Every finding on record at Scenic Manor

Based on clinical record review, staff, and provider interviews, the facility failed to properly obtain a physician order for a resident admitted to the facility on Coumadin/warfarin (an anticoagulant or blood thinner medication) after discharge from the hospital (Resident #3). Resident #3 admitted to the facility from the hospital following an admission related to acute strokes and atrial fibrillation (AF - rapid heart rate caused by poor blood flow). Resident #3 required the use of Coumadin to help prevent blood clots to prevent future strokes. When he admitted to the facility, the facility failed to ensure he had an order on admission to monitor the therapeutic levels of Coumadin. Resident #3 didn't have the thickness of his blood (INR) checked until 3 weeks after his admission to the facility, when he admitted to the hospital for pneumonia. When the hospital checked his INR, the result reflected a level of 8.85 (therapeutic is 2-3), reflecting an INR level 3-4 times higher than therapeutic. The facility reported a census of 65 residents. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] listed an admitted [DATE]. The MDS included diagnoses of medically complex conditions, nonrheumatic mitral valve insufficiency (causes blood to flow backwards into the heart), nonrheumatic aortic valve stenosis (aortic valve narrowed so blood flow became difficult to get into the heart). The assessment indicated Resident #3 stood 5 foot 6 inches tall and weighed 158 pounds. He used an anticoagulant (blood thinner), anti-platelet (makes the platelets more slippery to prevent sticking) and hypoglycemic (low blood sugar) medications within the lookback period. A Clinical Discharge Summary form dated 5/8/24 indicated Resident #3 arrived at the hospital on 5/1/24 at 12:55 AM with active diagnosis that included AF, Heart Failure (HF), Mitral insufficiency, Aortic Stenosis, an anticoagulation goal of an INR of 2 to 3 and Type 2 Diabetes Mellitus (DM). The History and Physical Final Report dated 5/8/24 listed Resident #3 admitted to the hospital on 5/1/24 and discharged [DATE]. The report indicated Resident #3's hospital stay included a Magnetic Resonance Imaging (MRI) test that diagnosed him with new strokes. The primary care provider (PCP) ordered a neurology referral. The Neurologist directed to start Aspirin (ASA) therapy. Resident #3's hospital admission included diagnoses of an acute CVA (Cerebrovascular Accident/strokes), AF, chronic anticoagulation with warfarin, elevated troponin (lab test to determine the amount of heart muscle damage), aortic stenosis (narrowing of the aortic value opening, which impedes the flow of blood from the heart to the rest of the body) and scattered subtle acute/subacute bilateral cerebral hemisphere lacunar infarcts (small asymptomatic strokes that occurred in both sides of the brain caused by blockages in tiny penetrating arteries). His lab work reflected an INR result on 5/8/24 at 5:38 AM of a 1.8 ratio (high). The provider changed the following medication for Resident #3 on discharge: a. Aspirin 81 milligrams (mg) every day (QD). b. Coumadin 5 mg QD. The Discharge Plan lacked an order or recommendations related to when to check Resident #3's PT/INR (used to measure therapeutic levels of Coumadin. Resident #3's May 2024 Medication Administration Record (MAR) form included the following physician orders: a. Aspirin 81 mg QD in the morning (for Paroxysmal AF) administered 5/9/24 thru 5/28/24. b. Warfarin Sodium 5 mg tablet every evening (for Paroxysmal AF) administered 5/8/24 thru 5/28/24. Review of a Flowsheet Print Request form with dates that ranged from 5/8/24 thru 5/29/24 revealed the following PT/INR values: a. No PT/INR drawn from 5/8/24 thru 5/28/24. b. 5/29/24 - 8.85 (high) c. 5.30. 24 - 5.86 (high) d. 6/1/24 - 2.54 (high) The undated Mayo Clinic Laboratories Critical Values/Critical Results List defined a critical value or critical result as a value/result that represents a pathophysiological state at such variance with normal (expected values) as to be life-threatening unless something is done promptly and for which some corrective action could be taken. The list reflected a critical high result for an INR as greater or equal to 5.0. An emergency room Note verified by a Physician on 5/29/24 at 5:27 PM indicated Resident #3's INR registered markedly elevated at 8.8. The hospital received a Physician order to hold his Coumadin. The Note included diagnoses of over anticoagulation therapy, chronic AF, and right lower lobe pneumonia. During an interview on 10/10/24 at 2:10 PM the hospital's Licensed Practical Nurse (LPN)/Admission and Discharge Nurse indicated the hospital staff held the resident's Coumadin/Warfarin for four (4) days following his readmission on 5/29/24. During an interview on 10/10/24 at 3:00 PM the hospital's Nurse Practitioner (NP) who cared for Resident #3 explained the hospital's standard of practice with an elevated and/or unstable PT/INR levels as to check the lab value QD until stable, then every other day (QOD), and eventually 1 time a week. The NP indicated the PCP had the primary responsibility to provide lab draw orders upon discharge from the hospital. She would expect the staff at the facility to follow up with his PCP as high PT/INR levels could cause hemorrhages and/or blood clots. During an interview on 10/11/24 at 9:32 AM Resident #3's primary NP's nurse confirmed the clinic's standard of practice for a resident admitted to a nursing facility on Coumadin. If a resident came without lab orders, the facility staff should have called the PCP to clarify those orders. During an interview on 10/11/24 at 9:53 AM Resident #3's primary NP indicated she would expect the hospital to order the labs, however, if they missed the lab orders, she expected the facility staff to follow up with the PCP, specifically with the PT/INR lab orders/values. The NP confirmed Resident #3's primary medical doctor (MD) performed rounds at the facility on 5/14/24, however, the facility staff failed to report to the MD Resident #3 didn't have PT/INR orders upon admission. The NP reported a drop from an 8.85 PT/INR to 5.86 INR as realistic. The NP also indicated with a PT/INR of 8.85 the resident wouldn't have exhibited signs of bleeding from his leg abrasion, sputum, and etcetera (etc.).

Based on observations, record review, staff interviews and manufacturer's insert, the facility failed to provide services that met professional standards regarding medication administration for 2 of 8 residents (Resident #30 twice) observed who did not have their insulin flex pen primed prior to administering insulin (to ensure the proper amount of insulin administered). The facility reported a census of 60 residents. Findings include: During an observation on 5/15/24 at 8:28 AM, Staff A, Registered Nurse (RN) administered Novolog 5 units to Resident #22. Staff A gave the shot in the upper right arm. She did not prime the insulin pen prior to administration. During an observation on 5/15/24 at 8:54 AM, Staff B, Licensed Practical Nurse (LPN) administered Novolog 9 units and Tresiba 54 units to Resident #30. Staff B gave both shots in the upper left arm. She did not prime either insulin pens prior to administration. Review of the facility's Insulin Administration policy, revised September 2014, did not have information specific to insulin pen administration. The policy stated the nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. During an interview with the Director of Nursing (DON) on 5/15/24 at 3:25 PM, revealed the expectation for nurses is to follow facility policy, indicating following manufacturer instructions. Review of the manufacturer insert for Novolog FlexPen revised 2/2023 stated small amounts of air may collect in the cartridge during normal use. An airshot must be done before each injection to avoid injecting air and to make sure the prescribed dose of the medicine is received. This is done by priming the insulin pen by injecting 2 units of insulin through the attached needle prior to administering the prescribed dose. Review of the manufacturer insert for Tresiba Flextouch Pen revised 7/2022 stated small amounts of air may collect in the cartridge during normal use. An airshot must be done before each injection to avoid injecting air and to make sure the prescribed dose of the medicine is received. This is done by priming the insulin pen by injecting 2 units of insulin through the attached needle prior to administering the prescribed dose.

Based on clinical record review, family interview, staff interviews and facility document review, the facility failed to notify a resident representative of a change in condition for 1 of 1 resident reviewed (Resident #50). Resident #50 was found to have a large raised area on her lower back on 2/2/24. The facility did not notify Resident #50's resident representative of the area until after the primary care provider (PCP) had seen the area on 2/7/24. The facility reported a census of 60 residents. Findings include: The Minimum Data Set for Resident #50 documented a Brief Interview of Mental Status score of 9 indicating moderately impaired cognition. The Clinical Resident Profile for Resident #50 listed her son as the emergency contact #1. A Timeline for Resident #50 provided by the Director of Nursing (DON) during the survey 5/13/24 to 5/14/24, documented the following: 1/17/24- skin review- no new areas of concern noted by nurse 1/24/24- skin review- no new areas of concern noted by nurse 1/31/24- skin review- no new areas of concern noted by nurse 2/2/24- the PCP notified of being put on rounds for 2/7/24, due to area on the back. No complaints of pain or difficulty. 2/5/24- Tylenol administered for pain, no further complaints and rates pain a zero. 2/7/24-Seen by PCP in house. PCP's note documented other than back pain, has no other complaints. Patient seen at bedside and has what appears to be a left low back mass that looks to be about 10 cm (centimeters) in diameter, protruding and stretching left low back skin. The patient only complained of noticing for couple of days as it's causing discomfort. Staff also does not recall seeing an left low back m ass in the past and she is bathed regularly. Flesh colored, mildly warm, no erythema. PCP wants to send to the ER (emergency room ) for evaluation. 2/7/24- ER notes state psoas (muscle in lower back) muscle mass/abscess extending into abdominal wall and subcutaneous fat. Call clinic in a.m. to make outpatient surgery referral. (Referral indicates no emergency as confirmed by PCP). If symptoms worsen or pain uncontrolled return to ER. 2/8/24 PCP notes he spoke with the son, discharge Hospice Care. discharged from hospice. 2/9/24- surgery scheduled-son (resident representative) took. 2/10/24- notes state likely an obstruction. On 5/13/24 at 1:03 p.m., Resident #50's resident representative stated he had an issue with his mom ending up in the hospital for several days. This representative stated his mother's kidney had erupted, and the urine was going into a pocket causing a lump on her lower back. The resident representative stated that according to the DON it happened over night but when this representative talked to another nurse they said they had been monitoring the area for a couple of weeks. This representative stated the area got to be the size of about 2 soft balls or 1/2 of a basketball. He stated the facility should have let him know when they first seen the area. On 5/15/24 at 11:30 a.m., Staff B, Licensed Practical Nurse (LPN), Stated a Certified Nurse Aide (CNA) was giving this resident a bath on 2/2/24 (Friday) and called Staff B in to look at an area on this resident's back. She stated the skin was intact, there was no redness and it was soft with palpation. The resident had no complaints of pain. The skin was tight around the lump. When asked how large the area was she did not remember. When shown that the provider documented on 2/7/24 (Wednesday) that the area was 10 cm (centimeters). She stated that it was probably that size when she saw it. This LPN stated she didn't feel the area needed to be seen right away or that it was emergent, but she did feel like it needed to be seen by a provider because it was abnormal. When asked if she documented her assessment, she did not remember. She stated she went to the Medical Records person who organizes the doctor's rounds schedules and asked her to put this resident on the schedule for the following week. She stated that she did ask for a different provider to see her on Tuesday but her PCP was scheduled to come on Wednesday, so he went ahead and saw the area on 2/7/24. When this nurse was asked if she notified this resident's representative regarding the area, she stated she did not. She stated she didn't notify him because she wasn't sure what was causing the area, so thought the doctor could take a look and then they would notify him. She stated she should have notified the resident representative the day she first saw the area. She stated she should have told this resident's representative what she observed and that she put this resident on the list to be seen at clinic the following week. Review of the Progress Notes for 2/7/24 revealed no entries regarding the new area. On 5/15/24 at 11:51 a.m., Staff E CNA/CMA (Certified Medication Aide), stated that a lot of times this resident refuses her showers. She stated that they were helping Resident #50 get dressed. Staff E stated when she saw the area she was like oh my gosh, this is a big lump on her back. Staff E stated she then called the nurse and reported it. Staff E stated she was not sure what the nurse did after that. Staff E stated that Staff E had kind of rubbed the area lightly to see if it hurt, and Resident #50 said no, it doesn't hurt. Staff E stated the area wasn't red or anything, you could press on it. Staff E stated the area didn't hurt this resident and it wasn't hard, there was just a lump there. Staff A stated the lump was approximately 4 inches or so and dome shaped, it's been a while since Staff E has seen it but the area was raised. The staff stated the resident didn't have any complaints. On 5/15/24 at 4:21 p.m., the Administrator sent an email stating they do not have a facility policy for family notification. On 5/15/24 at 4:30 p.m., the Administrator acknowledged the concern regarding not notifying Resident #50's representative of the area found on Resident #50's back on the day it was found.

Based on observations, clinical record review, staff interview, and manufacturer's package insert review, the facility failed to keep their medication error rate less than 5 percent. An observation of 39 medications being passed was completed with 3 medication errors noted giving the facility a 7.69% medication error rate. Resident #30 had 2 observations of insulin administration via FlexPen and both observations revealed no priming of the FlexPen. There was no way of knowing if the resident received the appropriate scheduled dose. The facility reported a census of 60 residents. Finding Include: 1. During an observation on 5/15/24 at 8:28 AM, Staff A, Registered Nurse (RN) administered Novolog 5 units to Resident #22. Staff A gave the shot in the upper right arm. She did not prime the insulin pen prior to administration. Review of current physician orders on the May 2024 Medication Administration Record/Treatment Administration Record (MAR/TAR) for Resident #22 revealed the resident to receive the following: a. Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject 5 unit subcutaneous three times daily. Review of the manufacturer insert for Novolog FlexPen revised 2/2023 stated small amounts of air may collect in the cartridge during normal use. An airshot must be done before each injection to avoid injecting air and to make sure the prescribed dose of the medicine is received. This is done by priming the insulin pen by injecting 2 units of insulin through the attached needle prior to administering the prescribed dose. 2. During an observation on 5/15/24 at 8:54 AM, Staff B, Licensed Practical Nurse (LPN) administered Novolog 9 units and Tresiba 54 units to Resident #30. Staff B gave both shots in the upper left arm. She did not prime either insulin pens prior to administration. Review of current physician orders on the May 2024 MAR/TAR for Resident #30 revealed resident was to receive the following: a. Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject 6 units subcutaneous before meals in addition to sliding scale. b. Novolog Solution 100 UNIT/ML (Insulin Aspart) inject as per sliding scale. Based on resident #30's blood glucose reading at the time, resident was to receive an additional 3 units of Novolog for a total of 9 units. c. Tresiba Flextouch Subcutaneous Solution Pen-Injector 100 UNIT/ML Inject 54 units subcutaneous in the morning. Review of the manufacturer insert for Tresiba Flextouch Pen revised 7/2022 stated small amounts of air may collect in the cartridge during normal use. An airshot must be done before each injection to avoid injecting air and to make sure the prescribed dose of the medicine is received. This is done by priming the insulin pen by injecting 2 units of insulin through the attached needle prior to administering the prescribed dose. During an interview with the Director of Nursing (DON) on 5/15/24 at 3:25 PM, revealed the expectation for nurses is to follow facility policy, indicating following manufacturer instructions. Review of facility's Insulin Administration policy, revised September 2014, did not have information specific to insulin pen administration. Policy stated the nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use.

Based on observations, policy review and staff interview, the facility failed to ensure the medication cart was locked on 2 separate occasions when Staff C, Licensed Practical Nurse (LPN), responsible for the cart, was not in direct sight of the cart. The facility reported a census of 60 residents. Findings include: 1. Observation on 5/13/24 at 12:29 PM revealed a medication cart unlocked and unoccupied on the west hall. Two residents observed self propelling passed the unlocked medication cart. At 12:34 PM (5 minutes later) Staff C, LPN returned to the cart and continued with the medication pass. During an interview on 5/13/24 at 3:48 PM, the facility Administrator revealed it is expected the nurses lock medication carts and computers when stepping away from the cart. 48886 2. On 5/13/24 at 11:33 AM, a medication cart observed unlocked and unattended in the hallway by the main dining room, the court yard dining room. Several residents observed to walk by the medication cart and several residents were seated near the medication cart. The staff member responsible for the cart was not present in the hallway or in the dining hall. Approximately two minutes later a staff member walking through the hallway noticed the medication cart was not locked, locked the cart and continued to walk down the hallway. At approximately 11:37 AM, Staff C, Licensed Practical Nurse (LPN) responsible for the medication cart, came back to the medication cart from another hallway. Staff C not in the dining room or near the medication cart when the medication cart first observed unlocked at 11:33 AM. Review of facility policy, Storage of Medications, with a revision date of November 2020, documents drugs and biologicals used in the facility are stored in locked compartments and compartments containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

Based on observation, staff interview and policy review, the facility failed to use appropriate infection control practices during urinary catheter care for 1 of 2 residents (Resident #46) reviewed. The facility reported a census of 60 residents. Findings include: The Care Plan for Resident #46, with a revision date of 1/5/24, documented under the focus area the resident has an indwelling catheter and instructed under the intervention and task section to maintain enhanced barrier precautions and to observe and document intake and output. During an observation on 5/14/24 at 4:08 PM, Staff D, CNA, prepared to complete the task of emptying the catheter bag for Resident #46, with the Director of Nursing (DON) present. Staff D her washed hands, donned a gown and donned gloves. Staff D used a gait belt, transferred the resident to his bathroom, and placed the resident on the toilet. Staff D lowered the resident's pants to have access to the leg catheter bag. Staff D placed a plastic container to capture the output inside another larger plastic container as a barrier, with a plastic liner in the larger container. Staff D touched several items with her gloved hands, such as the walker, the gait belt, the containers, the hand rail and the toilet, with the original gloves she placed on her hands prior to moving the resident to the bathroom. Staff D used a sanitizing wipe to wipe down the bag port, then began emptying the bag, wearing the same gloves. The container used to capture the urine output fell over, splashed urine onto the floor and on the resident's legs and inside the larger plastic container. Staff D finished emptying the catheter bag, reattached the bag to the resident's leg and then using the same gloved hands, took paper towels and wiped up the spilled urine off the floor. Using the same gloved hands, Staff D grabbed a wipe and cleaned the resident's legs where urine splashed. The CNA pulled the resident's pants back up, took off the gloves and transferred the resident back to the chair in his room. During an interview on 5/14/24 at 4:25 PM, the DON advised she would have expected Staff D to change gloves after placing Resident #46 on the toilet and before beginning to empty the catheter bag. The DON also advised she would have expected Staff D to change gloves after cleaning up the spillage of urine on the floor and prior to using the wipe to clean the resident. The DON advised Staff D did not follow proper infection control practices. Review of facility policy Catheter Care, Urinary, with a revision date September 2014, documents under the section Infection Control, to maintain clean technique when handling or manipulating the catheter, tubing or drainage bag and avoid splashing.

Based on clinical record review, family, and staff interview, the facility failed to ensure a resident had prescription medication readily available following discharge for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 61 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had an admitted [DATE] and a planned discharge date of [DATE]. The Care Plan initiated 1/8/24 revealed Resident #3 planned to return to the community with a goal to successfully return to the community after meeting all goals at the facility and a safe return to the community. Review of undated facility form titled, Discharge Summary/Post Discharge Plan Of Care, reflected the facility arranged pharmacy services for Resident #3 at a pharmacy in [NAME]. Review of an electronic mail (email) correspondence dated 2/5/24 at 8:37 AM to Staff A, Admission Coordinator, revealed a family member of Resident #3 inquired about the resident's prescription medication as the discharge papers indicated they would be at the pharmacy, but the pharmacy didn't have anything there. Review of email correspondence dated 2/5/24 at 8:40 AM to Staff A revealed a family member requested Staff A to fax the discontinued orders to the pharmacy as Resident #3 didn't have her medication yesterday. The family member further revealed she was concerned about the resident not having her medication for 2 days. During an interview 4/29/24 at 3:00 PM the Administrator revealed they did not have a policy in place regarding a discharge protocol other than for Care Planning. During an interview 4/30/24 at 10:31 AM, the Director of Nursing (DON) revealed she faxed Resident #3's physician's office the day before (4/29/24) to see if the physician had a note about the pharmacy reaching out to the clinic regarding her discharge medications. The clinic provided documentation revealing the pharmacy had reached out to their clinic on 2/5/24. Review of faxed documentation from Resident #3's primary provider revealed on 2/5/24 at 5:31 PM the provider listed the medications sent to the pharmacy. The provider further documented the pharmacy never received the fax from the nursing home that the nursing home said they sent regarding the medications. During an interview 4/30/24 at 10:31 AM, the DON stated it had never happened before where a resident didn't receive their medication right after discharging. The DON further revealed they don't usually use the pharmacy that Resident #3 used except this one time and stated moving forward they will contact that pharmacy to ensure they have received the order for discharge medications. The DON added they expected residents to have their medication lined up and available when discharging so that they don't miss a dose.

Based on observation, record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure 3 residents out of 10 residents (Resident (R) 8, R19, and R16) reviewed for oxygen administration had an accurate Minimum Data Set (MDS) assessment. Findings include: 1. An observation on 02/21/23 at 2:44 PM, R8 was in a wheelchair near the doorway of the room and an oxygen concentrator was located at the foot of the bed. Review of R8's electronic medical record (EMR) undated Admission Record, located under the Profile tab, indicated R8 was admitted to the facility on [DATE] with diagnosis including COVID-19. Review of R8's Orders tab in the EMR revealed a physician's order dated 12/08/22 documented oxygen (O2) 3 liters per minute (lpm) to keep oxygen saturation (SPO2) >90 percent (%) every one hour as needed related to COVID-19. Review of R8's Annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/27/22, failed to document in the Special Treatments section oxygen was administered while a resident in the facility. 2. During an interview on 02/20/23 at 2:51 PM, R19 and the resident's family member explained R19 uses the oxygen concentrator oxygen at night with a nasal canula. Review of R19's EMR undated Admission Record, located under the Profile tab, indicated R19 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of sleep apnea. Review of R19's Quarterly MDS located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 01/03/23, failed to document in the Special Treatments section oxygen was administered while a resident in the facility. 3. During an interview on 02/21/23 at 2:47 PM, Licensed Practical Nurse (LPN) 2 confirmed R16 had an oxygen concentrator in the resident's room and a bilevel positive airway pressure (BIPAP) machine and used the oxygen at night connected to the BIPAP. Review of R16's EMR undated Admission Record, located under the Profile tab, indicated R16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of sleep apnea. Review of R16's Orders tab in the EMR revealed a physician's order dated 04/01/20 documented check and fill distilled water for bilevel positive airway pressure (BIPAP) machine at bedtime for BIPAP use. Review of R16's Quarterly MDS located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 02/20/23, failed to document in the Special Treatments section oxygen was administered while a resident in the facility. During an interview on 02/23/23 at 12:43 PM the MDS Coordinator verbalized part of evaluating residents using oxygen was to observe oxygen equipment in resident' room. The MDS Coordinator confirmed the MDS reports for R8, R19, and R16 did not accurately reflect the oxygen therapy care provided by the facility and should have reflected the use of oxygen. During an interview on 02/23/23 at 1:57 PM, the Administrator confirmed the use of the RAI manual guidelines for the accuracy of documentation. Review of the RAI Manual, dated 10/01/19, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the Interdisciplinary Team (IDT) completing the assessment .

Based on observation, interview, and document review, the facility failed to ensure oxygen tanks were secured in resident rooms for two of 10 residents (Resident (R) 8 and R47) reviewed for oxygen therapy. This deficient practice had the potential to injure residents in the facility if the unsecured oxygen tank were to have the valve under pressure break the seal. Finding include: Review of the facility policy titled Oxygen Cylinder Safe Handling Training Policy, undated, revealed, The purpose of this policy/procedure is to ensure all staff have a safe working knowledge and adequate training when handling, securing and operating portable oxygen cylinders. 1. Review of R8's electronic medical record (EMR) undated Admission Record, located under the Profile tab, indicated R8 was admitted to the facility on [DATE]. An observation on 02/21/23 at 2:44 PM revealed an oxygen tank was not secured and standing next the oxygen concentrator at the end of the bed in R8's room. 2. Review of R57's electronic medical record (EMR) undated Admission Record, located under the Profile tab, indicated R8 was admitted to the facility on [DATE] and readmitted on [DATE]. On 02/21/23 at 10:50 AM, an oxygen tank was observed not secured against the wall in R57's room near an oxygen concentrator and an oxygen tank secure in a rolling carrier. On 02/21/23 at 3:07 PM, the Director of Nursing (DON) observed the free-standing oxygen tanks in R8 and R57's rooms and confirmed all oxygen tanks that were in the facility were to be secured, placed in a carrier, holder, or in the pocket on the back of a wheelchair to prevent the oxygen tank from being knocked over accidently.

Based on observation, interview, record review, and document review the facility failed to ensure residents had an active physician order for receiving oxygen therapy for 3 of 10 residents (Resident (R) 19, R16, and R66) reviewed for oxygen therapy. This deficient practice had the potential to provide inaccurate care without a physician's order directing the oxygen care to be provided. Findings include: 1. Review of R19's electronic medical record (EMR) undated Admission Record, located under the Profile tab, indicated R19 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of sleep apnea. During an interview on 02/20/23 at 2:51 PM, R19 and the resident's family member explained R19 used the oxygen concentrator oxygen at night with a nasal canula. Review of R19's Care Plan tab in the EMR initiated focus on 04/05/22 revealed respiratory treatments/oxygen: at risk for impaired gas exchange with the intervention to assess for signs and symptoms of impaired respiratory function and apply [oxygen] nebs and continuous positive airway pressure (CPAP) machine if ordered. Review of R19's Orders tab in the EMR revealed a physician's order dated 11/06/22 to change oxygen tubing on evening shift every 15 days. The physician orders lacked documentation of orders for oxygen administration. During an interview on 02/22/23 at 10:29 AM, Registered Nurse (RN) 1 verified R19 used oxygen by nasal cannula at night and confirmed there was no physician's order for how many liters to set on the oxygen concentrator for oxygen delivery. 2. Review of R16's EMR undated Admission Record, located under the Profile tab, indicated R16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of sleep apnea. During an interview on 02/21/23 at 2:47 PM, Licensed Practical Nurse (LPN) 2 confirmed R16 had an oxygen concentrator in the resident's room and a bilevel positive airway pressure (BIPAP) machine (a machine which facilitates breathing by pushing air into the lungs) and uses the oxygen at night connected to the BIPAP. Review of R16's Care Plan tab in the EMR initiated focus on 11/23/21 revealed I have oxygen therapy [related to] sleep apnea with the interventions for residents who should be ambulatory, provide extension tubing or portable oxygen apparatus and I have oxygen via nasal prongs/mask at two liters as needed. Review of R16's Orders tab in the EMR revealed a physician's order dated 04/01/20 documented check and fill distilled water for bilevel positive airway pressure (BIPAP) machine at bedtime for BIPAP use and lacked documentation of orders for oxygen administration. During an interview on 02/22/23 at 10:26 AM, RN1 verified R16 used the BIPAP machine at night connected to the oxygen concentrator and there was no order for oxygen administration or instructions/orders for BIPAP settings on the machine. RN1 confirmed there should be a physician's order for the oxygen administration, how many liters to set the machine, and orders to clarify the BIPAP settings on the machine. 3. Review of R66's EMR undated Admission Record, located under the Profile tab, indicated R16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of pneumonia. During an observation and interview on 02/21/23 at 2:24 PM, R66 was sitting in the wheelchair next to his bed with a nasal cannula for oxygen administration connected to the concentrator with a setting of 2 liters. R66 verbalized needing the oxygen to be able to breathe, especially with physical exertion. Review of R66's Wt/Vitals tab in the EMR revealed on 02/21/23 at 10:17 AM, the oxygen saturation level was 94 percent (%) with oxygen via nasal cannula and 02/21/23 at 10:38 PM the oxygen saturation level was 96% with oxygen via nasal cannula. Review of R66's Care Plan tab in the EMR initiated focus on 01/12/23 revealed respiratory treatments/oxygen: at risk for impaired gas exchange with the intervention to assess for signs and symptoms of impaired respiratory function and apply [oxygen] nebs and continuous positive airway pressure (CPAP) machine if ordered. Review of R66's Orders tab in the EMR lacked documentation of a physician's order for oxygen administration. During an interview on 02/22/23 at 10:20 AM, Licensed Practical Nurse (LPN) 1 confirmed R66 did not have a physician's order for oxygen administration and there should be an order to identify how many liters of oxygen the physician expected to be administered via nasal cannula. During an interview on 02/23/23 at 11:46 AM, the Director of Nursing (DON) confirmed the expectation that residents receiving oxygen therapy needed to have a written physician's order for the administration of oxygen, including BIPAP/CPAP machine instructions for treatment. Review of the facility policy titled CPAP/BIPAP Support, revised 03/15, revealed [to] review the physician's order to determine the oxygen concentration and flow, and the PEEP [positive end-expiratory pressure] pressure (CPAP, IPAP [inspiratory positive airway pressure] and EPAP [expiratory positive airway pressure]) for the machine. Review of the facility policy titled Oxygen Administration, revised 10/10, revealed [to] verify that there is a physician's order for this procedure. Review the physician's orders . for oxygen administration.

Based on observation, interview, and document review the facility failed to ensure outdated medications were removed from the medication cart for one of two medication carts reviewed for outdated medications. This deficient practice had the potential to affect any resident on medication receiving an outdated medication and possibly less effective medication. Findings include: On 02/22/23 at 3:58 PM, review of the North Hall medication cart revealed a bubble pack card for Resident (R) 21 for acetaminophen tabs 650 milligrams for an as needed (PRN) usage had an outdate printed on the front of the card of 01/12/23. There were 11 pills left in the bubbles in the card. On 02/23/23 at 3:59 PM, Registered Nurse (RN) 3 confirmed the acetaminophen ordered for R21 was currently outdated and the medication should not be given to the resident if needed. The outdated medication should go back to the pharmacy or be destroyed since it was expired. In an email communication on 02/23/23 at 5:21 PM, the Director of Nursing (DON) explained expired medications should be pulled from the carts and placed in the med rooms for storage until two nurses, DON, Minimum Data Set Coordinator (MDS) or other; were available to destroy the medications. Review of the facility policy titled Storage of Medications, with a revision date of 11/20, revealed drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, clinical records review, facility policies review, and staff interviews; the facility failed to ensure a level 4 controlled drug that required refrigeration was secured in a separately locked compartment within the medication refrigerator for 2 of 4 residents reviewed (Residents #2 and #3). Schedule II (2) - (through) V (5) controlled medications have a potential for abuse and may lead to a physical or psychological dependence. Additionally, the facility failed to destroy the ordered PRN (as needed) liquid [MEDICATION(S)] (anti-anxiety medication), that was discontinued after 14 days as it had not been reordered per the facility policy. The facility failed to complete the control shift count as directed by facility policy. The facility reported a census of 80 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 with severely impaired decision-making abilities, long, and short-term memory problems. The MDS identified the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident took antianxiety medications for seven out of seven days in the lookback period. Resident #2's Order Entry printed [DATE] documented an order start date as [DATE] for [MEDICATION(S)] solution 2 milligrams (MG) per (/) milliliters (ML), administer 0.25 ML sublingually every hour PRN for anxiety. The order's end date indicated indefinite. 2. The MDS assessment dated [DATE] identified Resident #3 with severely impaired decision-making abilities, long, and short-term memory problems. The MDS identified the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Order Details dated [DATE] documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order's end date indicated indefinite. An observation on [DATE] at 2:25 p.m. during the shift count for controlled medications of the north medication cart revealed Resident #3's [MEDICATION(S)] [MEDICATION(S)] liquid concentrate 2MG/ML was located in the medication refrigerator located in the medication room. The medication refrigerator was not locked and the medication was not stored in a locked compartment of the refrigerator. The Medication Control Record for Resident #2 documented 28.5 ML of the 30 ML dispensed of [MEDICATION(S)] was to remain. Observation revealed the [MEDICATION(S)] dispensed in a bottle with measurement marks only to 22 ML. The level of the liquid measured above the 22 ML measurement mark. Staff A, Licensed Practical Nurse (LPN), and Staff B, LPN, confirmed the count as accurate. Continued observation on [DATE] at 2:30 p.m. of the control count for the south medication cart, also located in the same medication room revealed Resident #2's [MEDICATION(S)] [MEDICATION(S)] concentrated liquid medication located in the unlocked medication refrigerator, not in a locked container. In an interview on [DATE] at 2:35 p.m. Staff C, LPN, and Staff D, LPN, confirmed that the residents' liquid [MEDICATION(S)] for the north and south medication carts was stored in the unlocked medication refrigerator and not stored within a separately locked container within the refrigerator and never has been. In an interview on [DATE] at 3:00 p.m. the Assistant Director of Nursing (ADON) confirmed that liquid [MEDICATION(S)] was now kept in a locked box in the medication refrigerator behind the locked door to the medication room. Additionally, the ADON confirmed Resident #3's liquid [MEDICATION(S)] was dispensed in a bottle that contained 30 ML of medication. However, the markings for the measurement on the side of the bottle only measured to 22 ML. The ADON demonstrated that level is above the 22 ML mark, however, responded that there would be no way to accurately measure what remained more than 22 ML. The resident's dosage is 0.25 ML PRN. A review with the ADON of the administration records revealed no liquid [MEDICATION(S)] administered in January and 28.5 ML was to remain in the bottle. The ADON stated staff are estimating due to being unable to accurately measure. During the continued interview on [DATE] at 3:30 p.m. the ADON confirmed that the expectation for controlled medications, such as liquid [MEDICATION(S)] should have been stored in a locked container within the medication refrigerator, as it is required to be double locked. In an interview on [DATE] at 10:30 a.m., the Administrator provided a document that had been prepared by the Director of Nursing (DON). It was reported the DON completed a review of the liquid medications contained in the medication carts and found 7 bottles of either liquid [MEDICATION(S)] or liquid [MEDICATION(S)] that had either expired or was discontinued for non-use. The ADON clarified that the [MEDICATION(S)] had been ordered PRN and by facility policy [CONDITION(S)] PRN orders are discontinued after 14 days if not reordered by a physician. The ADON confirmed that the medications had not been administered after expired, and had been ordered by the hospice provider. A further interview on [DATE] at 2:30 p.m., the ADON stated she would expect PRN [CONDITION(S)] medications to be discontinue after 14 days if not re-ordered and would expect the medications to be removed from the medication cart. In an interview on [DATE] at 2:50 p.m. Staff D stated that education had been provided following an incident on [DATE] that during shift narc count both staff must visualize the medication and the narcotic count sheet. Staff D confirmed that this did not occur prior to the education. In an interview on [DATE] at 8:07 a.m. Staff E, LPN, stated prior to the provided education, the narcotic shift count had become a bit complacent, and the staff had adopted an, it is what it is attitude because often times there was more liquid medication in a bottle than there should be with the scheduled medications. Staff E stated they hadn't paid that close of attention when they counted, but added they were very diligent now. The facility policy titled Control Count for Narcotics, dated [DATE] documented that the facility would ensure that controlled substances are handled in accordance with regulations regarding a system to record usage and disposition of all controlled medication with sufficient detail to allow reconciliation including destruction and disposal. The section labeled Counting indicated the following: A. Each card/bottle/patch of a controlled substance, along with the controlled drug receipt record/disposition form, will be visualized, counted, and verified by two nurses. B. These two nurses will both sign off on the controlled drug receipt record/disposition form at the end of each nurse's shift. The facility policy titled Discontinued Medications dated ,d+[DATE] indicated that the facility would properly dispose of any discontinued medications in accordance with established rules, regulations, and a licensed pharmacist. A facility memorandum, dated [DATE] reviewed the handling of controlled substances and directed: A. Each controlled medication along with the controlled drug count record would be visualized, counted, and verified by two nurses. B. that two nurses would both sign off on the controlled drug receipt record/disposition form at the end of each nurse's shift. One signature per line on the form. A review of an undated facility policy titled Medication Regimen Review indicated the purpose was to ensure that each resident's medication regimen remained free of unnecessary drugs. The section labeled Guidelines included the following: A. A [CONDITION(S)] medication is any drug that affects brain activities associated with mental process and behavior. Antianxiety medications were included in the [CONDITION(S)] medications. B. An unnecessary medication is any drug used for an excessive duration and without adequate monitoring, The section labeled Procedure directed that the facility would make sure that based on a comprehensive assessment the following: A. PRN orders for [CONDITION(S)] drugs are limited to 14 days, unless the attending physician or prescriber believes that it is appropriate for the PRN order and then the prescriber must indicate the duration of the PRN order. B. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending or prescriber evaluates the resident for the appropriateness of that medication.

Based on observation and staff interview, the facility failed to prepare food under sanitary conditions in order to reduce the risk of contamination and food-borne illness. The facility census was 60 residents. Findings include: 1. Observation on 12/17/19 at 9:30 a.m., revealed Staff A, cook was cutting up four pieces of butter to place in the four pans of carrots. Staff A picked up the butter with her bare hands and placed piece of butter into each pan. Staff A went to the sink and touched the water nozzle to fill water pitcher and proceeded to continue cooking without washing hands. Staff A grabbed the washcloth from the sanitizing bucket and wiped down the food preparation table. Staff A obtained ribs out of the warmer and cut them up for the ground and pureed meats without washing her hands after wiping the table. Observation on 12/17/19 at 9:53 a.m., Staff B walked into the food preparation area and obtained eggs from the refrigerator. Staff B was wearing a hair net that did not properly cover her hair. Observation on 12/17/19 at 10:15 a.m., revealed Staff B preparing the salads and desserts for the pureed diets. Staff B pureed the cake and took the measuring pitcher to the dishwasher touched the sink. Staff B grabbed the washcloth out of the sanitizing bucket and wiped down the food preparation area. Staff B obtained the pasta salad out of the refrigerator and scooped five servings of pasta into the blender. Staff B did not wash her hands after wiping down the food preparation table. Observation on 12/17/19 at 11:50 a.m., Staff A dropped butter on the kitchen floor while preparing a grilled cheese sandwich. Staff A began cooking the grilled cheese sandwich, wiped up the butter off of the floor and flipped over the grilled cheese sandwich without washing her hands. During interview on 12/17/19 at 1:05 p.m., Staff A she stated she usually washed her hands more during service and knew she should have washed hands after flipping the grilled cheese sandwich. During interview on 12/17/19 at 1:09 p.m., Staff B acknowledged she should have washed her hands after sanitizing the table and before she obtained the macaroni salad. During interview with the Dietary Manager on 12/18/19 at 2:51 p.m., she stated staff should have washed their hands after obtaining the washcloth from the sanitizing bucket.

Based on observation, clinical record review, staff and resident interviews, the facility failed to provide range of motion exercises as planned for three of five residents reviewed. (Resident #34, #11 & #52) The facility census was 60 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #34 had [DIAGNOSES REDACTED]. A review of the resident's restorative program revealed the resident was to receive passive and/or active Range of Motion (ROM) dated 9/4/19 to the upper and lower extremities due to increased weakness six times a week for 15 minutes. During observation on 12/16/19 at 10:39 a.m., the resident laid in bed on their left side propped up on a pillow with a fall mat next to the bed. During observation on 12/18/19 at 8:53 a.m., Staff D, Certified Medication Aide (CMA), complete upper extremity exercises for the resident. Staff D reported she would turn in the paper documentation once completed to the Director of Nursing (DON). A review of the tasks in the resident's chart showed no documentation related to the restorative nursing program. During interview on 12/18/19 at 9:01 a.m., the DON stated the restorative aides keep their paper documentation. The paper documentation was not turned into her but she would look to see if she could find them. During interview on 12/18/19 at 12:34 p.m., the DON said the Certified Nurse Aides (CNA) would chart in the computer under the point of care. She said the information would be driven by the tasks. The DON confirmed there was no location in the electronic record to document the resident's restorative. She stated they do not document the minutes. The DON stated once restorative was documented it would go to the MDS. 2. The MDS assessment dated [DATE], documented Resident #11 had [DIAGNOSES REDACTED]. The Care Plan dated 10/8/19, indicated a restorative program was in place. The Passive and/or Active Range of Motion Form dated 9/27/19 indicated the resident required passive/active ROM of bilateral upper and lower extremities for 15 minutes 6 times a week due to increased weakness and limited ROM with a goal to maintain current ROM and strength to assist with bed mobility and wheelchair mobility. The restorative therapy participation form dated 12/9/19-12/13/19 indicated the resident participated for 20 minutes on 12/11, 20 minutes on 12/12 and 20 minutes on 12/13. The restorative therapy participation form dated 12/16/19-12/20/19 indicated the resident participated for 20 minutes on 12/17/19. During interview on 12/17/19 at 8:52 a.m., Resident #11 indicated staff do not always complete the exercises to her legs because they have to work the floor. 3. The MDS assessment dated [DATE], documented Resident #52 had [DIAGNOSES REDACTED]. Record review revealed restorative program for Resident #52 dated 4/17/19, for lower extremity exercise 6-7 times a week. Record review from 11/19/19 to 12/18/19, documented the lower extremity exercises was provided on 11/21/19, 12/5/19, 12/12/19 & 12/17/17. During interview on 12/18/19 at 1:30 p.m., Staff G, Physical Therapy Assistant confirmed all restorative programs are written by therapy and expectation for programs to be followed. During interview on 12/18/19 at 1:58 p.m., Staff D, CNA, stated the residents restorative program was for 3-7 times a week and they try to complete the program 3 times a week but staffing was not always adequate to be able to allow time as they get pulled to the floor. Staff D confirmed she completed resident's restorative program 1 time this week from 12/16 to 12/18/19. During interview on 12/19/19 at 9:27 a.m., the DON confirmed restorative aides can get pulled to the floor approximately one time per week. The DON confirmed the expectation for staff to complete ROM program as ordered and to document refused if resident refuses.

Based on observation, clinical record review and staff interview, the facility failed to provide complete perineal care following an incontinent episode for one of six residents reviewed. (Residents #12) The facility census was 60 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], Resident #12 had [DIAGNOSES REDACTED]. During observation on 12/18/19 at 12:53 p.m., Staff F, Certified Medication Aide (CMA), and Staff E, Certified Nurses Aide (CNA), assisted the resident to the bathroom. Staff applied gloves and Staff F removed the old brief and applied a fresh pull-up. Staff stood the resident cleansed the resident's backside. Staff [NAME] washed the resident by washing up from the front to the buttock - no observed cleansing of the pelvis or hip area. Staff [NAME] and Staff F removed their gloves and walked the resident from the bathroom to the recliner. During interview on 12/18/19 at 2:16 p.m., the MDS Coordinator said she would not expect the staff to wash the buttock before washing the front side of the resident.

Based on clinical record review and staff interview, the facility failed to revise the plan of care for one of six residents reviewed. (Resident #34) The facility census was 60 residents. Finding include: 1. The Minimum Data Set (MDS) assessment dated [DATE], Resident #34 had [DIAGNOSES REDACTED]. The MDS dated [DATE], showed the resident required limited assistance with dining. The care plan dated 11/11/19, lacked documentation regarding the residents assistance needs during dining. Clinical record review revealed the resident was on a regular geriatric diet with a mechanical soft ground meat texture and nectar fluid consistency. The Speech Therapy Discharge Summary dated 10/31/19, indicated the resident required close supervision for oral intake. Progress notes dated 12/12/19 at 10:07 a.m., documented the resident fed self and also needed the assistance of one staff with eating breakfast. Progress notes dated 8/18/19 at 11:42 a.m., indicated the resident was prompted or assisted by staff as needed with meals and care plan reviewed. During interview on 12/18/19 at 2:16 p.m., the MDS Coordinator said she expected the care plan to include the amount of assistance required with meals

Based on clinical record review, facility policy review and staff interviews, the facility failed to provide a comprehensive care plan for one of three residents. (Resident #56) The facility census was 63 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], identified Resident #56 had [DIAGNOSES REDACTED]. The care plan dated 9/20/18, documented the resident had end stage [MEDICAL CONDITION] and dependence on [MEDICAL TREATMENT] required a renal diet and a fluid restriction of 1200 ml per day. The care plan lacked information which pertained to the [MEDICAL TREATMENT] facility, provider contacts, days of the week the resident had [MEDICAL TREATMENT], transportation to/from [MEDICAL TREATMENT], or staff directives for monitoring the resident for potential adverse problems related to the [MEDICAL TREATMENT] site or [MEDICAL TREATMENT] treatments. The hospital dismissal instruction sheet dated 2/9/18 revealed the resident needed follow up at a [MEDICAL TREATMENT] facility as scheduled on Tuesday, Thursday, and Saturday. During interview on 10/17/18 at 4:00 p.m., the MDS Coordinator and the Administrator confirmed the facility developed a care plan for all residents and care plans reviewed/updated at least quarterly. The MDS Coordinator and Administrator reviewed the plan of care and confirmed the care plan lacked specific [MEDICAL TREATMENT] information and directives for staff for monitoring for potential adverse problems related to the [MEDICAL TREATMENT] site or [MEDICAL TREATMENT] treatments and agreed the direct care staff should have specific directives of what to monitor for and report. Facility policy titled [MEDICAL TREATMENT] Care directed staff collaborated with the [MEDICAL TREATMENT] provide communication and coordination for [MEDICAL TREATMENT] adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular (vein) access site. Additionally, directed staff to contact and communicate any significant changes in the resident's status related to clinical complications or emergent situations that impact the [MEDICAL TREATMENT] portion of the care plan.

Based on observation, clinical record review and staff interview, the facility failed to follow the plan of care for one of one resident with a fall history. (Resident #39) The facility census was 63 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #39 had [DIAGNOSES REDACTED]. A progress note dated 8/30/18 at 1:47 p.m., documented the resident was laying on the bathroom floor on their back with both knees bent, feet flat on the floor with head facing to the east. Wheelchair was sitting in the bathroom doorway. Husband stated resident must have been attempting to transfer self onto the toilet and when stood fell on the floor. The Fall risk assessment form dated 8/27/18, documented the resident with a score of 17, indicating high risk for falls. The Plan of care dated 9/27/18, instructed staff to stay with the resident when on the toilet all shifts. During observation on 10/17/18 at 12:35 p.m., Staff E, certified nurse aide, CNA and Staff F, CNA assisted the resident into the bathroom and onto the toilet. Staff E asked the resident if they needed to sit on the toilet for a while, the resident stated they did, Staff E and Staff F left the bathroom at 12:44 p.m. At 12:56 p.m., Staff E and Staff F returned to the resident bathroom and assisted the resident to the wheelchair. During interview on 10/17/18 at 3;30 p.m., Staff D, nurse and the director of nursing confirmed staff needed to follow the care plan to stay with the resident while in the bathroom.

Based on clinical record review and staff interview, the facility failed to offer alternative interventions prior to the administration of an as needed anti-anxiety medication for one resident reviewed. (Residents #38) The facility census was 63 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #38 had [DIAGNOSES REDACTED]. A physician order [REDACTED]. The Medication Administration Record [REDACTED]. Review of the medication administration form dated 10/1/18-10/31/18 revealed staff administered [MEDICATION NAME] 0.5 mg prn on: *10/7/18 at 11:23 p.m., *10/8/18 at 5:17 p.m. *10/9/18 at 6:46 a.m. *10/9/18 at 2:46 p.m. *10/10/18 at 7:03 a.m. *10/10/18 at 2:17 p.m. *10/11/18 at 10:38 p.m. Progress Notes dated 10/7/18- 10/11/18, revealed no interventions attempted prior to the administration of prn [MEDICATION NAME]. During interview on 10/17/18 at 1:45 p.m., the director of nursing confirmed nursing staff needed to attempt alternate interventions prior to giving the as needed [MEDICATION NAME].

Based on observation, clinical record review and staff interview, the facility failed to utilize proper infection control technique when emptying a urinary drainage bag for one of one resident reviewed. (Resident #3) The facility census was 63 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #3 had an indwelling urinary catheter and had [DIAGNOSES REDACTED]. Interdisciplinary care plan dated 10/4/18, documented the resident had a indwelling Foley catheter to a leg bag and catheter cares twice a day. During observation on 10/17/18 at 2:27 p.m., Staff B, certified nurse aide, CNA entered the resident's room,washed hands and donned gloves and touched a variety of surfaces including the resident's lap blanket, clothing and the inside liner of resident's garbage can. Staff B failed to remove their gloves and wash hands prior to cleansing of port of the Foley catheter before and after draining the catheter bag. During interview on 10/17/18 at 2:43 p.m., Staff D, Quality Assurance Nurse stated Staff B should have changed gloves and washed hands after touched the garbage can prior to proceeding to drain catheter bag. During interview on 10/17/18 at 3:13 p.m., Staff B stated she should have changed gloves after touched the garbage can prior to draining the catheter bag.

Based on observation, record review and staff interviews the facility failed to follow door alarm procedures to ensure each resident receives adequate supervision to prevent elopement for 1 of 3 residents reviewed (Resident #1) Resident #1 exited the nursing facility section without staff knowledge resulting in an immediate jeopardy to resident health and safety. The facility reported a census of 65 residents. Resident #1 had a Minimum Data Set (MDS) assessment dated [DATE] that documented a [DIAGNOSES REDACTED]. The MDS documented a history of wandering and independent with ambulation in room and corridor. Resident #1's care plan with an effective date of 5/20/18 identified the resident at risk for injury. The care plan further identified in the area of safety and mobility that the resident was independent with a four wheeled walker, required secure care to four wheeled walker to alert staff of attempts to leave the facility unattended. The care plan identified a directive, dated as implemented on 8/12/18 to complete safety checks frequently every shift. A document titled Wandering Risk assessment dated [DATE] identified the resident scored an 11, which indicated high risk for wandering. The assessment further documented the resident assessed the following risk factors: forgetful/short attention span, exhibited fear and/or anxiety, had a recent medication change, independent with cane or walker for mobility, took antidepressants, has early dementia, and had a known history of wandering. An administrative note dated 8/12/18 revealed facility security camera footage had been reviewed by the Administrator and revealed Resident #1 visualized at 1:11 p.m. in her room. Resident #1 then pressed on the panic bar and exited the facility at 1:18 p.m. The footage further revealed Staff A, Certified Nurse Aide (CNA) responded to the door at 1:19 p.m., looked through the small window in the door, turned around and walked back down the hall. Independent living dietary staff member (Staff D) notified facility nursing staff at 1:35 p.m. Review of an undated facility document titled, CNA Orientation Check List outlined the review of safety devices, specifically Secure Care/Door alarms completed on day 2 of orientation. The Administrator confirmed in an interview on 8/28/18 at 9:00 a.m. staff trained and understood the following protocol labeled as Scenic Manor Door Alarm Procedure: When a door alarm is in alarm do the following: 1. Physically go to the door in alarm. 2. Turn the alarm off (the door is locked from the exterior when the door is alarming). 3. Open the door, go outside and look around for the cause of the alarm. 4. If no resident are in sight, notify the nurse. 5. The nurse must coordinate a check to ensure all residents are accounted for. During an interview on 8/27/18 at 2:35 p.m. Staff A, CNA stated on 8/12/18 after lunch, approximately 1:15 p.m. heard the West hall door alarm, completed transfer in process with Staff B, CNA and left the room and responded to alarm. Confirmed that she deactivated two alarms, the door alarm and the safe and secure alarm. Staff A revealed for the secure care alarm to activate a resident with a secure care band would had to have been close to the door and the resident would have tried to open door or had opened and exited. Staff A stated she then looked through the window on the door, didn't see anyone and went back to work. When questioned what should have done, she responded should have opened the door and checked. Further answered, if didn't see anyone then do a head count. Confirmed that she failed to open door, look around and when didn't find anyone failed to report to the charge person. During an interview on 8/28/18 at 10:05 a.m., Staff B, CNA confirmed on 8/12/18 she was with Staff A, CNA when heard the West door alarm. Stated Staff A responded to the alarm and Staff B followed. Further stated that she had not seen exactly what Staff A had done. Staff B stated she questioned Staff A if everything was OK, and stated Staff A responded that it was. During an interview on 8/28/18 at 9:45 a.m. Staff C, Licensed Practical Nurse (LPN) stated at the time of the elopement she did not hear the door alarm go off. Explained she was in a resident room in the Center hall. Confirmed was informed of the elopement by office staff after the resident had returned to the unit. Stated if unable to determine the cause of the alarm, as the charge person staff should have notified her so that a resident check could be completed to determine if a resident was missing. Confirmed on the date of the incident Staff A, CNA failed to notify her. Review of a written statement provided by Staff C, LPN documented that on 8/12/18 verbal counseling and education provided to Staff A on procedures of door alarms. In an interview on 8/29/18 at 1:33 p.m. Staff D, Dietary Aide stated she saw Resident #1 in Cedar Ridge independent living building just outside the dining room. Stated she recognized the resident as used to live in independent living and knew that nursing facility residents were not supposed to be in Cedar Ridge. Staff D called for help and stayed with resident until nursing staff arrived, stated felt the resident wouldn't be safe to leave alone. During an environmental tour on 8/27/18 at 3:15 p.m. the Administrator demonstrated the route the resident took on 8/12/18 after exiting the facility. After exiting the facility there was an unalarmed exit door immediately to the right, this door led to a grassy area outside, with a walking trail nearby. The resident then ambulated down a ramp, a second unalarmed exit was observed at the bottom of the ramp which led to a parking lot. Two additional unalarmed exits were observed, that led to the same parking lot before we arrived in the dining room where the resident was located by the dietary staff. Adjacent to the dining room the unalarmed main entrance/exit to the independent living was observed. This exit led to a parking lot with a residential street visible. The speed limit on the residential street was regulated to 25 mph. The Iowa Falls Municipal weather station reported the temperature on 8/12/18 at 1:35 pm. was 85 degrees Fahrenheit. Further interview on 8/28/18 at 9:00 a.m. with the Administrator confirmed expectation that staff always open door and visualize the cause of alarm after a door alarm sounds. Further stated if unable to visualize the cause of the alarm would expect staff to follow procedure and inform the nurse so resident check could be completed. Review of a document titled Scenic Living Communities, Notice of Disciplinary Action dated 8/13/18 documented that Staff A, CNA received a written warning for responding to a door alarm on 8/12/18 and failing to find out what caused the alarm and failed to notify the nurse to account for all residents. Further documented a resident had exited the facility and identified that Staff A failed to follow proper procedures. The immediate jeopardy was abated on (MONTH) 12, (YEAR) when all staff were educated/retrained on current policy. The facility also had each staff complete a competency test of the current policy for responding to alarms on (MONTH) 13, (YEAR).

Based on observation, record review and staff interviews, the facility failed to put interventions in place for a resident with a change in condition to prevent them from developing a pressure ulcer for 1 of 13 residents reviewed (Resident #3). The facility census was 58 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #3 with an assessment reference date of 5/22/17 revealed the resident required extensive assistance of 1 staff person to complete ADL's (Activities of Daily Living) such as bed mobility, transfers, ambulation, dressing, eating, and toilet use. The MDS revealed the resident had a pressure reducing device in their chair and bed. Resident #3 scored 8 out of 15 on the cognitive assessment (Brief Interview for Mental Status) which revealed impaired cognition. Resident #3's Interdisciplinary Care Plan dated 5/25/17 revealed Resident #3 needs limited to extensive assistance with activities of daily living due to Dementia, history of hospitalization [MEDICAL CONDITION], history of urinary tract infection [MEDICAL CONDITION] with indwelling Foley catheter and [DIAGNOSES REDACTED]. The care plan revealed Resident #1 required 1 assist with walker, gait belt for transfers and ambulation in room. Staff propels the resident in wheelchair to meals and for activities. The resident's care plan indicated a foam pressure reduction devices in place in bed and wheelchair. Gripper socks or shows with transfers and ambulation. Resident may refuse to wear gripper socks in bed. On 6/4/17 the care plan indicated no shoes, gripper socks only until left heel resolves; and when in wheelchair, heel cushion to left. Review of an MD/Nursing Communications dated 5/22/17 sent to inform the primary physician that Resident #3 had a decline in functional abilities with transfers, balance difficulty with safety concerns and requesting to have an order for [REDACTED]. According to the Therapy Referral form dated 5/22/17 physical therapy identified a change in functional abilities related to transfers and balance/safety concerns. The Braden Scale for predicting pressure sore risk dated 5/22/17 revealed Resident #3 at low risk of compromised skin. The assessment revealed the resident walks occasionally during the day, but for very short distances and spent the majority of each shift in bed or chair. In comparison to the prior Braden Scale dated 2/21/17 identified Resident #3 at low risk (score of 20) and walked frequently outside room at least twice a day and inside room at least once every two hours during walking hour. Review of Progress Notes for Resident #3 dated 5/31/17 reveals the resident began complaining of low back pain, leaning forward in their chair, and states they are unable to sit up straight without pain. Physician and family were notified and staff transferred Resident #3 to the emergency room to be evaluated. Resident #3 returned to the facility later the same day with orders for an antibiotic to treat a UTI (urinary tract infection) and for [MEDICATION NAME] and heat to the low back to treat the pain. The Progress Notes dated 6/1/17 revealed Resident #3 transfers with 2 staff assistances, walker and gait belt with much encouragement. Resident ate independently in dining room with no difficulty. The Progress Notes dated 6/2/17 revealed Resident #3 is alert and sitting in recliner chair. The Progress Notes dated 6/3/17 at 5:13 p.m., revealed Resident #3 continued on antibiotic treatment with no ill effects. Resident had been in bed most this shift, stating his/her back hurts and he/she does not want to get up. Room tray provided. Frequently liquids offered and taken well. Progress Notes dated 6/4/17 at 12:00 a.m., identified the resident yelled ouch and stated his/her leg was broken when repositioned. No abnormalities noted to left leg area. Review of Progress Notes for Resident #3 dated 6/4/17 at 2:30 a.m. reveals the resident began complaining of left leg pain, staff found a dark fluid filled spongy area to the left heel measuring 8 centimeters (cm) x 5 cm; resident denies pain to area. Staff applied [MEDICATION NAME] and covered with Allevyn for protection and padding. Heels up cushion will be used while resident is in bed. Staff would treat with [MEDICATION NAME] daily. Resident currently wears shoes and socks daily and will wear gripper socks to prevent extra pressure to heel. Care plan updated. At 6:38 p.m. the dressing to left heel was dry and intact, heel protector in place. Resident stated, ouch, ouch when the nurse assess foot. The resident unable to state pain rating, however the nurse determined the pain score of 6 based on pain scale faces. At 6:43 p.m. Tylenol is given for pain to left heel. Progress Notes dated 6/6/17 with a weekly skin assessment revealed fluid filled blister remains intact to left heel, no redness around, non-tender, measuring 5 x 8 cm and the resident is now wearing a foam boot to keep pressure off. At 6:55 p.m. the resident states his/her left heels hurts Review of the care plan for Resident #3 revealed no pressure relieving interventions in place until after the pressure area to the left heel developed. The facility completed Weekly Wound Documentation Progress Sheets from 6-6-17 to 7-17-17 including the following: a). On 6/6/17, the area was described as unstageable, measuring 5 cm in length by 8 cm in width, fluid filled blister with no odor, and intact pink wound edges with no pain. b). on 6/13/17 the area was described as unstageable measuring 7 (length) by 9 (width), no longer fluid filled, flat dry with no odor and larger. c). on 6/20/17 the area was described as unstageable, measuring 5 cm in length by 7 cm in width, dry frim blister black to tan in color with no odor, and intact pink wound edges with no pain. d). on 6/27/17, the area was described as unstageable, measuring 4 cm in length by 7 cm in width, eschar, black hard dried blister with no odor, and intact pink wound edges with no pain. e). on 7/11/the area was described as unstageable, measuring 5 cm in length by 8 cm in width, fluid filled blister with no odor, and intact pink wound edges with no pain. f). on 7/18/17, the area was described as 100% Eschar measuring 4 cm in length by 7 cm in width, black and hard with no odor, and intact pink wound edges, noted as decline as evidence by larger size and with pain when touched. During observation 7/18/17 at 11:00 a.m. the facility Skin Nurse performed a weekly assessment/measurement and treatment to the pressure area located on the inner left heel of Resident #3, the area measured 7 cm x 4 cm, appeared dark and hard with no drainage or redness noted, and the nurse performed the treatment as ordered and updated the primary physician on the condition. During an interview on 7/19/17 at 1:25 p.m. the facility Skin Nurse stated that each hall/unit has a primary nurse to oversee the care of the residents on their unit and if there is a decline or change in condition of a resident that would need added or changed interventions to prevent injury or in the case of Resident #3 the development of a pressure area/sore. The Skin Nurse stated that if a resident had a skin treatment then they would assess for any need to add or change interventions for that resident to promote healing. During an interview 7/19/17 at 3:20 p.m. the facility DON (Director of Nursing) also stated that if a resident like Resident #3 had a decline and needs interventions added to their plan of care to prevent injury that should be done by the unit primary nurse then that would be followed up on by the facility QA (Quality Assurance) nurse to determine if the interventions are effective. In the case of Resident #3 they started using a mechanical stand-up type lift for transfers because of their physical decline and it was reported to her that the pressure area on the resident's left heel resulted from using the mechanical lift without shoes on.

Based on record review and staff interviews, the facility failed to ensure a resident received adequate supervision against hazards and failed to implement care plan interventions intended to prevent injury for one (1) of five (5) residents. Resident #5 fell in his/her room and sustained a hip fracture. The resident's care plan directed staff to apply hipsters at all times and staff failed to implement the care plan intervention. The facility reported a census of 71 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], identified Resident #5 had [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed he/she sustained falls on 10/14/11, 10/30/11, 11/4/11, 11/12/11 and on 11/17/11 and on 12/21/11. The resident's Plan of Care dated 8/29/11 called for hipsters on at all times when available; the safety plan of care dated 11/21/11 was updated to use "Hipsters on at all times. " The same safety plan also included the following not limited to: 30 minute safety checks, pressure alarm at all times, gripper socks when not wearing shoes and grip strips to floor by bed, bathroom and in front of recliner. A web reference for the hipsters at: http:\\www.posey.com identified " Posey Hipsters feature impact absorbing, soft foam pads over the critical fracture area to help reduce the risk of injuries from a fall, such as hip fractures. The hipsters are a low profile pad over each hip. " An Incident Report dated 12/21/11 noted Resident #5 fell on [DATE], hit his/her head, complained of right hip, thigh, groin pain and was sent out of the facility for an X-ray. This report noted the Plan of Care was not followed. A computer generated nurse's progress note dated 12/21/11 at 4:05 p.m. noted alarm sounding, entered room to find Resident #5 on the floor laying on his/her back by the foot of the bed. Resident's head under a chair, kept by the sink. Legs extended outward, walker tipped over onto feet, both feet externally rotated per his/her usual. Resident stated he/she hit his/her head. Resident complaining of right hip and groin pain. Resident lifted by two staff into bed. Examination revealed resident had extreme pain to right hip thigh area with any movement. A History and Physical dated 12/21/11 identified Resident #5 had fallen with resultant right-sided hip fracture. The history and physical noted a previous left-sided hip fracture from a fall in May 2010. The document noted on 12/21/11 Resident #5 was up ambulating with his/her walker, his/her foot caught on something on the floor. He/she landed on his/her right side, and immediately had pain in his/her right hip that radiated down the right thigh. The X-rays revealed a right hip fracture. The physician assessed this resident with significant/chronic dementia. The physician documented surgery should not be delayed since the resident tolerate his/her hip fracture surgery in May 2010. When interviewed on 1/10/12 at 4:47 p.m. a night shift C.N.A., Staff B stated she cared for Resident #5 the night prior to his/her fall/fracture. She stated the resident was to wear Hipsters at all times. That night the resident had soiled all three pairs of hipsters and they were all in the wash. That night the resident did not wear Hipsters and she had informed the oncoming C.N.A. during their walk through report that Resident #5 did not have Hipsters on in bed as planned. When interviewed on 1/10/12 at 11:20 a.m. a day shift C.N.A., Staff A stated the morning of Resident #5's fall/fracture she received report from Staff B who informed her Resident #5 did not have Hipsters on. Staff A stated she assisted the resident up out of bed, and noted the absence of Hipsters. Staff A stated she failed to inform the nurse of the failure to use Hipsters as planned. She assisted the resident into a wheelchair and assisted the resident to the dining room, all without Hipsters. When interviewed on 1/5/12 at 2:00 p.m. a day shift C.N.A., Staff C stated on the day of this incident, she had assisted Resident #5 from the dining room, after breakfast to his/her bedroom. She assisted the resident to the toilet and noticed the resident was not wearing Hipsters as planned. She then assisted the resident to the easy chair in the resident's bedroom and left the resident without Hipsters. She stated she failed to inform the nurse of the lack of the planned hipsters. When interviewed on 1/10/12 at 10:50 a.m. a licensed practical nurse, Staff D stated on 12/21/11 she heard an alarm sounding from Resident #5 ' s room. She entered Resident #5 ' s room and found him/her on the floor. The resident complained of pain in his/her hip and groin. The resident's feet were externally rotated per usual. The resident could not move his/her right leg at that time, the resident could normally move the right leg without difficulty and/or pain. The resident complained of pain when nurse touched the right leg. The nurse stated she knew the resident probably had a fracture due to the pain. The nurse and an aide then picked the resident up off the floor and laid the resident on the bed. The nurse noted the resident was not wearing Hipsters at this time. The nurse sent the resident to the hospital for an x-ray. Staff D stated she knew this resident had an injury from the fall due to the resident's complaints of pain and the inability to move the leg, prior to them lifting the resident off the floor. According to Staff D she stated she had moved residents before that had a fall with an injury. The nurse was unable to say what the protocol/policy or procedure was regarding to moving a resident with an injury. The nurse stated she only moved the resident due to the floor was hard and would be uncomfortable for the resident.