their plan of removal. The Administrator indicated on [DATE] there were 26 residents with full code status.

Based on observation, interview and record review, the facility failed to incorporate the recommendations from the PASRR Level II determination for 1 of 2 residents (Resident #2) reviewed for PASRR (Pre-Admission Screening and Resident Review). The facility failed to provide and arrange for specialized durable medical equipment (DME) for Resident #2. Resident #2 did not have a customized manual wheelchair (CMWC) as discussed in the Service Planning Team (SPT) meeting on 10/05/17. This failure has the potential to affect the quality of life of the 3 residents identified as a Level II or PE PASRR by contributing to their not receiving specialized DME in the most appropriate setting. Findings include: Record review of Resident #2's undated Face Sheet, reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #2's Annual MDS dated [DATE], revealed she had a PASRR Level II [DIAGNOSES REDACTED].#2 was unable to complete the BIMS (Brief Interview for Mental Status) and is sometimes understood. Resident #2 required extensive assistance with one-person physical assist for transfers. For mobility, the MDS indicated she used a wheelchair. Record review of Resident #2's Care Plan Meeting dated 01/16/17, revealed Resident #2 was receiving PASRR services due to a PASRR positive diagnosis. Observation on 01/25/18 at 11:00 a.m., revealed Resident #2 sitting in her current standard wheelchair in her room. Resident #2 was unable to answer questions, but was smiling. In an interview on 01/24/18 at 10:40 a.m., the Complainant stated an IDT meeting was held on 10/05/17 and the facility was given 20 business days to submit the NFSS (Nursing Facility Specialized Services) form through the Long Term Care portal. The Complainant stated the facility was given an additional 6 days until 12/13/17, but to this date have not submitted the completed form. In an interview on 01/25/18 at 2:00 p.m., the MDS A stated the Therapy Department did everything they were supposed to do. She stated they were having trouble getting a DME company to come out to take measurements for a new custom wheelchair for Resident #2. The MDS A stated they finally found a DME company who came out in (MONTH) (YEAR) and assessed Resident #2, and took measurements for a CMWC. In an interview on 01/25/18 at 2:15 p.m., the Certified Occupational Therapist Assistant (COTA) stated they could not locate a DME company that would come out to the facility to measure Resident #2 for a CMWC, due to the rural location. The COTA stated they called many companies and attempted to contact any DME company that would come out to the facility. She stated they spoke with several companies and finally a representative from (Company Name) Medical Supplies came out to the facility and took measurements for Resident #2 in (MONTH) (YEAR). The COTA stated as of July, she has not heard back from the company and has not been able to get the proposal. The COTA has attempted to call the company on 09/07/17, 09/14/17, 09/28/17, 10/04/17, and 11/27/17; but no one has answered or returned her call. The COTA stated Resident #2 has been receiving Habilitation services through the Therapy Department in order to improve her daily function. She stated they are new to this and are trying the best they can. She stated if she had known how to submit the NFSS form properly, she would have waited for the DME company to get back to her with the proposal first. She stated you have to have all three completed before sending in the information to the Simple system: the NFSS, the DME and the physician's signature. The COTA stated she has learned the hard way and will never again submit a form, until she has all her ducks in a row, meaning everything completed. She stated Resident #2 currently uses a wheelchair, but needs a more individualized wheelchair. The COTA stated she is not sure what will happen if they can't get in contact with the DME company because they do not have a backup company. Record review of Social Service Notes dated 01/16/17, reflected PASRR and therapy were going to collaborate for more long term therapy and a new wheelchair. Record review of the PASRR Specialized Services (PSS) form dated 01/17/17, reflected the following: Specialized services provided by the nursing facility to be monitored by the service coordinator (LIDDA): to receive a wheelchair better suited to Resident #2's needs. Record review of Resident #2's Occupation Therapy Progress Report dated 07/29/17 through 09/26/17, reflected the following: As of 07/29/17, wheelchair (WC) has been measured and consultant has put the order in for review. Record review of Resident #2's Occupation Therapy Progress Report dated 09/2717 through 10/06/17 and 10/07/17 through 10/16/17, reflected the following: As of 09/27/17, wheelchair (WC) has been measured and consultant has put the order in for review. Still being processed by WC company. Record review of physician's orders [REDACTED]. Record review of physician's orders [REDACTED]. Record review of the PASRR Specialized Services (PSS) form dated 01/17/17, reflected in the SPT meeting, they had selected a CMWC on the List of Nursing Facility Specialized Services. The MDS B, the LIDDA and a family member (the legally authorized representative) were in attendance. Record review of the Individual Service Plan/Transition Plan - NF dated 01/04/18, reflected the following: Resident #2's Profile: Adaptive Aids and Medical Supplies: I need a wheelchair that can allow me to propel myself with my feet. I need an attachement on my wheelchair that will help me hold my head up. I need support for my head. Record review of the Individual Service Plan/Transition Plan - NF dated 01/04/18 reflected the following: 10/05/17: Her wheelchair is in the financial stages (PASRR application). She needs a standing frame with a vibrating board for sensory input. Record review of the Individual Service Plan/Transition Plan - NF dated 01/04/18, reflected the following: 01/04/18: It was reported by the DON that Resident #2 is doing pretty good. She is using that head band (supportive head strap) but she can take it off when it gets to hurting her. So, because of the pressure and force of her neck she gets tired of it before she gets through eating. We (therapy department) put sheep skin on it (head band/strap) and that seems to help but it does (not) fix the problem. We just need to get that wheelchair for her. It's hard for her to eat drink when her head is bent so far down. According to the Director of Nurses, there are 3 residents in the facility that are PASRR positive, including Resident #2.

Based on observation, interview, and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice, for 1 of 9 residents (Resident #1) reviewed for resident rights. The facility did not allow Resident #1's family to enable the audio feature on the electronic monitoring device. This failure could place 1 resident, dependent on an electric monitoring device, at risk for their preferences not being met. Findings included: Review of Resident #1's face sheet reflected a [AGE] year old female admitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE], reflected: a Brief Interview for Mental Status interview was not conducted because Resident #1 is rarely/never understood. Resident #1 has short and long memory problems and has severely impaired decision-making skills. Resident #1 also has inattention and disorganized thinking. Review of Resident #1's Care Plan dated 10/12/17, reflected the following: Resident has cognitive impairment as evidenced by memory problems; impaired ability to understand others; impaired ability to make daily decisions; is total assist for ADLs; is incontinent of bowel and bladder; has delusions and behavioral problems. Observation on 01/25/18 at 4:55 a.m., revealed Resident #1 in bed, asleep. Bed was in low position, call light was attached to right partial handrail. One mattress was placed on each side of her bed. No foul odors were detected. Resident #1 was covered with blankets. A camera was noted to be on top of the resident's dresser. Resident #1 is in a room by herself, in the bed position furthest from the door. Observation on 01/25/18 at 6:00 a.m., revealed a sign posted outside Resident #1's door stating, Audio and video surveillance on duty at all times. In a telephone interview on 01/25/18 at 9:01 a.m., Resident #1's family member stated she was told they were allowed to have a camera in her grandmother's room, but they could not have the sound on. She stated she was told by the facility it was a violation of HIPAA to have the sound on; but she feels she should be able to hear what is going on with her grandmother, because her grandmother has told her staff laughs at things she says. She stated Resident #1 is in a room by herself. In an interview on 01/25/18 at 8:30 a.m., the Administrator stated having sound on the resident's camera is a HIPAA violation, according to Corporate. She stated if there are people standing in the hallway outside of the resident's room, what they talk about can be heard on the camera. Record review of Request of Authorized Electronic Monitoring form dated 10/13/17, reflected the following: Form was signed by the legal authorized representative, to allow for authorized electronic monitoring. Resident no longer resides in a multi-person room. Record review of a note written by the Administrator dated 10/13/17, stated the following: Resident #1's family purchased camera to be used to monitor Resident #1. Spoke with the Compliance Officer and she indicated that it's our company practice to not allow for audio to be enabled on cameras used in our facilities to ensure there is no breach of our HIPAA (Health Insurance Portability and Accountability Act) compliance for her or any other resident that resides here. Family looked into returning camera and getting new one. but our maintenance director did find a way to just disable the audio and family was very agreeable to this solution. The camera audio was disabled and tested to the family's satisfaction. A policy for electronic monitoring devices with regard to HIPAA was requested, but none was furnished. According to the Director of Nurses, one resident (Resident #1) has Authorized Electronic Monitoring enabled in the facility.

Based on interview and record review, the facility failed to train all employees in emergency procedures to meet all potential emergencies and disasters for 2 of 4 employees interviewed for disaster preparedness (CNA A and NA B). This deficient practice could place the 47 residents at risk for an unsafe, slow, and inefficient evacuation from the facility, in the event of an emergency. Findings include: During an interview on 7/25/2017 at 10:40 a.m., CNA A was asked, What is the order of evacuation? CNA A stated that the order was bedbound resident, residents in wheelchairs, and then the ambulatory would be able to guide themselves out of the building. During an interview on 7/25/2017 at 11:27a.m., NA B was asked What is the order of evacuation? NA B stated that during an evacuation she would transfer the residents who are bedbound into wheelchairs and then evacuate them because the resident who are ambulatory can exit the building on their own. Interview on 7/25/2017 at 3:40 p.m. DON stated that all staff have been in-serviced that the order of evacuation is ambulatory, wheelchair, and bedbound residents. Review of In-service Training report dated 7/21/2017 reflected that staff were in-services on disaster planning. Review of Emergency preparedness plan, revision date of February 2016, reflected the priority of evacuation shall be in the following order: 1. Ambulatory, 2. Wheelchair Residents, and 3. Bed-ridden residents. Review of the facility's CMS form 672 dated 7/24/2017 reflected a census of 47.

Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 1 residents (Resident #1) observed during a hoyer lift; 1 of 1 resident (Resident #6) observed for incontinent care, observation of 1 of 1 laundry rooms; 1 of 1 residents (Resident #6) observed for oxygen; 1 of 5 staff reviewed for [DIAGNOSES REDACTED] Screening. A. CNA A failed to perform hand hygiene after use of the Hoyer lift. B. CNA A failed to use the proper cleansing technique while performing Resident #6's incontinent care. C. There was no Personal Protective Equipment available in the laundry room. D. CNA B placed oxygen tubing lying on the floor onto Resident #6's face. E. Personnel Records revealed that CNA D did not have [DIAGNOSES REDACTED] skin test results available. This deficient practice could place 4 residents who are transferred by hoyer lift; 31 residents who are incontinent of bladder and 22 residents who are incontinent of bowel; 47 residents who reside in the facility and linens are cleaned by laundry room; 3 residents who require the use of oxygen; and 47 residents who reside in the facility at risk for at risk for transmission of microorganisms, cross contamination of bacteria and the spread of infection which could potentially result in deterioration in condition and the need for additional treatment and/or medication. Findings include: A. Review of Resident #1's face sheet reflected that resident is a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's care plan, problem onset date of 1/18/2017, reflected that Resident #1 is at risk for pressure ulcers and requires two persons to assist with repositioning to avoid skin friction/shearing and needs a mechanical lift for transfers. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected that Resident #1 is total dependent two person physical assist with transfers. Observation on 7/25/2017 at 10:05 am - 10:20 a.m. revealed hoyer transfer for Resident #1 performed by CNA A and CNA C. Observation revealed: - 10:05 a.m. CNA A and CNA C entered Resident #1's room and did not wash/sanitize hands prior to placing gloves on and pulling sheets off of Resident #1. - 10:10 a.m. CNA C stated that she needed to stop and needed to wash her hands. CNA A and CNA C ensured that resident was safe and proceeded to wash hands and re-glove and complete hoyer transfer with Resident #1. - 10:20 a.m. CNA A ungloved her hands, did not wash/sanitize hands, and propelled Resident #1 in her wheelchair to the facility's dining room and did not return to Resident #1's room. Interview on 7/25/2017 at 10:25 a.m. CNA C stated that they are trained to wash hands prior and after any type of treatment. Interview on 7/25/2017 at 10:33 a.m. CNA A stated that she should have washed her hands prior to leaving Resident #1's room. CNA A stated that she realized that she did not wash her hands when she was already out of the room. CNA A stated that they are trained to wash hands prior and after treatment. Interview on 7/25/2017 at 3:30 p.m. DON stated that it is her expectations that staff wash their hand prior and after treatment. Review of facility Hand washing policy, dated September 2015, reflected that it is the policy of this home that hand hygiene is the primary means to prevent the spread of infection. Policy reflected that employees must wash their hands for at least twenty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and adter direct resident contact (for which hand hygiene is indicated by acceptable professional practice) Review of Facility Infection Control Prevention and Control Program, dated September 2015, reflected the program will implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross- contamination. Per facility report there are 4 residents who require a Hoyer lift for transfers. B. Review of Resident #6's face sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Care Plan initiated 03/31/17 and updated 06/30/17 reflected: I require assistance with all ADLs; I am always incontinent of bowel; and I am always incontinent of urine. Review of Resident #6's Minimum Data Set ((MDS) dated [DATE] reflected: B0800: 1. Usually understands - misses some part/intent of message but comprehends most conversation; C0500: Brief Interview for Mental Status score - 11; G 2: Toilet use - Support provided: 2 + persons physical assist; H0300: Urinary continence: 3. Always incontinent; H0400: Bowel continence: 3. Always incontinent; O0100C2: Treatment: oxygen therapy - while resident. Observation on 07/26/17 at 3:15 pm revealed CNA A and CNA B performing incontinent care for Resident #6. During incontinent care, CNA A cleaned the shaft of the penis from the base upwards to the top of the urethral opening, using a clean wipe. An interview on 07/26/2017 at 3:30 p.m. occurred with CNA A regarding the observed care that was provided. When asked how the shaft of the penis should be cleaned, CNA A stated, Top to bottom, I went in the wrong direction. I should've gone top to bottom instead of bottom to the tip of the penis. On 07/26/17 at 3:30 p.m. the DON stated when cleaning the penis, the CNA is to start from the tip of the penis in a circular motion down to the base of the penis, so as not to introduce bacteria into the urethral opening. Record review of the facility's policy titled, Perineal Care, dated 2/2016 reflected Procedure: 8. For a male resident: 2. Wash the perineal area starting with urethra and working outward; 2. Wash and rinse urethral area using a circular motion; 3. Continue to wash the perineal area including the penis, scrotum and inner thighs. Per facility report there are 31 residents incontinent of bladder and 22 residents incontinent of bowel. C. Interview on 7/25/2017 at 9:00 a.m. Laundry Aide A could not identify what Personal Protective Equipment (PPE) she would need to use if a resident was on isolation precautions. Observation on 7/25/2017 at 9:00 a.m. in the laundry room did not reveal PPE in the laundry room. Interview on 7/25/2017 at 3:30 p.m. DON stated that laundry personnel have been in-serviced on isolation precautions and PPE. DON stated that there are no residents at this time that are on isolation precautions; however, they have had a resident in the past that was. DON stated that there should be PPE in the laundry room at all times just in case the staff need to use it. Observation on 7/25/2017 at 3:40 p.m. with DON present revealed that there was not PPE present in the laundry room. Review of Facility Infection Control Prevention and Control Program, dated September 2015, reflected the program will properly store, handle, process, and transport linens to minimize contamination. Per CMS 672 dated 7/24/2017 reflected a census of 47. D. Review of Resident #6's face sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Care Plan initiated 03/31/17 and updated 06/30/17 reflected: I require assistance with all ADLs; I am always incontinent of bowel; and I am always incontinent of urine. Review of Resident #6's Minimum Data Set ((MDS) dated [DATE] reflected: B0800: 1. Usually understands - misses some part/intent of message but comprehends most conversation; C0500: Brief Interview for Mental Status score - 11; G 2: Toilet use - Support provided: 2 + persons physical assist; H0300: Urinary continence: 3. Always incontinent; H0400: Bowel continence: 3. Always incontinent; O0100C2: Treatment: oxygen therapy - while resident. Observation on 07/26/2017 at 3:15 p.m. revealed CNA A and CNA B performing incontinent care for Resident #6. When they had finished, CNA B picked up the oxygen tubing lying on the floor to the right of Resident #6's bed and placed the soiled tubing on his face. In an interview on 07/26/17 at 3:35 p.m., CNA B stated she shouldn't have placed the tubing that was on the floor back on the resident. CNA B stated she should've call for a nurse to replace the tubing. In an interview on 07/26/17 at 3:30 p.m., the DON stated staff should never place soiled tubing from the ground onto a resident; staff needs to replace it, if it falls onto the floor. Record review of the facility's policy titled, Infection Control Prevention & Control Program, dated 09/2015 and revised 02/2016 reflected, 2. Prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions. Per facility report there are 3 residents receiving oxygen therapy. E. Records Review on 7/25/2017 at 3:00 p.m. of Personnel Records revealed that employee CNA D did not have TB skin test results available. CNA D has a hire date of 5/31/2017. Record Review on 7/26/2017 at 8:45 a.m. of Employee Immunization Records revealed that CNA D does not have records confirming that she took a TB skin test. Interview with facility ADON on 7/26/2017 at 11:15 a.m. confirmed that CNA D did not have medical records or facility records of TB skin test results or that the employee took the test. ADON stated that the employee must be hired on as Pro re nata (PRN). ADON printed a Facility Employee List/Employee Roster and the certified nurse assistant (CNA) schedule for the month of June. ADON stated that CNA D may have worked in the kitchen. Record of Review of Employee List/Employee Roster on 7/26/2017 at 11:17 a.m. revealed that CNA D is still on the facility payroll. Record review of CNA schedule for the month of June 2017 revealed that CNA D was not on the schedule. Interview with the Administrator on 7/26/2017 at 11:25 a.m. revealed that it is the responsibility of the ADON or in the absence of ADON the DON is responsible for making sure new employees get a TB skin test and to get the results of the test. Record Review of the Facility Infection Control - [DIAGNOSES REDACTED] (TB) Testing of Employees Policy on 7/26/2017 at 1:15 p.m. revealed that the policy states: It is the policy of the facility that all employees will be tested for [DIAGNOSES REDACTED] (TB) upon hire, prior to providing services in the facility, and at least annually thereafter, according to CDC guidelines. Interview with the Dietary Director on 7/26/2017 at 2:15 p.m. revealed that CNA D is her daughter in-law and that she did train in the kitchen for one day but that she recently moved to San(NAME)with her husband. The Dietary Director stated that CNA D was hired on as PRN and only works weekends. The Dietary Director stated that CNA D worked as a trainee on June 7th 2017 on the floor and again in the kitchen as a trainee on June 17th 2017. Per CMS 672 dated 7/24/2017 reflected a census of 47.

Based on observations, record, reviews, and interviews the facility failed to: - Ensure all medications were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 resident (Resident #6) observed during medication pass - The facility failed to provide a separately locked, permanently affixed compartment for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse. A. Resident #6's Lamictal (Lamotrigine) blister package for 200 mg 2 times a day was changed to 150 mg 2 times a day by the pharmacy. There was no change of dosage sticker and the medication was not properly reconciled by nursing staff. B. The facility failed to provide secure storage of discontinued /unused Schedule III and IV controlled drugs prior to the facility drug destruction This failure could affect 7 residents on anti-seizure medications at risk for medications not being properly administered and 21 residents on controlled medications The findings were: A. Review of Resident #6's face sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Care Plan initiated 03/31/17 and updated 06/30/17 reflected: I am at risk for seizures: Give me my seizure meds as ordered. Review of Resident #6's Minimum Data Set ((MDS) dated [DATE] reflected: B0800: 1. Usually understands - misses some part/intent of message but comprehends most conversation; C0500: Brief Interview for Mental Status score - 11; I5400: Seizure disorder or epilepsy - checked. Review of the Consolidated Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. The medications were initialed by LVN B at 9:00 a.m. Observation on 07/24/17 at 10:45 a.m. during the medication pass with LVN B revealed the Lamotrigine (Lamictal) 150 mg - 1.5 tablets was administered to Resident #22 via [DEVICE]. Observation during the medication pass on 07/24/17 at 10:45 a.m. revealed that Resident #6's Lamotrigine (Lamictal) blister package label was for administration of 150 mg tablets - take 2 tablets per tube ([DEVICE]) 2 times per day, which was crossed out. During an interview on 07/24/7 at 11:30 a.m., LVN B stated The dosage is wrong, this should be 200 mg instead of 150 mg. I will get this fixed. LVN B confirmed the Lamotrigine (Lamictal) did not have a change of dosage sticker from the pharmacy. LVN B stated she did not reconcile the medication when it was received from the pharmacy, because she did not have time. During an interview on 07/25/17 at 2:00 p.m., the DON stated, This medication error was a one-time thing. After this surveyor turned over the blister package to show the DON there were approximately 5 blister spaces covered with tape, the DON stated, Oh, I didn't see that. The DON acknowledged the wrong dosage was given more than once and she confirmed the half tablets must have been stored inside the taped spaces, to be used later. Review of the facility's policy titled, Medication Ordering and Receiving From Pharmacy Provider - Medications and Medication Labels dated 05/16 revealed: 3. Improperly or inaccurately labeled medications are refused and returned to the dispensing pharmacy; 6.a. If the prescriber's directions for use change or the label is inaccurate, the nurse may place a direction change, change of order-check chart or similar label on the container indicating there is a change in directions for use, taking care not to cover important label information; and 6.b. When such a direction change label appears on the container, the medication nurse checks the resident's Medication Administration Record [REDACTED]. B. Observation on 07/26/17 at 10:00 a.m. revealed the file cabinet reserved for drug destruction/storage in the DON's office with no medications in the cabinet. There was observed a 2 drawer file cabinet locked, inside the larger tall file cabinet. It was noted neither the small nor the large file cabinet was secured to the wall. In an interview on 07/26/17 at 10:00 a.m., the DON stated she did not know the medication cabinets for storage/drug destruction had to be secured to the wall. In an interview on 07/26/17 at 12:49 p.m., the DON stated after this surveyor pointed out the file cabinets that were not attached, Maintenance had permanently affixed the cabinets to the wall; which was confirmed by this surveyor. Review of information provided by the DON revealed 7 residents who receive anti-seizure medication at the facility and 21 residents who receive controlled medications.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of one (1) of one (1) resident (Resident #6) reviewed for pharmacy services. The facility failed to ensure Resident #6's morning medications were administered within the required timeframe on 07/25/17. This deficient practice could affect 24 residents (who resided on the 100 hall and on the even-numbered rooms on the 300 hall), who depend on the facility to follow orders from the physician. Findings included: Review of Resident #6's face sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Care Plan initiated 03/31/17 and updated 06/30/17 reflected: I am at risk for seizures: Give me my seizure meds as ordered; I am always incontinent of bowel: Administer my laxative or stool softener as ordered. Review of Resident #6's Minimum Data Set ((MDS) dated [DATE] reflected: B0800: 1. Usually understands - misses some part/intent of message but comprehends most conversation; C0500: Brief Interview for Mental Status score - 11; I5400: Seizure disorder or epilepsy - checked. Observation on 07/24/17 at 10:45 a.m. revealed LVN B passing 9:00 a.m. medications late to Resident #6. Medications that were given late were: Iron supplement (to treat anemia), Nexium (to treat GERD), Lactulose (to treat constipation), oyster shell calcium (to treat osteoporosis), Levetiracetam (to treat seizures), Lamotrigine (to treat seizures), Methylphenidate (to treat traumatic brain injury), Gabapentin (to treat seizures), and acidophilus (a probiotic). During an interview on 07/24/17 at 11:15 a.m. with Resident #6's family member, she stated his medications were not always late, but sometimes they were. During an interview on 07/25/17 at 11:30 a.m., LVN B stated she knew Resident #6's medications were late, but she could not help it. LVN B stated her meds are often late because she has to assist in the dining room. LVN B stated her shift starts at 7:00 a.m., but she has medications to give out at 7:00 a.m., 8:00 a.m., 9:00 a.m. and at other times throughout the day. LVN B stated she had been asking the nurses on the overnight shift (7:00 p.m. to 7:00 a.m.) to give residents their 7:00 a.m. medications she is assigned to, because this is the only way she can manage to get the 7:00 a.m. medications passed out on time. LVN B stated she has 5 residents to give medications to at 7:00 a.m., and 13 residents to give medications to at 8:00 a.m. LVN B stated she has to go to the dining room at 7:30 a.m., and returns at 8:30 a.m. after the residents have finished eating. She stated the nurses are mostly in the dining room for one hour during any given meal, which causes them to become backed up with charting. LVN B stated this added duty means she has about 30 minutes to give 13 residents their 8:00 a.m. medications before they are late. LVN B stated it was easier before the facility switched from 8 hour shifts to 12 hour shifts. LVN B stated with 8 hour shifts, she was able to get her medications passed on time. During an interview on 07/25/17 at 2:00 p.m., regarding late medication pass for Resident #6, the DON stated the nurses just moved to 12 hour shifts and they are expected not to pass late medications but they are adjusting. Regarding nursing staff working duty in the kitchen causing medications to be given late, the DON stated she knew there would come a time when they would gave to address this issue. The DON stated the facility has had a growth spurt and she is well aware she needs to address the growth they've had. The DON stated she needs to look into adding more staff to relieve the nurses, so mistakes don't occur. Review of the Consolidated Physician order [REDACTED]. 1. Ferrous Sulfate (Iron) elixir mg/5mg - give 10 ml via peg QD (each day) at 9AM 2. Nexium 40 mg - 1 tab via peg tube QD at 9AM 3. Lactulose solution 20gm/30ml - give 30 ml via peg QID (four times a day) 4. Calcium 500 mg via peg BID (twice a day) 5. Keppra solution (Levetiracetam) 100mg/ml - give 10 ml via peg BID 6. Lamictal (Lamotrigine) 200mg - give 1.5 tab via peg BID 7. Ritilin (Methylphenidate) 20mg - give 1 tab via peg BID 8. Gabapentin 400mg - give 1 capsule via peg TID (three times per day) 9. Lactobacillus (Acidolphilus) - 500 million units via peg TID Review of the Medication Administration Record [REDACTED]. The medications were initialed by LVN B at 9:00 a.m. Review of the facility's policy titled Medication - Administration and dated September 2015 reflected: 8. Medications are administered within 60 minutes of scheduled time, unless otherwise specified by the physician. Review of the facility's CMS form 802 dated 07/24/17 reflected 24 residents (who resided on the 100 hall and on the even-numbered rooms on the 300 hall) requiring medication from nursing staff.

Based on observation, interview and record review, the facility failed to ensure adequate staffing to provide nursing related services to ensure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 resident (who resided on the 100 hall) of 11 residents (Resident #6) reviewed for nursing services. The facility administered physician ordered iron supplement, [MEDICATION NAME], calcium, Levetiracetam, [MEDICATION NAME], and Acidophilus on 07/24/17 late to Resident #6 because LVN B had to leave during medication pass in order to assist in the dining room for breakfast. This failure could affect the quality of care and quality of life of 24 residents (who resided on the 100 hall and on the even-numbered rooms on the 300 hall) by having too few licensed staff to respond to their needs, and by having LVNs who were stressed from working dining room duty to provide care when needed. Findings include: Review of Resident #6's face sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Care Plan initiated 03/31/17 and updated 06/30/17 reflected: I am at risk for [MEDICAL CONDITION]: Give me my [MEDICAL CONDITION] meds as ordered. Review of Resident #6's Minimum Data Set ((MDS) dated [DATE] reflected: B0800: 1. Usually understands - misses some part/intent of message but comprehends most conversation; C0500: Brief Interview for Mental Status score - 11; I5400: [MEDICAL CONDITION] disorder or [MEDICAL CONDITION] - checked. Observation on 07/24/17 at 7:45 a.m. revealed LVN B in the dining room passing trays in a rushed manner. LVN B noted to be placing trays down in front of multiple residents quickly and rushing to do tray set up. Observation on 07/24/17 at 10:45 a.m. revealed LVN B passing 9:00 a.m. medications late to Resident #6. Medications that were given late were: Iron supplement (to treat [MEDICAL CONDITION]), [MEDICATION NAME] (to treat GERD), [MEDICATION NAME] (to treat constipation), oyster shell calcium (to treat [MEDICAL CONDITION]), Levetiracetam (to treat [MEDICAL CONDITION]), [MEDICATION NAME] (to treat [MEDICAL CONDITION]), [MEDICATION NAME] (to treat [MEDICAL CONDITION]), [MEDICATION NAME] (to treat [MEDICAL CONDITION]), and acidophilus (a [MEDICATION NAME]). Observation on 07/25/17 at 7:40 a.m. revealed LVN B in the dining room passing trays to multiple residents in a rushed manner. LVN B was observed quickly unwrapping juice cups, and setting up residents' trays. Observation on 07/25/17 at 8:45 a.m. revealed LVN B passing 8:00 a.m. medications for 13 residents in a 15 minute span, before 9:00 a.m. LVN B was noted to be hurried. During an interview on 07/25/17 at 8:30 am, LVN C, she stated the nurses have to spend about an hour in the dining room on alternating shifts for meals every day. She stated this was rough on them, but they were required to be there in case of a choking incident with a resident. LVN C stated this added duty causes them to be late giving scheduled medications to the residents about 30% of the time, because this takes a lot of the nurses' time up. LVN C stated with charting and no allowance for overtime, their charting is lacking in quality as well. LVN C stated LVN B assists in the dining room for breakfast, LVN C assists for lunch and they alternate dinner shifts. LVN C gave the example, If you have meds at 1:00 p.m., and meds at 2:00 p.m., and lunch is at 1:00 p.m., you are going to be late with those 1:00 p.m. meds. LVN C stated they used to get help from the MDS nurse, but she is new and doing Assistant Director of Nurses (ADON) duties. During an interview on 07/25/17 at 11:30 a.m., LVN B stated she knew Resident #6's medications were late, but she could not help it. LVN B stated her meds are often late because she has to assist in the dining room. LVN B stated her shift starts at 7:00 a.m., but she has medications to give out at 7:00 a.m., 8:00 a.m., 9:00 a.m. and at other times throughout the day. LVN B stated she had been asking the nurses on the overnight shift (7:00 p.m. to 7:00 a.m.) to give residents their 7:00 a.m. medications she is assigned to, because this is the only way she can manage to get the 7:00 a.m. medications passed out on time. LVN B stated she has 5 residents to give medications to at 7:00 a.m., and 13 residents to give medications to at 8:00 a.m. LVN B stated she has to go to the dining room at 7:30 a.m., and returns at 8:30 a.m. after the residents have finished eating. She stated the nurses are mostly in the dining room for one hour during any given meal, which causes them to become backed up with charting. LVN B stated this added duty means she has about 30 minutes to give 13 residents their 8:00 a.m. medications before they are late. LVN B stated it was easier before the facility switched from 8 hour shifts to 12 hour shifts. LVN B stated with 8 hour shifts, she was able to get her medications passed on time. During an interview on 07/25/17 at 2:00 p.m., regarding late medication pass for Resident #6, the DON stated the nurses just moved to 12 hour shifts and they are expected not to pass late medications but they are adjusting. Regarding nursing staff working duty in the kitchen causing medications to be given late, the DON stated she knew there would come a time when they would gave to address this issue. The DON stated the facility has had a growth spurt and she is well aware she needs to address the growth they've had. The DON stated she needs to look into adding more staff to relieve the nurses, so mistakes don't occur. Record review of the facility job description titled Charge Nurse - LVN' and dated 9/1/15 reflected, Essential Functions - Administers medications as prescribed; Contributes to assurance of resident care consistent with accepted standards of care and established policy and procedure. Record review of the facility policy Medication-Administration and dated September 2015 reflected, 8. Medications are administered within 60 minutes of scheduled time, unless otherwise specified by the physician. Review of the facility's CMS form 802 dated 07/24/17 reflected 24 residents (who resided on the 100 hall and on the even-numbered rooms on the 300 hall).

Based on observation, interview, and record review, the facility failed to develop and implement a care plan based on an accurate comprehensive person-centered care plan for 2 of 11 residents reviewed for comprehensive care plans. (Residents #1 and Resident #6) Resident #1's and #6's care plan did not include specific interventions for dressing. This deficient practice could affect 44 residents who require the assistance of one to two staff for dressing in the facility by them not getting the care and services needed to obtain or maintain the highest physical level possible. Findings include: Review of Resident #1 facesheet reflected that resident is a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 quarterly MDS assessment dated [DATE] reflected that Resident #1 is total dependent one person physical assist for dressing. Review of Resident #1 care plan, problem onset date of 1/18/2017, reflected that Resident #1 requires staff assistance with ADLs (Activity of Daily Living). Approaches did not reflect that resident required assistance with dressing. Review of Resident #6 facesheet reflected that resident is a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6 quarterly MDS assessment dated [DATE] reflected that resident is total dependence two person physical assist. Review of Resident #6 care plan, problem onset date 3/31/2017, reflected that Resident #6 require staff assistance with ADLs. Approaches did not reflect that resident required assistance with dressing. Interview on 7/25/2017 at 1:00 p.m., ADON stated that she just took over the care plans so she was unable to know if there were any inconsistencies in the care plans. Interview on 7/25/2017 at 3:40 p.m., DON stated that ensuring that the care plans are accurate and up to date is the responsibility of the ADON. DON stated that she is unsure why residents dressing ADL is not care planned and all ADLs should be care planned. Review of facility policy titled Care Plan -Resident with a revision date 1/2017 reflected that it is the policy of this facility that staff must develop a comprehensive care plan to meet the needs of the resident. Review of Procedure Concerns and problems reflected sources are, but are not limited to problems relating to diagnosis, activity problems, rehabilitation problems, and all problems identified on all assessments. Approach and Plan reflected to list care to be provided for the problem listed. The care must be necessary and appropriate to accomplish the goal stated. Coordinate care to be provided to the resident for the most effective, efficient, utilization of resources. Communicate vital information to staff providing direct resident care. Review of CMS 672 date 7/24/2017 reflected that 44 residents required 1 to 2 staff assistance with dressing.

Based on observation, interview, and record review, the facility failed to ensure 1 of 11 residents received services in the facility with resonable accomodation of needs. (Resident #1) The facility did not ensure that a call light was in reach of Resident #1 while in her room This failure could place 16 residents who reside on the 100 hall for not receiving assistance in a timely manner and could increase the risk of falls and injury's. Findings include Review of Resident #1 facesheet reflected that resident is a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 quarterly MDS assessment dated [DATE] reflected that Resident #1 is total dependent one person physical assist. Review of Resident #1 care plan, problem onset date of 1/18/2017, reflected that Resident #1 requires staff assistance with ADLs (Activity of Daily Living). Resident #1 exhibits random yelling mostly at night. Resident #1 has impaired vision and to place items directly in front for better viewing. Observation on 7/24/2017 at 10:10 a.m. Resident #1 was sitting up in her wheelchair in the doorway with call light observed to not be in reach of Resident #1. Observation of Resident #1 revealed that room is at the end of the 100 hall away from the nurse's station. Observation on 7/24/2017 at 10:15 a.m. CNA C came into Resident #1 room and propelled her by the bed and handed Resident #1 the call light and explained to use the call light if she needed any assistance. Observation on 7/25/2017 at 8:30 a.m. revealed Resident #1 was in her room and by her t.v. stand. Observation revealed that a call light was not in reach of Resident #1. Observation on 7/25/2017 at 8:35 a.m. revealed RN A walking down the 100 hall. RN A stated that she heard Resident #1 calling out help so she came down to check on the resident. RN A stated that she would need to get some assistance because it appeared that the resident needed to be repositioned in her chair. Interview on 7/25/2017 at 8:45 a.m. RN A stated that she is unsure who placed Resident #1 in her room and did not place the call light with resident but that could be a problem. RN A stated that the resident is able to press the call light and she came down to the room due to resident was calling out for assistance. Interview on 7/25/2017 at 3:30 p.m. DON stated that it is her expectation that the call lights are put in reach of the residents at all times. DON stated that Resident #1 is able to push the call light and able to make her needs known. Review of facility policy dated September 2015 title Call Light reflected that it is the policy of this facility to ensure resident have a call light within reach that they are physically able to access and that they have been instructed on its use. Per facility report on 7/26/2017 there are 16 residents who reside on the 100 hall.