Every finding on record at Shady Lane Nursing Care Center

Based on interview and record review, the facility did not ensure the resident environment was as free of accident hazards as possible for 1 resident (R) (R52) of 4 sampled residents. When staff lowered R52's bed on 4/28/26, the bed became caught on a radiator below the windowsill which caused the bed to tilt at an angle. The positioning of the bed was not reported to administration or addressed in R52's care plan. The following day, R52 fell out of bed and sustained a skin tear on the right forearm that required 6 sutures. R52's bed was caught on the radiator and tilted at a 30 degree angle at the time of the fall. This example is being cited at past non-compliance.Findings include: The facility's Fall Policy, dated 6/2016, indicates: The facility is committed to minimizing resident falls to maximize mental and psychosocial well-being .It is the facility's policy to facilitate as safe an environment as possible .The facility must ensure the resident environment remains as free from accident hazards as possible to include identifying hazards and risks. R52 was admitted to the facility on [DATE] and had diagnoses including age-related cognitive decline, diabetes, osteoarthritis, and edema. A Significant Change Minimum Data Set (MDS) assessment, dated 2/4/26, stated R52's Brief Interview for Mental Status (BIMS) score was 3 out of 15, indicating severe cognitive impairment. The assessment also indicated R52 had limited range of motion in both upper and lower extremities and required moderate staff assistance for rolling left to right in bed. R52 passed away at the facility on 5/4/26. A fall risk assessment, dated 1/30/26, indicated R52 was at moderate risk for falls. A health status note on 4/29/26 at 5:30 AM indicated R52 rolled out of bed and was on the floor alongside the bed in a prone position. R52 had a cut on the right arm from the call light. Staff treated the wound with an ABD pad and gauze wrap and notified Hospice. An ER visit note on 4/29/26 at 6:19 AM indicated R52 fell out of bed and sustained a Y-shaped laceration that was approximately 15 centimeters (cm) in length on the right hand/wrist from a call light clip. A laceration repair procedure note on 4/29/26 at 7:00 AM indicated R52 had a skin tear on the right hand/wrist that was 15 cm long and 3 cm deep. The wound was repaired with 6 sutures and strips of Mepitel. A health status note on 4/29/26 at 7:37 AM indicated R52 would return to the facility soon and had injuries on the right temple, right and left forearms, and had sutures in the right arm. A note at 7:25 PM indicated R52 was moaning when repositioned. Tylenol was administered. A health status note on 4/30/26 at 3:29 AM indicated R52 experienced intermittent pain in the right arm. PRN morphine was administered. R52's right arm was elevated with a pillow for comfort and to decrease swelling in the hand. A note at 9:23 PM indicated R52 received PRN morphine due to increased pain in the left thumb and an ice pack was somewhat effective. A health status note on 5/1/26 at 1:30 PM indicated R52 moaned in response to questions and had a swollen and bruised left thumb. A note at 9:03 PM indicated R52 had pain with movement related to injury. PRN morphine was administered. A Hospice note on 5/3/26 at 9:11 AM indicated Hospice would fax an order for scheduled morphine every four hours to keep R52's pain under control. A Hospice note at 3:05 PM indicated Hospice was updated regarding R52's uncontrolled pain. R52 received PRN Ativan and morphine at 1:30 PM and had been moaning, wincing, and crying. A one-time order was received for an increased dose of morphine. A Hospice note at 3:58 PM indicated R52 continued to cry out, moan, and wince in pain. A Hospice note at 5:45 PM indicated a Hospice nurse saw R52 and updated their medication orders. A fall investigation root cause analysis form, dated 4/29/26, indicated R52's bed was slanted sideways. R52 was last toileted at 1:10 AM during which time R52 appeared to be resting with no concerns. On 6/24/26, Surveyor reviewed a facility-reported incident (FRI) submitted to the State Agency (SA) regarding the fall with injury. The investigation indicated R52's bed was tilted at a 30 degree angle (due to being caught on a radiator) at the time of the fall and staff were aware it had also happened prior to the fall on 4/29/26. Certified Nursing Assistant (CNA)-C's written statement on 4/29/26 indicated they last saw R52 at approximately 1:10 AM when they changed R52's brief. CNA-C stated R52's bed always looked lopsided and the remote control did not work well. CNA-C stated they did not move the bed up or down during incontinence care and left the bed at waist height. CNA-C stated R52's bed looked like it usually did at 10:00 PM and 1:10 AM, slightly lopsided and at waist height with R52 positioned in the middle. CNA-C stated R52's bed was completely tilted at 3:50 AM and they were unable to fix the bed position at that time. CNA-E's undated written statement indicated on 4/28/26 (one day prior to R52's fall with injury), CNA-E and CNA-F positioned R52 in bed after lunch and noticed R52's bed was tilted away from the window and toward the door. CNA-E stopped moving the bed and notified Medication Technician (MT)-H. MT-H helped CNA-E pull the bed away from the wall where the frame was catching on the window sill/radiator and causing the bed to go sideways. CNA-E indicated the bed worked fine after that. CNA-F's undated written statement indicated on 4/28/26, CNA-F noted R52's bed was not properly fixed and asked MT-H for help. The bed was moved away from the window with no further concerns that shift. CNA-G's written statement on 4/30/26 indicated R52's bed got stuck on the window once in a while but staff moved the bed over. MT-H's written statement on 4/30/26 indicated MT-H was informed on 4/28/26 that R52's bed was tilting. MT-H observed the bed with CNA-E and noted the bed was slanted away from the window and toward the door. The bed was caught on the window sill/radiator and when pulled away worked fine. MT-H suspected that when doing cares/positioning R52, staff leaned into the bed and pushed it back against the wall/window sill. MT-H informed the oncoming PM shift to watch for it in case it happened again. LPN-D's written statement on 4/30/26 indicated they were not aware of any concerns with R52's bed prior to the fall on 4/29/26. LPN-D verified R52's bed was tilted toward the floor and away from the window/radiator after the fall. Registered Nurse Supervisor (RNS)-I's written statement on 5/1/26 indicated R52's bed appeared to be tilted away from the wall with the window/radiator. RN-J's written statement on 5/7/26 indicated they heard in report on 4/29/26 that R52 had fallen out of bed and sustained a large skin tear from the call light clip. RN-J asked how CNA-C and LPN-D did not notice R52's bed was tilted at a 30 degree angle. RN-J was not aware the bed could be lowered onto the window sill/radiator until after the incident. As a result of the investigation, Director of Nursing (DON)-B updated R52's care plan to include a high/low bed and provided education to all nursing and CNA staff to ensure positioning of beds, use caution when lowering beds, and notify maintenance and/or administration of equipment concerns. DON-B also completed audits to ensure beds were arranged for safety and proper functioning. R52 was moved to a larger room and given a different bed. On 6/23/26 at 12:58 PM, Surveyor observed R52's former room and noted several large dark scuff marks on the top edge of the radiator. On 6/23/26 at 12:24 PM, Surveyor interviewed DON-B who verified education was provided to all facility and agency staff following the incident. DON-B indicated they would have liked to know that R52's bed was catching on the window sill/radiator sooner so they could have rearranged the room for safety. DON-B indicated they were not aware of the issue until after R52's fall on 4/29/26. On 6/23/26 at 1:12 PM, Surveyor interviewed Service Representative (SR)-K who verified a service technician was at the facility on 4/29/26 to check the bed. The technician indicated R52's old bed had caught on the window sill and no longer worked properly.

Based on observation, staff and resident representative interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection for 1 resident (R) (R14) of 1 resident who used a humidifier and contracted Legionnaires' disease. The facility also did not ensure COVID-19 positive staff members returned to work in accordance with the facility's policy. In addition, the facility did not ensure enhanced barrier precautions (EBP) were implemented for 1 resident (R25) of 2 sampled residents. R14 used a humidifier that was filled with tap water and was diagnosed with Legionnaires' disease on 3/4/25. The facility did not have a policy and procedure for the use of humidifiers and the facility's water management program did not address humidifiers as a potential source for Legionella bacteria. The first example is being cited at a level G. The facility's COVID-19 outbreak line list indicated five staff (Dietary Aide (DA)-M, Certified Nursing Assistant (CNA)-H, Social Worker (SW)-N, Licensed Practical Nurse (LPN)-O, and CNA-P) returned to work earlier than the facility's policy which follows the Centers for Disease Control and Prevention (CDC) return to work guidelines. R25 had an indwelling Foley catheter. R25 did not have an EBP sign or or near R25's door or a personal protective equipment (PPE) cart outside R25's room. In addition, CNA-E did not wash hands prior to donning gloves and did not wear a gown during catheter care. Findings include: Wisconsin Healthcare-Associated Infections in Long-Term Care (LTC) Coalition: Use of Stand-Alone Room Air Humidifiers in Nursing Homes, dated 2/2021, indicates: .Peer reviewed medical journals have reported that stand-alone room air humidifiers have been associated with cases and outbreaks of pneumonia associated with Legionella pneumoniae .Guidance related to the use of stand-alone room air humidifiers: There is a lack of evidence to support the medical benefit in the use of stand-alone room air humidification devices in nursing homes .The decision to incorporate this device as part of a resident's plan of care should be based on a case-by-case basis. The following factors should be considered prior to and during use of a stand-alone room air humidification device: 1. These devices should be used in the context of an organization's general infection control risk assessment. There are several other critical considerations that need to be addressed including: a. Policies and procedures to address proper assessment, use, maintenance, and documentation of compliance with cleaning and maintenance procedures and processes. b. Staff education and competency validation in device maintenance. c. Documentation of discussions related to resident/family education of device use, safety, and maintenance .2. Most accounts of stand-alone room air humidifier associated infections have been attributed to aerosol generating humidifiers .3. Follow the manufacturer's instructions regarding cleaning, disinfecting, and maintenance of stand-alone room air humidification devices, water reservoirs, evaporative screens, and other water contact surfaces. 4. In the absence of clear manufacturer's instructions, empty the tank, wipe all surfaces dry, and refill the water in portable humidifiers daily to discourage microbial growth or formation of biofilms. 5. Use of sterile water is recommended to minimize microbial growth. Note: Distilled water has been suggested to reduce dissemination of mineral particulates which may cause adverse health events .8. Incorporate cleaning, disinfection, and maintenance strategies of stand-alone room air humidification devices into the organization's water management treatment program. The CDC's Legionella Toolkit-Version 1.1, dated 6/24/21, indicates: .Legionella can grow in many parts of building water systems that are continually wet and certain devices can then spread contaminated water droplets. Examples include: humidifiers .Non-steam aerosol-generating humidifiers. The CDC's Interim Guidance for Managing Healthcare Personnel (HCP) with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, dated 3/1/24, indicates: HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) have improved. The facility's Transmission-Based Precautions policy, dated 4/25, indicates: Enhanced barrier precautions (EBP) expands the use of personal protective equipment (PPE) beyond situations in which exposure to blood and bodily fluids is anticipated and refers to the use of a gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staffs' hands and clothing. EBP is recommended for residents known to be colonized or infected with an MDRO as well as those at increased risk for MDRO acquisition .Examples of high-contact resident care activities requiring gown and glove use: Device care or use: central line care, urinary catheter, feeding tube, tracheostomy/ventilator .Implementation: When implementing contact precautions or EBP, it is critical to ensure staff are aware of the facility's expectations about hand hygiene and gown/glove use, have initial and refresher training, and have access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside the resident's room indicating the type of precautions and required PPE. For EBP, signage should also clearly indicate the high-contact resident care activities that require the use of a gown and gloves. Make PPE available .outside the residents' room. 1. From 4/14/25 to 4/16/25, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] and had diagnoses including dementia, chronic obstructive pulmonary disease (COPD), and stroke. R14's Minimum Data Set (MDS) assessment, dated 3/1/25, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R14 had severe cognitive impairment. R14 had an activated Power of Attorney (POA) (POA-F). R14's medical record indicated POA-F reported to staff on 3/2/25 that R14 was not feeling well and was warm. Staff obtained R14's vital signs and noted a temperature of 99.5 degrees. Tylenol was administered. Staff checked R14's vital signs an hour later and noted R14 had a temperature of 102.9 degrees. R14's blood pressure was 122/70, oxygen saturation was 89%, respiratory rate was 16, and heart rate was 80 beats per minute. R14 was transferred to the hospital and admitted with a diagnosis of pneumonia. R14's hospital discharge summary, dated 3/4/25, indicated R14's primary discharge diagnosis was community-acquired pneumonia of the lower lobe of the right lung. R14 was treated with Rocephin and azithromycin (antibiotic medications) for a positive Legionella urinary antigen. Upon review of R14's hospital discharge summary, ADON-C noted R14's urine tested positive for Legionella. The facility contacted the Public Health Department and discussed water testing. R14's humidifier was determined to be a plausible source of the Legionella. R14's medical record contained a discontinued (as of 3/4/25) order to fill R14's humidifier morning (AM) and evening (HS) two times per day. The order was created by CNA-I on 2/12/25. R14's February 2025 Treatment Administration Record (TAR) contained an order to fill R14's humidifier morning (AM) and evening (HS) two times per day, dated 2/12/25. The order was initialed as completed two times per day from 2/12/25 to 3/2/25. The order was discontinued on 3/4/25 by Assistant Director of Nursing (ADON)-C. On 3/6/25, an independent company conducted water testing at the facility and a sample was taken from R14's humidifier. The facility notified POA-F and indicated the facility disposed of the humidifier. On 3/14/25, water testing results indicated no Legionella was found. The sample from the humidifier was noted to contain multiple bacteria and the results were inconclusive. There were other suspected areas, however, there were no conclusive test results that confirmed the presence of Legionella bacteria. On 3/24/25, the Public Health Department obtained water samples from the facility. The results were received on 4/8/25. On 4/9/25, Director of Nursing (DON)-B was notified via e-mail that three positive Legionella samples were obtained. The results indicated the fourth floor whirlpool tub (which had not been used for approximately six years) was tested with the jets running (which the independent water testing company did not do) and was positive for Legionella. (Of note: R14's room was within close proximity of the fourth floor tub room.) Detailed remediation efforts and control measures were implemented by the facility. On 4/14/25 at 10:39 AM, Surveyor interviewed POA-F who confirmed R14's humidifier was brought from home and filled with tap water from R14's bathroom faucet two times daily. POA-F indicated staff were aware R14 had a humidifier and assisted with filling the humidifier. (Of note: R14's medical record did not indicate when the humidifier was brought to the facility or when R14 started using the humidifier.) On 4/15/25 and 4/16/25, Surveyor interviewed Maintenance Director (MD)-D regarding water management. MD-D indicated MD-D flushed all vacant areas in the facility, including tubs, showers, toilets and anything that was stagnant on closed units. MD-D indicated the rehab unit was closed in 2020 and remained closed until September of 2024. MD-D indicated weekly flushing was completed in the closed areas, however, MD-D did not document the weekly flushes. MD-D did not indicate if the fourth floor whirlpool tub jets were run during the flushing. On 4/16/25 at 10:23 AM, Surveyor interviewed Public Health Staff (PHS)-Q who confirmed the facility reported R14's humidifier was filled with tap water. On 4/16/25 at 4:37 PM, Surveyor interviewed CNA-G who indicated only nurses were allowed to fill R14's humidifier. CNA-G indicated POA-F talked about filling R14's humidifier with tap water in the evening. On 4/16/25 at 4:42 PM, Surveyor interviewed CNA-H who indicated only Medication Technicians or nurses could fill R14's humidifier with water. On 4/16/25 at 4:58 PM, Surveyor interviewed Registered Nurse (RN)-J who was not sure if the facility had a humidifier policy. On 4/16/25 at 5:15 PM and 5:28 PM, Surveyor interviewed DON-B who indicated the facility did not have a Legionella plan aside from what was contained in the facility's water management policy. DON-B confirmed ward clerks, CNAs, and Medication Technicians can enter nursing orders which do not need to be signed by a nurse or provider. DON-B indicated the facility did not have a policy and procedure for transcribing orders. DON-B was not sure why CNA-I entered the humidifier order. DON-B attempted to contact CNA-I during the survey but was unsuccessful. (Of note: DON-B was not aware CNA-I had entered the order prior to the survey and was not aware R14 had a humidifier until R14 returned from the hospital on 3/4/25.) DON-B indicated if DON-B or ADON-C were aware that R14 had a humidifier prior to 3/4/25, the order would have indicated only distilled water could be used. DON-B confirmed the facility did not have a humidifier policy prior to R14 testing positive for Legionnaires' disease and indicated humidifiers should not be used. DON-B indicated DON-B posted a memo by the time clock to provide education for staff on Legionnaires' disease and humidifier use. Surveyor obtained a copy of the memo posted by the time clock and a sign-in sheet that confirmed which staff read the memo. The memo and sign-in sheet, dated 3/6/25, contained 33 staff signatures and provided education on Legionnaires' disease and the use and care of humidifiers. (Of note: The facility had 116 total staff, 64 of which were nursing staff.) On 4/18/25, Surveyor received an e-mail from DON-B that contained an education sign-in sheet that indicated education was mailed on 4/17/25 to staff who were not present to sign and other staff signed on 4/17/25. (Of note: The survey was completed on 4/16/25.) The e-mail contained the facility's education on Legionnaires' disease, indicated humidifiers were no longer allowed in the long-term care, and contained information on the use and care of home humidifiers. The email also included a transcribing physician orders policy, 6/12/08, and a cleaning humidifiers policy, dated 1/2016. 2. From 4/15/25 to 4/16/25, Surveyor reviewed the facility's COVID-19 positive staff line list for December 2024 through February 2025 and the facility's staff call-in list and noted staff return to work dates were not within the CDC's return to work guidelines. For December 2024: ~ CNA-H tested positive for COVID-19. The Health Department was notified on 12/31/24. CNA-H's last worked date was 11/29/24. CNA-H had an onset date of 12/2/24 with symptoms of a sore throat. CNA-H's last symptom and return to work dates were 12/7/24. According to the CDC guidelines, CNA-H's return to work date should have been 12/13/24. ~ SW-N tested positive for COVID-19. The Health Department was notified on 12/31/24. SW-N's onset date was 12/28/24 with symptoms of a headache and congestion. SW-N's last worked date was 12/30/24. SW-N's last symptom and return to work dates were not listed on the COVID-19 staff line list. The facility's call-in list indicated SW-N's last symptom date was 1/3/25 and return to work date was 1/6/25. According to the CDC guidelines, SW-N's return to work date should have been 1/8/25. For January 2025: ~ LPN-O tested positive for COVID-19. The Health Department was notified on 1/7/25. LPN-O's last worked date was 1/3/25. LPN-O's onset date was 1/4/25 with symptoms of nausea and a sore throat. LPN-O's last symptom date was 1/9/25 and return to work date was 1/10/25. According to the CDC guidelines, LPN-O's return to work date should have been 1/15/25. ~ CNA-P tested positive for COVID-19. The Health Department was notified on 1/7/25. CNA-P's last worked and onset dates were 1/5/25 with symptoms of nasal congestion. CNA-P's last symptom date was 1/11/25 and return to work date was 1/13/25. According to the CDC guidelines, CNA-P's return to work date should have been 1/16/25. For February 2025: ~ DA-M tested positive for COVID-19. The Health Department was notified on 3/3/25. DA-M's last worked and onset dates were 2/21/25 with symptoms of a sore throat and cough. DA-M's last symptom and return to work dates were 2/27/25. The call-in list indicated DA-M's last worked date was 2/20/25. According to the CDC guidelines, DA-M's return to work date should have been 3/4/25 when calculated with an onset date of 2/21/25. On 4/16/25 at 8:55 AM, Surveyor interviewed DON-B who called ADON-C regarding the facility's return to work policy. ADON-C indicated the policy is reviewed when there is a CDC revision and when there are changes to the guidance. ADON-C indicated the facility's infection prevention and control employee health policy indicates the return to work date is five days and five days of strict masking when staff return following COVID-19 illness. When Surveyor informed ADON-C that the guidance was for non-healthcare workers, ADON-C indicated the facility follows the CDC guidelines and the facility did not have additional information on return to work dates. DON-B reviewed the facility's COVID-19 positive staff line list for December 2024 through February 2025 and confirmed return to work dates were not within the CDC's return-to-work guidelines. On 4/16/25 at 11:15 AM, Surveyor interviewed RN-K regarding the facility's return to work policy. RN-K indicated staff should be off for five days. RN-K indicated if symptoms improve, staff can return to work and wear a mask for seven days. RN-K indicated staff are not subjected to a COVID-19 re-test and indicated management calls to inquire about signs and symptoms and let staff know a return to work date. On 4/16/25 at 11:34 AM, Surveyor interviewed Dietary Manager (DM)-L who indicated DA-M was sick on 2/20/25 per DA-M's timecard and returned to work on 2/27/25. DM-L indicated DA-M tested positive for COVID-19 and DA-M's return to work date was not within the CDC's return to work guidelines. 3. From 4/14/25 to 4/16/25, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] and had diagnoses including dementia and history of urinary tract infections (UTIs) with painful urination. R25 had an indwelling urinary catheter. R25's MDS assessment, dated 4/9/25, indicated R25 had severely impaired cognition. On 4/15/25 at 11:06 AM, Surveyor observed CNA-E complete catheter care for R25. Surveyor noted CNA-E did not wash hands prior to donning gloves and did not wear a gown during catheter care. Surveyor interviewed CNA-E who was unsure if a gown should be worn during catheter care and indicated a gown was only needed if a resident was sick. CNA-E verified there was not an EBP sign or PPE cart outside R25's room. On 4/15/25 at 11:18 AM, Surveyor interviewed DON-B who indicated an EBP sign should be posted on or near R25's door. DON-B indicated CNA-E should have washed hands prior to donning gloves and verified CNA-E should have worn a gown during catheter care per the facility's EBP policy and procedure.

Based on staff interview and record review, the facility did not ensure a timely fall intervention was implemented for 1 resident (R) (R32) of 1 sampled resident. R32 fell on [DATE]. The facility did not implement timely and appropriate fall interventions before R32 fell again on 9/9/24 and 11/12/24. Findings include: The facility's Falls I&A policy, revised 6/2016, indicates: The Interdisciplinary falls team is key to addressing the issue of resident falls which shall be responsive to assuring resident safety within the limits of practicability .The facility is committed to minimizing resident falls so as to maximize each resident's mental and psychosocial well-being .It is the facility's policy to act in a proactive manner to identify and assist those residents at potential for risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible .Avoidable accident means that an accident occurred because the facility failed to: Implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident. Monitor the effectiveness of the interventions and modify the interventions as necessary .2) Care plan will be updated and adjusted as needed . On 4/14/25, Surveyor reviewed R32's medical record. R32 had diagnoses including dementia mild with mood disturbance, increased weakness and health decline including history of falls, encephalopathy, muscle weakness, unsteadiness on feet, and other abnormalities of gait and mobility. R32's Minimum Data Set (MDS) assessment, dated 1/8/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R32 had severe cognitive impairment. R32 had an activated healthcare decision maker. R32's care plan, dated 12/29/24, indicated R32 required the assistance of two staff and an EZ stand (mechanical lift) for transfers and the assistance of two staff for ambulation with a four-wheeled walker. R32 could also self-propel a wheelchair. R32's medical record indicated the following dates: ~ On 9/4/24, R32 had an unwitnessed fall and was unable to indicate what caused the fall. R32 was found seated on the floor in front of R32's wheelchair. An intervention added to R32's care plan indicated R32 would see R32's primary care physician. ~ On 9/9/24, R32 had an unwitnessed fall in the dining room when R32 attempted to self-transfer from R32's wheelchair. An intervention added to R32's care plan indicated to offer toileting prior to and after meals, midday, at bedtime, and as needed. ~ On 11/12/24, R32 had an unwitnessed fall in R32's room and was unable to indicate what R32 was attempting to do. An intervention reminder of Don't self transfer was added to R32's care plan. (Of note. R32 had severe cognitive impairment.) ~ On 1/1/25, R32 had an unwitnessed fall and was found sitting on the floor in the hallway in front of R32's wheelchair. An intervention was added to R32's care plan for a Dycem seat cushion to prevent sliding from the wheelchair. Surveyor reviewed R32's falls investigations which indicated R32 could not comprehend or understand how to use a call light. Surveyor also noted the intervention for R32's fall on 9/4/24 of will see primary care physician did not occur until 9/10/24 and after R32's fall on 9/9/24. On 4/15/25 at 12:08 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R32's falls on 9/4/24, 9/9/24, and 11/12/24 occurred when R32 attempted to self-transfer. DON-B indicated interventions were added to R32's care plan. DON-B verified the intervention for R32's fall on 9/4/24 was for R32 to be seen by R32's primary care physician. DON-B confirmed R32 was seen by the physician on 9/10/24. DON-B indicated DON-B would review R32's medical record to see if another intervention was implemented to prevent a fall from occurring prior to the fall on 9/9/24. On 4/16/25 at 11:17 AM, DON-B approached Surveyor and indicated there were no other fall interventions implemented after R32 fell on [DATE]. DON-B indicated R32 was seen for a regularly scheduled visit with R32's primary care physician on 9/10/24. DON-B indicated another fall intervention should have been implemented and added to R32's care plan to reduce the risk of future falls.

Based on staff interview and record review, the facility did not ensure monitoring interventions for adverse reactions to a high-risk medication were implemented for 1 resident (R) (R8) of 5 sampled residents. R8 had an order for oxycodone (an opioid medication use to treat moderate to severe pain). R8's medical record did not contain monitoring interventions for adverse reactions to the high-risk medication. Findings include: The facility's High Risk Medications policy, dated 1/2025, indicates: Medications are an integral part of the care provided to residents of nursing facilities. They are administered to try to achieve various outcomes, such as curing an illness, arresting or slowing a disease process, reducing or eliminating symptoms, or as part of diagnosing or preventing a disease or symptom .The regulations associated with medication management include consideration of .Adequate monitoring for efficacy and adverse consequences and preventing, identifying, and responding to adverse consequences .Facility has standing orders for high-risk medications. Current guidance indicates a need for routine monitoring for side effects for medications that are high risk for complications and adverse events. For residents on these medications, utilize standing orders on the Medication Administration Record (MAR) .These include: opioids . https://medlineplus.gov indicates opioid medications can cause side effects such as drowsiness, mental fog, nausea, and constipation. They may also cause slowed breathing, which can lead to overdose. Signs of an overdose may include: Very small pupils, falling asleep or loss of consciousness, slow, shallow breathing, choking or gurgling sounds, vomiting, limp body, pale, blue, or cold skin, faint heartbeat, and purple lips or fingernails. When using opioid medication, there is also a risk of opioid use disorder (OUD) which refers to a problematic pattern of using opioids that causes distress and impairment and can interfere with daily life . On 4/16/25, Surveyor reviewed R8's medical record. R8 had a diagnosis of spinal stenosis. R8's Minimum Data Set (MDS) assessment, dated 3/26/25, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R8 had moderate cognitive impairment. R8 had an activated healthcare decision maker. R8 had an order for oxycodone HCl 5 milligrams (mg) give .5 tablet by mouth once daily. Surveyor noted R8's medical record did not contain monitoring interventions for adverse reactions to opioid medication. On 4/16/25 at 11:21 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated monitoring interventions for high-risk medication, including opioids, should be entered on a resident's MAR when the order for the medication is transcribed. DON-B indicated DON-B would review R8's medical record and provide Surveyor with monitoring documentation. On 4/16/25 at 1:20 PM, DON-B approached Surveyor and indicated R8's medical record did not contain monitoring interventions for adverse reactions to opioid medication. DON-B indicated monitoring interventions were not re-entered into R8's medical record when R8's oxycodone order was previously discontinued and then restarted.

Based on staff and resident representative interview and record review, the facility did not ensure a resident representative was notified of a change in condition for 1 Resident (R) (R1) of 3 residents reviewed. R1's coccyx pressure injury worsened and R1 developed additional pressure injuries on 8/7/23. The changes were not communicated to R1's activated Power of Attorney for Healthcare (POAHC). Findings include: The facility's Significant Change in Clinical Condition/Notification of Physician and Resident's Family policy, dated 6/16/09, indicates: Examples of conditions which may cause significant change but are not life threatening and require communication with the physician and family include but are not limited to: .i. change in skin condition. On 11/30/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, type 2 diabetes, and chronic pain. R1's most recent Minimum Data Set (MDS) assessment, dated 8/2/23, indicated R1's cognition was severely impaired and R1 required extensive assistance with activities of daily living (ADLs). R1's POAHC was activated in January 2023. On 11/30/23, Surveyor reviewed R1's wound notes and noted R1 developed a stage 2 pressure injury to R1's coccyx on 7/2/23. The pressure injury was assessed as larger in size on 8/7/23. In addition, R1 developed two bilateral stage 2 pressure injuries on R1's buttocks. R1's medical record did not indicate the changes were communicated to R1's POAHC. On 11/30/23 at 10:45 AM, Surveyor interviewed R1's POAHC who verified they were not notified of the extent or number of pressure injuries on R1's coccyx and buttocks until R1 was referred to the wound clinic on 9/12/23. On 11/30/23 at 1:14 PM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B would normally update a resident's POAHC if the resident developed new pressure injuries or if a current pressure injury worsened enough to require physician notification. DON-B stated R1 had a care conference on 8/9/23 during which DON-B thought the facility updated R1's POAHC regarding R1's pressure injuries, however, a care conference note did not indicate R1's pressure injuries were discussed during the meeting.

Based on observation, record review, and staff interviews, the facility did not ensure 1 Resident (R) (R36) of 2 residents reviewed for pressure injuries received appropriate care and services to promote healing. R36's medical record included documentation that R36 was at risk for pressure injuries and had a current re-opened Stage 4 pressure injury to the coccyx that was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R36's medical record indicated that R36 developed a stage IV pressure injury (indicating full thickness tissue loss and palpable bone) on 5/30/19 and that it had healed as of November of 2020. R36's current care plan included the following interventions: low air loss alternating air mattress (no specified settings), alternating pressure cushion for wheelchair (no specified settings), daily skin checks, reposition every 2 hours, and a padded dressing to the scar tissue. According to Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . They also direct clinicians not to leave moving and handling equipment under the individual after use. According to A Laboratory Study Examining the Impact of Linen Use on Low-Air-Loss Support Surfaces (2013), The beds that healthcare facilities utilize are specialized support surfaces for pressure redistribution designed to manage tissue loads, micro-climate, and/or other therapeutic functions. Even a small number of layers of bed linens have been shown to negatively impact the therapeutic value of these support surfaces. A progress note, dated 11/29/21 at 10:32 AM, states: Incident Note: Resident's right buttock old wound area reopened. Stage 4 pressure injury noted. Assessment (RN)/Appearance (LPN): Right lower buttock reopened. Superficial open area. Area cleansed with NS (normal saline), acuacel AG, Gauze and [MEDICATION(S)] (foam dressing) applied. R36's power of attorney (POA) and nurse practitioner (NP) were notified. An intervention was added to R36's care plan, stating R36 is to be up in chair 1 hour per day x 3. R36's record contained the following wound assessments: -11/29 - 1.1 x 1.5 x .1, beefy red, no tunneling, no infection -12/3 - 1.1 x 1.5 x .1, beefy red, no tunneling, no infection -12/9 - 2.5 x 4.5 x .1, drainage and odor noted - also notes reddened left heel, blanchable (indicating high pressure area with potential to develop into an injury). Added heel boots to care plan interventions. -12/15 - 2.5 x 2.5 x .05, 100% granulation, no bone or tendon, no signs of infection (from the wound clinic) On 12/13/21 at 1:21 P.M., Surveyor observed R36 laying on alternating air mattress with a thick pad between R36 and the mattress. Buttons of mattress pump were worn off; no alternating time was set. On 12/14/21 at 9:44 A.M., Surveyor observed R36 lying in bed with a thick pad between R36 and the mattress, pump settings were the same as 12/13, no alternating time was set. At 1:15 P.M., Surveyor observed R36 lying in bed with a Hoyer lift sling and a thick pad between R36 and the mattress and no heel boots on. At 1:45 P.M., Surveyor interviewed Certified Nursing Assistant (CNA) - F who verified that R36 should be wearing heel boots while in bed. CNA - F stated that the sling was underneath R36 because R36 was, going to be getting up for Bingo at 3:15 PM. CNA-F was unsure of what settings R36's alternating air mattress was supposed to be set to. At 2:37 P.M., Surveyor observed R36's current positioning and mattress settings with Registered Nurse (RN) - C, who is the facility's wound care nurse. RN-C verified that R36 should have heel boots on while in bed and that the pad and the sling should not be underneath R36. RN-C stated that the mattress appeared to not be cycling (alternating) and that maintenance would have to be called. RN-C verified that the worn mattress pump panel would make it difficult for anyone to verify that R36's mattress settings were correct. At 2:50 P.M., Surveyor interviewed Maintenance Worker (MW) - G, who verified that the mattress had not been alternating based on the buttons that were lit on the mattress pump. MW-G stated that the pump would have to be replaced. At 3:14 P.M., Surveyor interviewed Nurse Intern (NI) - H, who stated that, mattress functioning is on the TAR (treatment administration record) but that they were unsure of what it should be set at. NI-H stated that they push my hand onto the mattress and if it refills, it's working. At 3:21 P.M., Surveyor interviewed Registered Nurse (RN) - E, who stated that if the mattress is not working right, it will beep. RN-E was unaware of any orders to check the mattress or what the mattress settings should be set at. At 3:43 P.M., Surveyor observed R36 sitting in R36's wheelchair during an activity, with a lift sling between R36 and the alternating wheelchair cushion. At 3:50 P.M., Surveyor interviewed RN-C, who stated that R36 should not have the sling underneath R36 when they are in the bed or the wheelchair, unless it is specified in the care plan due to safety. RN-C verified that R36's care plan did not indicate that the lift sling could be left underneath R36. RN-C also stated that MW-G had replaced R36's mattress pump and that all nursing staff had been educated to remove the thick pad and lift sling from underneath R36. RN-C indicated that specific settings (firmness level, alternating times) for both the mattress and the wheelchair cushion would be added to the care plan.

Based on observation, interview, and record review, the facility did not ensure supervision and assistance to prevent accidents was provided to each Resident (R) for 4 (R32, R28, R92, and R12) of 12 sampled residents. Staff did not ensure R32's [MEDICATION(S)] (bronchodilator) inhaler was secured when R32 was not present. The facility did not assess R12 for safety to self-administer nasal saline spray. Surveyor observed R12 nasal saline spray on bedside table. R12 confirmed to Surveyor independent use of nasal saline spray. R28 was observed to have 1 pill on R28's bedside table. R28 was not in R28's room. R92 was observed to be putting in Refresh Eye Drops into R92's eyes when Surveyor entered R92's room. Findings include: 1. From 12/13/21 through 12/15/21, Surveyor reviewed R32's medical record which documented R32 was safe to self-administer [MEDICATION(S)] inhaler and [MEDICATION(S)] tablets. R32's Primary Care Provider (PCP) ordered that R32 could keep [MEDICATION(S)] inhaler at bedside and self-administer. On 12/13/21 at 10:43 AM, Surveyor observed R32's [MEDICATION(S)] inhaler in room on bedside table but R32 was not in R32's room. On 12/14/21 at 10:47 AM, Surveyor interviewed Director of Nursing (DON)-B regarding medications in resident rooms. DON-B indicated that if a medication was to be kept by resident, the resident is provided a lockbox to put medication in when medication is not with resident. On 12/14/21 at 11:07 AM, DON-B indicated that between 10:47 AM interview and 11:07 interview, Registered Nurse (RN)-E located R32's [MEDICATION(S)] in R32's room while R32 was out of the facility at an appointment. RN-E secured R32's [MEDICATION(S)] inhaler in medication cart. DON-B confirmed R32 had a lock box in room and indicated R32 would be reminded of the facility policy that medications be locked in box when medication is not with resident. On 12/14/21 at 11:11 AM, RN-E verified RN-E located and secured R32's [MEDICATION(S)] inhaler from R32's resident room while R32 was out of the facility. secured [MEDICATION(S)] only 2. Surveyor reviewed R12's medical record. No evidence of self-administration assessment of nasal saline spray was found in R12's record. Care plan indicated to discontinue orders to obtain self-administration of medication. Duo medication was discontinued on 11/27/21 and nasal saline spray was discontinued on 11/20/21. On 12/14/21 at 10:09 AM, Surveyor interviewed R12 and observed nasal saline spray on tray table near bed. R12 explained R12 used nasal spray on a daily basis independently. On 12/14/21 at 10:48 AM, Surveyor interviewed the Director of Nursing (DON)-B regarding self-administration of medication. Residents deemed safe to self-administer medication could have a locked box in their room to safely store medication. Not all medications that are self-administer are kept in resident rooms. The facility determines after assessment finding the secure placement of medication. On 12/14/21 at 11:08 AM, DON -B verified that the nasal saline was removed from R12's room and locked in the medication cart. 3. On 12/13/21, Surveyor reviewed R28's medical record. R28's self-administration of medication assessment indicates Oral meds (medications). Staff to store/set up meds. Staff may leave meds with R28, R28 must be present and take meds and not leave meds unattended. R28's Physician's order states, staff may leave medications with R28 present, R28 can take R28's meds independently once set up by staff. Staff to store med in the med cart/set up. On 12/13/21 at 10:32 AM, Surveyor walked by R28's door and observed 1 pill on R28's bedside table. R28 was not in R28's room and no staff were in R28's room. On 12/13/21 at 10:34 AM, Surveyor interviewed Medication Tech (MT)-D regarding 1 pill in R28's room. MT-D verified 1 pill was left unattended in R28's room. On 12/14/21 at 10:03 AM, Surveyor interviewed Director of Nursing (DON)-B regarding 1 pill being left in R28's room unattended. DON-B verified MT-D did not follow R28's self-administration of medications assessment when medication was left unattended and with R28 not present in R28's room. 4. On 12/13/21, Surveyor reviewed R92's self-administration of medication assessment and R92's assessment indicates No to the question stating, Will the resident be self-administering medications or a portion of their medications? On 12/13/21 at 10:36 AM, Surveyor knocked on R92's door. Surveyor heard R92 say, come in. As Surveyor opened door, R92 was observed to be putting in Refresh Eye Drops into both of R92's eyes. On 12/14/21 at 10:03 AM, Surveyor interviewed DON-B regarding R92 having a bottle of Refresh Eye Drops in R92's room. DON-B verified R92 does not self-administer medications and R92 should not have Refresh Eye Drops in R92's room. On 12/14/21 at 11:08 AM, DON-B and Registered Nurse (RN)-C verified that the Refresh Eye Drops were removed from R92's room. DON-B discussed R92's Refresh Eye Drops were brought in by R92's family and were not the Refresh Eye Drops the facility provided. On 12/15/21 at 9:45 AM, Surveyor interviewed R92 and R92's Family Member (FM). R92 and R92's FM discussed R92 had the Refresh Eye Drops since the first week admitted to the facility. R92 discussed has being using them multiple times a day and keeps them on the window sill or bedside table. R92 discussed at least once dropping the cap to the Refresh Eye Drops and staff assisted R92 to put cap back on the bottle. R92 was unable to identify the staff member.

Based on staff interview and record review, the facility did not ensure a written notification of transfer was provided to a Resident (R) transferred to the hospital for care for 4 (R3, R13, R36, and R12) of 4 sampled residents reviewed for hospitalization s. The facility did not provide R3 and/or R3's resident representative with a written transfer notification when R3 was transferred to the hospital on 9/14/21. The facility did not provide R13 and/or R13's resident representative with a written transfer notification when R13 was transferred to the hospital on 11/18/2021. The facility did not provide R36 and/or R36's resident representative with a written transfer notification when R36 was transferred to the hospital on 11/20/21. The facility did not provide R12 and/or R12's resident representative with a written transfer notification when R12 was transferred to the hospital on 11/20/21. Findings include: 1. From 12/13/21 through 12/15/21, Surveyor reviewed R3's medical record which documented the facility transferred R3 to the hospital on 9/14/21. Surveyor noted R3's record did not contain a written transfer notice. On 12/15/21 at 11:18 AM, Surveyor interviewed Registered Nurse (RN)-E, who verified being the RN who was responsible for R3 at the time of transfer to hospital on 9/14/21. RN-E explained forms sent to hospital at time of all resident transfers and confirmed no written notification of transfer was provided to residents or resident representatives at the time of transfer to hospitals. RN-E indicated families would be aware of which hospital a resident transferred to because residents and resident representatives declared a preferred hospital at the time of admission which was documented on the resident's profile. On 12/15/21 at 1:41 PM, Surveyor interviewed Director of Nursing (DON)-B who verified the facility did not provide a written notification of transfer to residents and/or resident representative. 2. From 12/13/21 through 12/15/21, Surveyor reviewed R13's medical record which documented the facility transferred R13 to the hospital emergency department on 11/18/21. Surveyor noted R13's record did not contain a written transfer notice. See RN-E and DON-B's interviews at example 1. 3. On 12/15/21, Surveyor reviewed R36's medical record. R36 was transferred to the hospital on 11/20/21 for a change in mental status. R36's medical record did not include documentation that a written transfer notice was provided to R36 or R36's representative at the time of the transfer. See RN-E and DON-B's interviews at example 1. 4. From 12/13/21 through 12/15/21, Surveyor reviewed R12's medical records. Documentation indicated R12 was transferred to the hospital from the facility on 11/20/21. R12's medical record did not include a copy of a transfer notice given to the resident and/or resident representative. See RN-E and DON-B's interviews at example 1.

Based on observation and interview the facility did not establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the transmission of communicable diseases and infections for 13 Residents (R) (R1, R2, R3, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14) of 42 residents observed for infection prevention. The facility did not ensure adequate hand hygiene was performed after a CNA made contact with potentially contaminated resident environments and prior to contact with residents or their environment. Findings: According to the CDC (Centers for Disease Control and Prevention), performing hand hygiene with alcohol based hand rub or soap and water prevents the spread of infectious diseases. One opportunity the CDC recommends to perform hand hygiene is, after touching a patient or the patient's immediate environment. According to the World Health Organization's 5 Moments for Hand Hygiene, moment number five states, When? Clean your hands after touching any object or furniture in the patient's immediate surroundings when leaving - even if the patient has not been touched. Why? To protect yourself and the health-care environment from harmful patient germs. The facility policy, entitled, Standard Precautions, dated effective 5/2011 and revised 4/14/2020, states: Standard Precautions are intended to be applied to the care of all personal in all healthcare settings, regardless of the suspected or confirmed presence of an infectious agent. Implementation of standard precautions constitutes the primary strategy for preventing healthcare-associated transmission of infectious agents among residents and healthcare personnel. Appropriate infection control measures should be used in each resident interaction. Standard precautions include but are not limited to hand hygiene . On 8/19/2020 at 9:00 AM, Surveyor observed CNA-G and CNA-F on the 4th floor unit picking up resident's breakfast trays from their rooms. CNA-F was pushing the cart down the hall and CNA-G had a soiled tray in both hands after exiting R14's room while wearing gloves and a mask. CNA-G cleaned off the items from the tray, placed tray on the cart, and walked into R1's room after knocking on the door wearing soiled gloves. R1 is on droplet and contact precautions (transmission based precautions requiring staff entering a room to be wearing certain personal protective equipment (PPE) in order to decrease the spread of infectious diseases). CNA-G exited R1's room, cleaned items from the tray, placed tray on the cart, and entered R2's room wearing the same soiled gloves. CNA-G exited the room with a soiled tray, cleaned items off the tray while wearing the same pair of soiled gloves and entered into the dining area where R3 was sitting at a table. R3 needed assistance with a napkin. CNA-G took the napkin and wiped a piece of food from near the resident, set napkin down, touched behind R3 either on R3's back or the chair (Surveyor could not see what CNA-G's left hand touched behind the Resident). CNA-G then took the pair of soiled gloves off and performed hand hygiene. At 9:40 AM, Surveyor observed CNA-G exiting R11's room with a cup of water. Interview with CNA-G stated CNA-L revealed CNA-L delivers the clean water cup to the residents while CNA-G goes into the room and takes the used water cup. CNA-G was wearing gloves when CNA-G exited R11's room. Without changing gloves or performing hand hygiene, CNA-G entered R12's room, left with the soiled water cup, placed the cup on the cart and entered into R13's room. CNA-G exited R13's room, put the soiled water cup on the cart, entered into R5's room with the same soiled gloves on, exited with the soiled water cup, placed the cup on the cart, and entered into R6's room (R6 is on contact and droplet precautions). CNA-G exited R6's room, placed soiled cup on the cart, and entered into R14's room with the same pair of soiled gloves. CNA-G exited R14's room, placed the soiled cup on the cart, and entered R1's room (R1 is on contact and droplet precautions) with the same pair of soiled gloves on. CNA-G knocked on R7's door, entered, took soiled water cup, placed cup on cart, and with the same pair of soiled gloves entered R2's room. CNA-G entered R8's room, exited with a soiled water cup, placed the cup on the cart, and with the same soiled gloves entered R9's room. CNA-G exited with a soiled water cup, placed cup on cart, and with the same pair of soiled gloves entered R10's room, exited with a soiled water cup, placed cup on cart, took gloves off and washed hands with soap and water. At 9:50 AM, Surveyor interviewed RN-C who stated the staff can wear the same pair of gloves going between rooms and gathering soiled items like meal trays and water cups, then stopped and stated, But on second thought. RN-C offered a nod indicating no, the staff should not wear the same pair of gloves in-between resident rooms. At 11:40 AM, R7 was sitting in the common area when CNA-G approached R7 and attempted to position R7's cloth face covering on R7's face over mouth and nose. CNA-G went behind nurse's station, took a white cloth face covering, and brought to R7. R7 declined the new cloth face covering because R7's mouth and nose were adequately covered. CNA-G brought the white cloth face cover back to the bin behind the nurse's station. CNA-G did not have gloves on or perform hand hygiene prior to touching R7's face and taking the cloth face covering. CNA-G walked around the corner and entered R18's room. Surveyor did not observe CNA-G perform hand hygiene, but CNA-G was not in direct line of vision just before entering R18's room. At 11:45, Surveyor observed CNA-G exit R18's room and perform hand hygiene. Surveyor asked CNA-G to take the white cloth face cover that was in the bin behind the nurse's station and place it in the soiled laundry due to the potential contamination. CNA-G took the white face covering and walked around the corner of the nurse's station on CNA-G's way to the dirty linen room, and stopped to help R8 with R8's cloth face covering that was falling off R8's face. CNA-G reached with both hands while holding the potentially contaminated white face covering in the right hand, and adjusted R8's mask. CNA-G then disposed of the white cloth face covering in the dirty linen room. CNA-G performed hand hygiene.

Based on observation, record review and staff interview, the facility used multi-dose medications beyond the recommended use by dates and not in accordance with professional standards of practice. These practices affected 5 Residents (R) (R27, R231, R4, R9, and R19) and had the potential to affect multiple other residents. R27's [MEDICATION NAME] Solution 0.5 % eye drops were opened on 12/27/2019 and in med cart for administration on 2/12/20. R31's Fluorometholone Suspension eye drops were opened on 12/10/2019 and in med cart for administration on 2/12/20. R4's [MEDICATION NAME] eye drops were opened on 12/31/2019 and in med cart for administration on 2/12/20. R9's [MEDICATION NAME] Balance Solution 0.6 % were opened on 12/28/19 and in med cart for administration on 2/12/20. R19's [MEDICATION NAME] Gel 0.4-0.3 % were opened on 12/30/19 and in med cart for administration on 2/12/20. Findings include: United States Pharmacopeia (USP) General Chapter 797 (16) recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer's expiration date. The manufacturer's expiration date refers to the date after which an unopened multi-dose vial should not be used. The beyond-use-date refers to the date after which an opened multi-dose vial should not be used. The beyond-use-date should never exceed the manufacturer's original expiration date. Facility Medication Storage Policy dated (MONTH) (YEAR) states: D. The expiration date of vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating . 1. On 2/12/20 at 8:33 AM, during the review of medication cart 1, the Surveyor and RN (Registered Nurse) - D observed several medications in multi-dose packaging with open dates being used past the recommended use by dates for open vials of medication: R27's [MEDICATION NAME] Solution 0.5 % eye drops were marked open on 12/27/2019 and marked to expire on 2/21/2020. R31's Fluorometholone Suspension eye drops were marked open on 12/10/2019 and marked to expire on 2/21/2020. 2. On 2/12/20 at 8:37 AM, during the review of medication cart 2, the Surveyor and MT (Medication Technician)-E observed several medications in multi-dose packaging with open dates being used past the recommended use by dates for open vials of medication: R4's [MEDICATION NAME] eye drops were marked open on 12/31/2019 and marked to expire on 2/25/2020. R9's [MEDICATION NAME] Balance Solution 0.6 % were marked open on 12/28/19 and marked to expire on 2/26/2020. R19's [MEDICATION NAME] Gel 0.4-0.3 % were marked open on 12/30/19 and marked to expire on 3/26/2020. On 2/12/20 at 10:29 AM, Surveyor interviewed DON (Director of Nursing)-B who indicated awareness of the current standard of practice regarding 28 day expiration for eye drops. DON-B was unsure why drops were marked with two month expiration dates.

Based on record review and staff interview, the facility did not ensure 1 Resident (R) (R296) of 14 sampled residents reviewed for advanced directives had appropriate signature on the Department of Health Services (DHS) Form F- Emergency Care Do Not Resuscitate (DNR) Order form, thus rendering the DNR order invalid. Upon admission to the facility, R296 completed and signed an Emergency Care Do Not Resuscitate (DNR) Order form. The facility did not ensure R296's DNR order was signed by a physician. Findings Include: DHS Emergency Care DNR Order form F- page 1 of 2 contained a signature and date line for the Patient/Legal Guardian/Health Agent and for the Attending Physician to sign. Below these two signature lines the form reads, The above signatures and dates are required for this order to be valid and its intent carried out. Page 2 of 2 of the DNR Order form outlines background and instructions which includes the following: Cardiopulmonary resuscitation (CPR) is a procedure used after [MEDICAL CONDITION] in which cardiac massage, drugs, and artificial ventilation are used to restore breathing and circulation. It is standard medical practice to perform CPR on all persons found to be in cardiac or respiratory arrest in the absence of directives from an attending physician to withhold such action. However, patients may legally and ethically decline these treatments. The DNR order is used to implement the decision that CPR is not to be performed. Page 2 of 2 of the DNR Order form further outlines guidelines for completing the form: Two dated signatures are required for this document to be valid and its intent carried out. 1. Patient, legal guardian, or health care agent's signature and date signed. 2. Attending Physician's signature and date signed by the physician. The Facility's CPR and DNR policy with last revision date of ,[DATE] states, It is the policy of Shady Lane Inc. to provide basic life support, including CPR - Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to a physician order [REDACTED]. Nurses and other care staff are educated to initiate CPR, as recommended by the American Heart Association (AHA) unless: A valid Do Not Resuscitate order is in place. Resident presents with obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection or decomposition) are present. Initiating CPR could cause injury or peril to the rescuer. R296 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. (narrowing of the valve in the large blood vessel branching off the heart). R296's cognitive status was assessed by the facility on [DATE] revealing little to no impairment of mental status. On [DATE] at 1:30 PM, Surveyor conducted a record review of R296's medical record. R296's patient profile in the electronic medical record indicated R296 was DNR status. Neither the active electronic medical record, nor the paper record for R296 contained a DNR Order form. On [DATE] at 8:21 AM, Surveyor interviewed Rehabilitation Unit Registered Nurse (RN)-C who explained that if DNR Order forms are awaiting physician signature they are placed in a plastic black box in the nurse's station. The box contained alphabetic dividers which housed the plastic DNR bracelets for those residents who were DNR status. RN-C explained that because R296's form was still awaiting the attending physician's signature, the form was folded and placed in this box until signature could be obtained on the form as well as on the plastic DNR bracelet inserts. Surveyor reviewed R296's DNR order form which contained R296's signature dated [DATE]. Surveyor noted that the DNR order form had not been signed by a physician. Surveyor reviewed R296's plastic DNR bracelet inserts located in the same section of the black box as the DNR form. It was noted that the bracelet inserts were also not signed by a physician. Upon further interview, RN-C reported should an emergency cardiac event occur for R296, RN-C would not perform CPR. Surveyor confirmed with RN-C that this order was awaiting signature since admission date of [DATE]. In relation to confirming a resident's status in the event of a [MEDICAL CONDITION], RN-C indicated facility staff would confirm the resident's CPR or DNR status in the electronic medical record; RN-C showed Surveyor R296's status was documented in the resident's profile area as DNR in the electronic record. RN-C indicated checking this area vs the signed DNR form was the quickest way to locate the information. On [DATE] at 11:45 AM, Surveyor interviewed Long Term Care Unit RN-D who reported in the event of a [MEDICAL CONDITION] of a resident in which a DNR Order was pending a physician signature, RN-D would attempt to call a physician on the telephone to obtain a verbal order not to perform CPR on the resident. On [DATE] at 9:15 AM, Surveyor interviewed Director of Nursing (DON)-B who reported that on admission the physician gives a written or verbal order indicating CPR or DNR status for each resident. DON-B provided surveyor with a verbal physician order [REDACTED]. DON-B confirmed the physician had not signed the order.

Based on interview and record review, the facility did not conduct a comprehensive, standardized assessment within the required timeframe for 3 Residents (R) (R290, R289, and R7) of 15 sampled residents. R290 had an admission Minimum Data Set (MDS) Assessment that was 19 days overdue. R289 had an admission MDS that was 20 days overdue. R7 had an annual MDS that was 22 days overdue. Findings Include: The Resident Assessment Instrument (RAI) Manual, revised (MONTH) (YEAR), states that For the Admission assessment, the MDS Completion Date must be no later than 13 days after the Entry Date For all non-Admission OBRA and PPS assessments, the MDS Completion Date (Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD). On 3/12/19, the Surveyor reviewed R290's medical record. R290 had an entry date of 2/9/18. R290 had an admission MDS dated [DATE] that was still in progress. This assessment was 19 days overdue. On 3/12/19, the Surveyor reviewed R289's medical record. R289 had an entry date of 2/8/19. R289 had an admission MDS dated [DATE] that was still in progress. This assessment was 20 days overdue. On 3/12/19, the Surveyor reviewed R7's medical record which documented R7's annual MDS status, ARD dated 2/5/19 that was still in progress. This assessment was 22 days past due. On 3/12/19 at 2:58 P.M., the Surveyor interviewed the Director of Nursing (DON)-A. DON-A verified that the assessments for R289, R290, and R7 were not completed timely.

Based on observation, interview, and record review, the facility did not ensure the the resident environment remained as free of accidents hazards as possible for 1 Resident (R) (R31) of 5 residents reviewed for accidents. R31 was locked in R31's room on multiple occasions and the facility did not keep a key on the unit where R31 is located. The facility did not review the safety risks of locking the door with R31 or R31's family. Findings Include: On 3/11/19 at 9:13 AM, the Surveyor observed R31's room door to be locked with the resident inside. The Surveyor questioned RN-B if R31 was available for an interview. RN-B went to retrieve the key for R31's room. RN-B returned at 9:21 A.M. to unlock R31's door. The Surveyor interviewed RN-B, who verified that the only keys in the building are with the maintenance person and the nursing supervisor. RN-B further stated that R31's door was not supposed to be locked while R31 was inside and that R31 had poor safety judgement. On 3/11/19, the Surveyor reviewed R31's medical record. R31 had [DIAGNOSES REDACTED]. R31 had a cognition score of 10 on a 15 point scale which indicated moderate cognitive impairment. R31's Minimum Data Set (MDS) Assessment indicated that R31 required extensive assistance with transferring, mobility, dressing, toileting, and hygiene. R31's care plan, revised 1/19/18, indicated R31, requests room door to be locked when not in room. The Surveyor reviewed R31's progress notes for the past 6 months. ~ On 9/12/18, R31 fell into the locked open door and it swung shut. The nursing supervisor had to unlock the door. R31 had complaints of wrist pain. ~On 2/5/19, R31's door was found to be locked during the bedtime medication pass. The maintenance staff had to unlock the door and R31 was found sitting on the floor. No injuries were noted. A progress note dated 3/11/2019 at 4:24 P.M. stated, Resident signed the AMA (Against Medical Advice) (form). Resident was explained that injury may occur when the door is closed and locked. Staff may not have immediate access to key to unlock the door. Resident understood it but still wanted to use the lock system with her own key. On 3/12/19 at 9:40 A.M., the Surveyor interviewed Director of Nursing (DON)-A, who verified that there were only two keys in the building for R31's door due to R31 not wanting a key on the unit. R31 did not want a key on the unit because R31 is distrustful of staff stealing things from room. DON-A stated that on 3/11/19, when it was brought to her attention by RN-B and the Surveyor, DON-A reviewed the risks of locking R31's door with R31 and R31's family. DON-A also had R31's representative sign an AMA form.

Based on observation, record review and staff interview, the facility did not provide pharmacy services to ensure the accurate administration of medication for 1 Resident (R) (R34) of 1 sampled resident observed self-administering medication. R34 was observed self-administering a nebulizer treatment. The facility did not assess R34 to ensure R34 was capable of administering the medication in accordance with the manufacturer's recommendations and the physician's order. R34's most recent self-administration assessment indicated R34 was incapable of self-administering medications. Findings include: The facility's Self-Administration of Drugs Policy dated 07/03, states: POLICY: Residents who are alert, oriented and meet to the criteria to safely self- administer medications, may do so when ordered by their health practitioner. PR[NAME]EDURE (includes but is not limited to): 1. Determine if the resident wishes to self- administer medications: [REDACTED]. (Nursing or medication aides may need to give medications until the appropriate assessment is completed). 2. Based on the information gathered, the IDT will decide if the resident can safely self-administer medications. 3. If for any reason, the resident's mental or physical function changes, the continued right to self-medicate will be revoked and re-evaluated by the interdisciplinary team. 4. Resident's with a self-administration of medication program in place will be evaluated with annually, quarterly and significant changes; for continued appropriateness/safety of self-administration plan. 5. The plan of care should reflect current self-administration of medication plan. On 3/12/19, the Surveyor observed R34 self-administering a nebulizer treatment in R34's room. The Surveyor did not observe nursing staff in or near R34's room. On 3/12/19 at 9:07 AM, the Surveyor interviewed RN (Registered Nurse)-B regarding R34's ability to self-administer medication. RN-B stated she sets up R34's nebulizer, then in approximately 12 minutes, returns to R34's room to remove the nebulizer. RN-B stated an order is received from R34's physician to self-administer nebulizers after set up by the nurse. RN-B and the Surveyor reviewed R34's physician orders. There was no physician's order for R34 to self-administer the nebulizer treatment. On 3/12/19 at 9:24 AM, the Surveyor interviewed DON (Director of Nursing)-A regarding R34's nebulizer self-administration. DON-A stated a self-administration assessment is completed to ensure that R34 understands the medication and if R34 is able to safely administer the nebulizer independently. On 3/12/19 the Surveyor reviewed R34's medical record. A self-administration assessment was completed on 11/14/18 that deemed R34 to be incapable of self-administration of medications.

Based on record review and interview, the facility did not electronically transmit encoded, accurate and complete Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) System for 4 Residents (R) (R1, R2, R3 and R4) of 18 sampled and supplemental sampled residents. R1's quarterly MDS dated [DATE] was Exported to CMS at the time of survey. R2's quarterly MDS dated [DATE] was Exported to CMS at the time of survey. R3's annual MDS dated [DATE] was Exported to CMS at the time of survey. R4's annual MDS, dated [DATE], was Exported to CMS at the time of survey. Findings include: 1. On 03/12/19, the Surveyor reviewed the medical record for R1. R1's most recent annual MDS had an Assessment Reference Date (ARD) of 1/22/19. The Surveyor noticed the Status of the annual MDS indicated Exported. 2. On 3/12/19, the Surveyor reviewed the medical record for R2. R2's most recent quarterly MDS had an ARD of 1/22/2019. The Surveyor noticed the Status of the quarterly MDS indicated Exported. 3. On 3/12/19, the Surveyor reviewed the medical record for R3. R3's most recent quarterly MDS had an ARD of 1/22/2019. The Surveyor noticed the Status of the quarterly MDS indicated Exported. 4. On 3/12/19, the Surveyor reviewed R4's medical record which documented R4's Annual MDS status, ARD dated 1/29/19, was export ready but not yet transmitted to CMS. On 03/12/19 at 02:39 PM, the Surveyor interviewed Director of Nursing (DON)-A. DON-A verified the MDS assessments for R1, R2, R3 and R4 were completed and ready to go to CMS, however, the MDS data was not transmitted to CMS on time. DON-A stated the facility has corrected the issue and the data has now been transmitted to CMS as of 3/12/19.

Based on staff and family interviews and record review, the facility did not make prompt efforts to resolve a grievance for 1 (resident # 9) of 17 sampled residents reviewed. Resident #9's FM (Family Member)-D voiced a concern to staff on 9/19/15 that resident #9 had been missing a scapular (a religious necklace). The facility staff did not fill out a missing item form that would be distributed to all departments to assist and attempt to locate resident #9's missing scapular. Findings include: On 9/28/15, surveyor # reviewed the facility's policy entitled Resident Missing Items with a revised date of March 2009. The policy stated The facility shall intervene, assist and attempt to locate resident missing personal items. A resident has the right to prompt efforts by the facility to resolve grievances the resident may have including those with respect to the behavior of other residents. The procedure indicated The facility will provide missing item forms for those noticing resident personal items missing. Forms can be initiated by any person noticing or has been reported to in regards to missing items. Forms should be initiated as soon as item is noted to be missing and appropriate departments and copies of the form should be distributed. Social Services Department will monitor forms daily and follow up as indicated. Each department involved is responsible for searching for the item . On 9/24/15, surveyor # reviewed resident #9's medical record. Resident #9's most current MDS (minimum data set) assessment dated [DATE], documented the resident had scored a 9 out of a possible 15 on the cognition assessment (the higher the score, the more cognizant) and was assessed to be dependant on staff for all ADL's (Activities of Daily Living). Additionally, the MDS indicated it was very important for resident #9 to participate in religious practices. Resident #9's electronic medical record included a nursing note dated 9/19/15, which indicated FM-D stated resident does not have (resident's)scapular. Staff to keep an eye out for it. On 9/24/15 at 3:00 p.m., surveyor # interviewed RN (Registered Nurse)-E regarding the above nursing entry for resident #9. RN-E verified FM-D reported resident #9 was missing the scapular on 9/19/15. RN-E stated I searched resident #9's room, talked to the AM shift staff, but could not find it. RN-E verified a missing item form had not been filled out and Social Services had not been notified. RN-E stated, I was too busy. On 9/24/15 at 3:30 p.m., surveyor # interviewed SW (Social Worker)-C regarding resident #9's missing scapular. SW-C stated I did not know about the missing scapular. I did not receive any information verbally or in writing regarding the necklace. Staff should have initiated a missing item form when the scapular was reported missing. The form would initiate a search of the item and ensure follow-up or resolution. SW-C indicated FM-D had not been updated on if the scapular was found or if the concern brought forward had any resolution. SW-C indicated he would follow-up with FM-D right away. On 9/28/15 at 4:10 p.m., surveyor # interviewed FM-D via the telephone. FM-D stated I spoke with a nurse from the facility on 9/19/15 regarding my mother's missing scapular. Resident #9 was very religious and involved with the church. FM-D indicated the scapular was a gift that had been given to resident #9 from a close friend, who meant a lot to resident #9. My mother was going to be buried with the necklace, it can't be replaced. On 9/29/15 at 1:00 p.m., surveyor # interviewed DON (Director of Nursing)-F regarding missing items. DON-F stated Staff should have filled out the missing item form to notified all departments.

Based on record review and staff interview, the facility did not consistently implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents for 1 of 10 sampled staff assessed during the caregiver program compliance check. The facility's policy and procedure indicates staff screenings are to be completed. The facility did not ensure accurate information was used to complete a background check for one applicant. Findings include: The facility's Abuse Investigation Reporting Requirements policy, dated 3/98, states: PURPOSE: 1. All residents at Shady Lane Nursing Home have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. Shady Lane prohibits mistreatment, neglect and abuse of residents and misappropriation of resident property. 3. Shady Lane will not employ any individual who has been found guilty of abusing, neglecting or mistreating residents by a court of law. The facility will also not employ nursing assistants who have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, mistreatment of [REDACTED]. PROCEDURE: 1. Staff screenings to be completed, including but not limited to: A. Reference Checks B. Licensing Board or Registry Check C. Criminal Background Check On 9/23/15, surveyor # completed a caregiver program compliance check for 10 sampled direct and contracted staff employed by the facility. MT (Medication Technician)-G was hired by the facility on 10/23/95. MT-G's BID (Background Information Disclosure) form, dated 11/11/4, indicated MT-G had either pending criminal charges or a disorderly conduct conviction. MT-G's IBIS (Integrated Background Information System) letter and DOJ (Department of Justice) form were completed on 11/25/14 and indicated no findings. MT-G also had no findings on the Wisconsin Caregiver Misconduct Registry. MT-G's DOB (date of birth) on the BID form documented MT-G was born in 1971; however, the IBIS letter and DOJ form were run with a birth year of 1991. In addition, MT-G did not list additional information regarding the disorderly conduct charge. The facility did not follow-up with MT-G until it was brought to the facility's attention by surveyor # . HRD (Human Resources Director)-H resubmitted MT-G's IBIS letter and DOJ form with the correct birth year and had MT-G provide a written statement regarding the disorderly conduct charge. MT-G stated the charge was from 11/07, was resolved and was no longer on MT-G's record. MT-G's corrected IBIS letter and DOJ form indicated no findings. HRD-H also checked with the Clerk of Courts and requested a copy of the disorderly conduct charge from the Manitowoc Police Department on 9/24/15.

Based on observation, record review and staff interview, the facility did not provide the necessary care and services to maintain the highest practical physical well being in accordance with the comprehensive assessment and plan of care for 1 (resident #1) of 18 sampled residents. Resident #1 had a [DIAGNOSES REDACTED]. The resident was to be non-weight bearing on the right lower extremity at all times. During a transfer and repositioning observation, the resident grimaced, winced, cried and displayed obvious signs of pain. Following the observation, staff did not let the nurse know the resident was in pain. Findings include: 1. On 9/23/15, surveyor # reviewed the medical record of resident #1. The resident had [DIAGNOSES REDACTED]. Resident #1's most recent MDS (Minimum Data Set) assessment dated [DATE], documented the resident required extensive assistance of staff for transfers, bed mobility and toileting. The resident was admitted to the facility from a local hospital following a fall, displaced [MEDICAL CONDITION] and surgery. The resident was to be non-weight bearing on the right lower extremity at all times and transferred with a pivot disk and 2 staff. Resident #1's most recent pain assessment dated [DATE], indicated the resident expressed pain verbally and used medication, repositioning and rest for pain relief. The resident had both scheduled and PRN (as needed) pain medication. Resident #1's temporary Alteration in Comfort Care Plan dated 6/15/15, indicated the resident used repositioning, rest and diversional activities for pain relief and indicated the resident groaned and grimaced when in pain. On 9/23/15 at 12:50 p.m., surveyor # observed CNA (Certified Nursing Assistants)-I and CNA-J provide toileting and repositioning for resident #1. CNA-I and CNA-J transferred resident #1 from the wheelchair to commode using a gait belt, pivot disk and walker. As CNA-J moved the resident's legs, the resident stated It hurts a lot. Surveyor # observed resident #1 wince in pain during the transfer. CNA-I remained with the resident, and as CNA-J left the room to find out the afternoon activity, resident #1 stated, I don't' have to go. My hip feels terrible. After cares were completed, CNA- I and CNA-J transferred the resident back to the resident's wheelchair. CNA-I and CNA-J then prepared the resident's bed and used a gait belt, pivot disk and walker to transfer resident #1 into bed. Surveyor # again observed resident #1 wince in pain during the transfer. As resident #1 was positioned in bed and a pillow was placed between the resident's legs, resident #1 grimaced and began crying. On 9/28/15 at 10:50 a.m., surveyor # interviewed resident #1 regarding the resident's pain. Resident #1 stated They (staff) are not giving it (pain medication) to me. I'm not sure if I have scheduled and PRN medication. I'm always in pain. It doesn't go away. On 9/28/15 at 10:55 a.m., surveyor # interviewed LPN (Licensed Practical Nurse)-K regarding resident #1's pain. LPN-K indicated the resident has orders for [MEDICATION NAME] 5/325 mg (milligrams) TID (three times daily) and 1 tab every 4 hours PRN, and an order for [REDACTED].#1 rarely asked for PRN pain medication and rarely complained of pain. Resident #1's September 2015 MAR (Medication Administration Record) documented the resident received PRN [MEDICATION NAME] on 9/4/15 and PRN Tylenol on 9/17/15. LPN-K verified the resident did not receive PRN pain medication following the resident's transfer the previous day. LPN-K indicated resident #1 receives scheduled [MEDICATION NAME] at 7:30 a.m., 7:00 p.m. and 1:00 a.m. daily. LPN-K commented resident #1 receives pain medication at 1:00 a.m. because the resident had problems repositioning during the night. LPN-K also indicated the resident's [MEDICATION NAME] was increased on 8/18/15 at the resident's care conference due to the resident's complaints of pain during the night. LPN-K was not sure if a [MEDICATION NAME] had been attempted or suggested for resident #1. On 9/28/15 at 3:00 p.m., surveyor # interviewed CNA-J regarding resident #1's pain during surveyor # 's observation on 9/23/15. CNA-J stated That's the way (resident #1) always is .always in pain. I didn't tell the nurse after the observation because they know (resident #1) is always in pain. (Resident #1) is always in pain during movement. On 9/29/15 at 11:15 a.m., surveyor # interviewed DON (Director of Nursing)-F who indicated she would expect any CNA who witnessed a resident in pain to report it to a nurse. On 9/29/15 at 11:50 a.m., surveyor # interviewed DON-F regarding resident #1. DON-F indicated the resident was on shift to shift report from 8/18/15 to 8/21/15 for pain and depression monitoring following an increase in pain medication and the start of [MEDICATION NAME] (an antidepressant). When the resident was removed from shift report on 8/21/15, the resident was noted to have decreased pain and an improvement in mood. DON-F also indicated resident #1 was on shift to shift report from 9/17/15 to 9/21/15 for monitoring during transfers due to a decline. DON-F indicated resident #1 was agreeable to receiving medication at 1:00 a.m., due to complaints of pain in the early morning. DON-F stated the resident's pain medication was changed on 9/28/15 to [MEDICATION NAME] BID (twice daily) with the addition of a 12 mcg (microgram) [MEDICATION NAME] ([MEDICATION NAME]) patch to be changed every 72 hours. On 9/29/15 at 2:10 p.m., surveyor # interviewed LPN-L regarding resident #1. LPN-L stated resident #1 Never tells me (resident #1) has pain. You can see (resident #1) moan with cares when you change the bed .just with movement. LPN-L indicated the resident reported a pain level of 3 out of 10 yesterday and stated the pain was better than it was earlier in the day. LPN-L also indicated CNAs do not usually report if the resident is in pain after cares. On 9/29/15 at 2:15 p.m., surveyor # interviewed CNA-M regarding resident #1. CNA-M indicated resident #1 is usually in pain, but had no complaints of pain when CNA-M recently assisted the resident with toileting.

Based on observation, staff interviews and record review, the facility did not ensure that 1 (resident #18) of 2 supplemental sampled residents observed with a GT (Gastrostomy Tube) received the appropriate treatment and services to prevent complications. Resident #18 was administered 10 medications together via GT without flushing between each medication. Findings include: The facility policy entitled 'Medication via [DEVICE]' with an effective date of 08/2013, indicated liquid medications should be administered first, then those that need to diluted. Flush tube with 5 ml (milliliter) of water between medications. According to the S & C (Survey and Certification) memo 13-02 The most common improper administration technique includes mixing multiple drugs together to give at once and failing to flush the tube before giving the first drug and between subsequent drugs. Appropriate administration techniques must be used to prevent compatibility issues .and tube occlusions Medication Administration in A.S.P.E.N. (American Society for [MEDICATION NAME] and Enteral Nutrition) enteral nutrition practice recommendations, dated 3/15/10 indicated, .Each medication should be administered separately through an appropriate access .Prior to administering medication, stop the feeding and flush the tube with at least 15 ml water. Dilute the solid or liquid medication as appropriate and administer using a clean oral syringe. Flush the tube again with at least 15 ml water taking into account patient's volume status. Repeat with the next medication (if appropriate). Flush the tube one final time with at least 15 ml water . On 9/24/15 at 9:28 a.m., surveyor # observed LPN (Licensed Practical Nurse)-B commingle resident #18's medications for administration via a gastrostomy tube. LPN-B stated have order to comingle because they (medications) don't have any contraindications to being given together. LPN-B crushed nine pills and then poured 10 ml (milliliter) of [MEDICATION NAME] liquid 100 milligram/5 ml in a medication cup. LPN-B then poured the [MEDICATION NAME] in the same cup with the nine crushed medications and added 50 ml of water to the medications. At 9:40 a.m., LPN-B administered the 10 medications together rather than administering each medication with a flush of water between the medications. On 9/24/15 at 11:00 a.m., surveyor # interviewed RN (Registered Nurse)-C regarding administering all the medications together via GT for resident #18. RN-C stated the facility asks the physician to review (the medications) and if able to comingle (the medications) will give an order to do so. The pharmacy lets us know if can or can't mix them (medications). No medical reason why resident 18's medications are mixed together for administration. On 9/24/15, surveyor # reviewed resident #18's physician orders. The current physician's orders [REDACTED]. On 9/24/15, the facility provided surveyor # with information provided to staff administering medications. The information indicated when administering medications via GT, you must follow the attached procedure. If medications are going to be comingled, you must have justification and an order from the physician.

Based on record review, observation and staff interview, the facility did not ensure residents were free of a medication error rate of five percent or greater for 2 (resident #10 and resident #18) of 4 sampled and supplemental sampled residents observed during medication administration. Three of 39 opportunities observed during medication administration resulted in errors to equal an error rate of 7.6 percent. Resident #10's [MEDICATION NAME] was not administered per manufacturer guidelines. Resident #18's gastrostomy tube was not flushed with the appropriate amount of water before administration of medications, per the current standard of practice. Additionally, resident #18 was not administered the correct dose of one liquid medication as ordered by the physician. Findings include: 1. On 9/24/15 at 8:40 a.m., surveyor # observed RN (Registered Nurse)-A hand resident #10 an [MEDICATION NAME] 250/50 inhaler ready for inhalation. RN-A did not provide the resident with instructions to breathe out as long as possible prior to the inhalation, to hold breath for 10 seconds or longer after the inhalation and did not advise the resident to breathe out slowly as long as the resident could after inhaling the medication. Resident #10 inhaled the medication without breathing out as long as possible prior to the inhalation, did not hold breath for 10 seconds or longer after inhalation and did not breathe out slowly for as long as the resident could after inhaling the medication. RN-A verified the above observations and verified instructions were not provided to the resident prior to the administration of the inhaler. RN-A then stated instructions were not provided to the resident because the resident knows how to use the inhaler. According to the manufacturer guidelines of [MEDICATION NAME], the person should breathe out (exhale) through the mouth as long as possible before breathing in the dose from the inhaler. Put the mouthpiece to lips. Breathe in quickly and deeply through the inhaler. Remove the inhaler from mouth and hold breath for about 10 seconds, or for as long as is comfortable. Breathe out slowly as long as possible. 2. On 9/24/15 at 9:28 a.m., surveyor # observed LPN (Licensed Practical Nurse)-B commingle resident #18's medications for administration via a gastrostomy tube. LPN-B crushed the nine pills and then poured 11 ml (milliliter) of [MEDICATION NAME] liquid 100 milligram/5 ml in a medication cup. LPN-B verified 11 ml was in the medication cup ready to be administered to the resident. After surveyor # asked if 10 ml should be administered rather than 11 ml, LPN-B removed one ml from the medication cup. At 9:40 a.m., LPN-B checked the placement of the gastrostomy tube and administered the 10 medications without flushing the tube with water prior to the administration of the medication. After the medications were administered, LPN-B flushed the tube with 50 ml water. LPN-B verified the tube was not flushed with water prior to administering the medications and stated I forgot to flush the gastrostomy tube with water prior to administering the medications. According to A.S.P.E.N (The American Society for [MEDICATION NAME] & Enteral Nutrition 2009), the tube should be flushed with at least 15 ml of water prior to administering medications. The facility's policy entitled 'Medication via [DEVICE]' with an effective date of 08/2013, indicated the MAR (Medication Administration Record) should be checked to determine the amount of water flush to be delivered. On 9/24/15, surveyor # reviewed resident #18's physician orders. The current physician orders [REDACTED]. On 9/24/15, the facility provided surveyor # with information provided to staff administering medications. The information indicated when administering medications via GT, you must follow the attached procedure. Flush the tube prior to med administration. The information provided also indicated when measuring liquid medications, place the cup on a flat surface and measure at eye level to assure accurate measurement. Additionally, the information provided indicated when administering inhalers you must remind/encourage the resident to exhale prior to the dose being administered and encourage the resident to hold their breath for at least 10 seconds after the administration.

Based on observations, record review and staff and family interviews, the facility did not ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable for 1 (resident #5) of 6 sampled residents reviewed for pressure ulcers. Resident #5 developed a stage IV avoidable pressure ulcer due to staff positioning the resident's lower leg on top of Foley catheter tubing. The pressure ulcer required surgical debridement twice, use of a [DEVICE], and introduction of 2 antibiotics into the resident's medication regime. Not all staff from all floors of the building had been in serviced on repositioning techniques with residents requiring use of medically related devices. Additionally, staff had not consistently free floated resident #5's heels per her plan of care during the time of the survey. Failure of the facility to implement appropriate preventative and treatment interventions for resident #5 resulted in an avoidable stage IV pressure ulcer. This created a situation of Immediate Jeopardy, which began on 4/18/14 when staff became aware of pressure ulcer. NHA (Nursing Home Administrator)-J and DON (Director of Nursing)-C were formally notified on 9/17/14 that an Immediate Jeopardy situation existed. The Immediate Jeopardy was removed on 4/18/14, however the deficient practice continues at a scope/severity level of D (No actual harm with potential for more than minimal harm that is not immediate jeopardy). Resident #5 was at high risk for pressure ulcer development and had a history of [REDACTED]. Resident #5's written plan of care included to elevate heels off the bed with pillows. Multiple observations were made of resident #5's bilateral heels in full contact with mattress. Findings Include: The Quick Reference Guide entitled, "Pressure Ulcer Prevention", published by the National Pressure Ulcer Advisory Panel in 2009 indicated high pressures over bony prominence's, for a short period of time, and low pressures over bony prominence's, for a long period of time, are equally damaging. In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure he/she is exposed to. Ensure that the heels are free of the surface of the bed. Heel protection devices should elevate the heel, completely off loading them. Risk Assessment. Conduct a structured risk assessment on admission, and repeat as regularly and as frequently as required by the individual's condition. Reassessment should also be undertaken if there is any change in patient condition. Skin Assessment. Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration. The frequency of inspection may need to be increased in response to any deterioration in overall condition. Observe the skin for pressure damage caused by medical devices. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown is classified as full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stage (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. Category/Stage IV: Full thickness tissue loss (muscle/bone visible) is classified as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling. Further description: The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/;or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] likely to occur. Exposed bone/muscle is visible or directly palpable. The NPUAP article entitled, "MDRPU (Medical Device Related Pressure Ulcers): The Hidden Epidemic Across the Lifespan" published in October of 2013 indicated that MDRPU's occur because of: ? "rigidity & inelasticity of devices ? difficulties in adjusting/securing to the body ? may be difficult to safely remove/lift ? prolonged pressure in the same place ? altered microclimate with increased moisture and heat ? tight securement ? poor positioning or fixation of device ? inappropriate size, selection ? obscured skin from visualization ? lack of awareness of [MEDICAL CONDITION] impact The article also indicated that 2010 research indicated patients with a medical device were 2.4 times more likely to develop a pressure ulcer. The standard of practice relating to pressure ulcers is to include thorough skin assessment under devices every shift if not medically contraindicated; avoid replacing devices on injured skin as feasible; ensure proper sizing (resize with [MEDICAL CONDITION]). Resident #5's admission face sheet dated 2007 indicated the resident had [DIAGNOSES REDACTED]. Resident #5's MDS (Minimum Data Set) assessment dated [DATE], indicated the resident was assessed to score 5 of 15 on the cognitive screen (the higher the score, the more cognizant), required extensive assistance for bed mobility and transfers and did not ambulate. Resident #5 had range of motion deficits in bilateral lower extremities and was at risk for pressure ulcers with a current stage IV pressure ulcer present. The resident was 62 inches tall and weighed 151 pounds. The resident's age was listed as 93. Resident #5's skin risk score assessment dated [DATE], indicated the resident was assessed to be at high risk. The resident has a history of pressure ulcers on her coccyx in 2011 and most recently in May of 2014 assessed to be a stage III pressure ulcer which is presently healed. The resident has a chronically indwelling Foley catheter in place due to [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] and [MEDICAL CONDITION]. A nursing entry in the resident's medical record dated 4/18/14, indicated resident #5 had presented with an 8 cm (centimeter) x 2 cm pink area to right lateral shin area after it appeared the resident's right leg was resting on the side and on top of Foley catheter tubing. On 9/16/14 at 1:35 p.m., surveyor # interviewed CNA (Certified Nursing Assistant)-H regarding resident #5. CNA-H indicated they had repositioned resident #5 at approximately 6:00 p.m. on 4/18/14 and when the CNA returned to the resident's room at approximately 8:00 p.m. that evening to reposition and complete cares for the resident, CNA-H noticed the red spot on the right lower leg from the leg lying on top of the catheter tubing. CNA-H indicated the resident was lying on her right side and the bare catheter tubing was pressing against the leg of the resident. CNA-H indicated she had in-servicing before the incident had occurred regarding proper placement of Foley tubing with residents with catheters. On 4/18/14, resident #5's care plan was revised to include an intervention to assure the Foley strap was not positioned under the leg and that it was laying next to the resident's leg to prevent pressure on skin. On 4/25/14, an additional care plan intervention was added to the resident's plan of care to include that the Foley catheter was to be padded at all times. On 9/16/14 at 8:45 a.m., surveyor # interviewed RN (Registered Nurse)-G regarding resident #5. RN-G functions as the facility's wound nurse. RN-G verified to the surveyor that resident #5 spends most of her time in bed. RN-G also verified to the surveyor that after the pressure ulcer had occurred on resident #5's lower leg due to being repositioned on the Foley catheter tubing, the facility posted on 4/18/14 a communication that staff were to review and sign relating to resident #5 only and the communication was only posted in the third floor nurses station. The directive indicated that staff were to "Assure Foley strap not under leg and is laying next to (resident #5's) leg to prevent pressure on skin." There are two additional floors that house residents that were not given this communication. On 9/16/14 at 2:56 p.m., surveyor # interviewed LPN(Licensed Practical Nurse)-I regarding resident #5. LPN-I indicated when she went in to assist with cares with resident #5 on 4/18/14, the resident was on the right side with the leg turned to the side and the Foley tubing over top of the leg and shin and the tubing was caught and laying on the lateral aspect of the lower leg shin area. When the resident was moved to the left side, LPN-I noticed a pink area on the lower leg from the Foley tubing. LPN-I assessed the area along with measurements to include an 8 cm by 2 cm pink area to the lateral right shin which was blanchable and not open. On 4/21/14, the facility's ulcer flow sheet completed for resident #5 documented the area as described above as a deep tissue injury measuring 3.0 cm x 2.0 cm, with the center having purple discoloration, peri wound was red, indurated, and not open. On 4/29/14, the facility's ulcer flow sheet completed for resident #5 documented the wound to be open in the center indicating the presence of a stage III pressure ulcer measuring 2.0 cm by 1.0 cm by < (less than) 0.1 cm. On 5/29/14, resident #5's leg wound required surgical debridement down to the fascia (fibrous tissue network located between the skin and the underlying structure of muscle and bone) and down to the muscle by a surgeon. A Physician's note dated 6/16/14, indicated resident #5's wound had decompensated and had to be surgically debrided again which exposed part of the fibula. The Surgeon had determined the wound was a stage IV full thickness necrotic ischemic pressure ulcer due to the right leg lying on top of Foley catheter tubing. Pulse volume recordings at the right ankle were flat line, and with near flat line pulse volume recordings for the left ankle. [DEVICE] treatment was started and the resident was started on the antibiotic [MEDICATION NAME] VK 500 mg (milligrams) three times a day for 7 days. On 6/23/14, the resident was started on an additional antibiotic via IV (Intravenous) infusion per the Surgeon's orders. The medication was listed as [MEDICATION NAME] 1 gram every 12 hours times 14 doses. The additional antibiotic was initiated due to bloody drainage and foul odor coming from resident #5's leg wound. A pressure ulcer flow sheet documented on 8/14/14 the resident's [DEVICE] was discontinued. By 9/3/14 the leg wound was closed, and by 9/10/14 (greater than 4 months), the leg wound was resolved. On 9/17/14 at 11:35 surveyor # interviewed RN-G regarding resident #5. RN-G indicated that she in-services the CNA's on placement of Foley tubing per the National Pressure Ulcer Advisory Panel standards of practice. RN-G also indicated the expectation that the CNA's are aware and understand the placement of Foley tubing with residents with catheters as to not cause pressure and that because of this expectation, interventions relating to the above are not listed on the resident plan of care. Resident #5's CNA care plan dated 5/14/14, included an intervention to include free floating of heels in bed with use of pillows. On 9/16/14 at 7:55 a.m., surveyor # observed resident #5 in bed, positioned on back with a pillow positioned under the right side. Resident #5's legs were resting on pillows with both socked heels in full contact with mattress. On 9/16/14 at 8:50 a.m., surveyor # observed resident #5's socked heels, both in full contact with mattress and pillows. Resident #5 was positioned lying flat on back. On 9/16/14 at 9:00 a.m., surveyor # observed resident #5's socked heels again both in full contact with mattress and not free floating as per plan of care. On 9/16/14 at 9:20 a.m., surveyor # observed CNA-K and CNA-L reposition resident #5 and noted prior to the repositioning, the resident's heels were not free floating and in full contact with mattress. Surveyor # observed resident #5's heels at that time. Both heels were blanchable with no redness and the skin was intact. CNA-K and CNA-L at this time repositioned resident #5 utilizing 2 pillows to free float heels. The surveyor immediately interviewed CNA-K who verified to the surveyor that neither of resident #5's heels were free floating and were in full contact with the mattress. On 9/16/14 at 9:32 a.m., surveyor # observed resident #5's in bed with the left socked heel in full contact with mattress. It was noted by the surveyor that the resident had one pillow under each calf and pillows were folded in two and were not promoting free floating of the left heel. On 9/16/14 at 9:42 a.m.,surveyor # and RN-G observed resident #5 in bed. RN-G verified resident #5's left heel was not free floating and was in full contact with the mattress. RN-G indicated resident #5's heels should be free floating while in bed and at this time adjusted resident #5's left heel to free float. On 9/18/14 at 1:25 p.m., surveyor # interviewed resident #5's FM (Family member). FM-F indicated she was the resident's ADPOA-HC (Activated Durable Power of Attorney for Health Care). FM-F indicated the facility did not necessarily tell her anything about the importance of free floating resident #5's heels, but did bring up wearing boots one time, but resident #5 did not want to wear them. FM-F also indicated when she visits sometimes resident #5's heels are touching the mattress and sometimes they are not. FM-F also indicated when she was visiting resident #5 yesterday, RN-G came into the room and showed somebody how to free float heels. FM-F stated this was the first time she had noticed that they really made sure resident #5's heels were elevated. FM-F further indicated resident #5 received a sore from lying on her catheter tubing and at that time she believes the catheter tubing was not covered with anything and now it is. FM-F indicated the sore just kept getting worse and the doctor had to cut away tissue two different times and that resident #5 was put on a [DEVICE] and protein drinks to help heal the sore. FM-F stated, "I definitely believe the facility is at fault for not watching the positioning of the tubing. This upset me because that was their negligence, she is much more bed ridden and they have to keep an eye on that." The immediate jeopardy was removed on 4/18/14 when the facility posted a communication that staff were to review and sign relating to resident #5 in the third floor nurses station. The directive indicated that staff were to "Assure Foley strap not under leg and is laying next to (resident #5's) leg to prevent pressure on skin."

Based on record review, staff and resident interviews, the facility did not provide pharmaceutical services including accurate dispensing and administration of all drugs and biologicals resulting in hypoglycemic reactions and risk of serious harm and/or death to 1 resident out of 10 sampled (resident #1.) Resident #1 had physician orders [REDACTED]. Facility staff inaccurately changed and administered 30 units on 2/1/12, 2/2/12, and 2/3/12 resulting in resident #1 experiencing episodes of [DIAGNOSES REDACTED] (low blood sugar) on 2/1/12 and 2/3/12. The Immediate Jeopardy began on 2/1/12 when staff incorrectly transcribed the order and a second nurse did not verify the written the physician order [REDACTED]. Nursing staff then administered 10 times the ordered amount of insulin for 3 days. The NHA (Nursing Home Administrator) was notified of the immediate jeopardy at 4:30 p.m. on 2/17/12. The Immediate Jeopardy was removed on 2/4/12, but the noncompliance remains at at the lower scope and severity level of D (potential for more than minimal harm that is not immediate jeopardy/isolated) because an additional medication error was identified by the survey team. Resident #2 had a physician order [REDACTED]. On 2/12/12, resident #2 did not receive the additional 5 units, as ordered for a blood sugar of 228. Findings include: The Mayo Clinic notes, [DIAGNOSES REDACTED] is defined as blood sugar below 70 milligrams per deciliter (mg/dL). This occurs when there is too much insulin and not enough sugar (glucose) in your blood. [DIAGNOSES REDACTED] is most common among people who take insulin, but it can also occur if you're taking oral diabetes medications. [DIAGNOSES REDACTED] may result from taking too much insulin. The Mayo clinic notes, "Pay attention to early warning signs so you can treat low blood sugar promptly. Treatment involves short-term steps - such as taking glucose tablets - to raise your blood sugar into a normal range...Left untreated, diabetic [DIAGNOSES REDACTED] can lead to seizures and loss of consciousness. This is considered a medical emergency..." A 2009 federal hearing decision (Hallmark House vs. CMS), which involved a resident who received ten times the ordered amount of insulin, noted that severe [DIAGNOSES REDACTED] can cause "brain damage, seizures, lack of consciousness, coma and even death." 1) On 2/15/12 surveyor # completed a record review for resident #1. The undated admission record documented resident #1 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The hospital discharge summary dated 1/31/12 provided the following physician orders [REDACTED]. *Insulin aspart (Novolog) 100 Units/ml (milliliter) subcutaneous injection, Inject 3 Units into the skin once daily with breakfast. The physician orders [REDACTED]. The sliding scale insulin indicated the following: *Insulin aspart (Novolog) 100 Units/ml subcutaneous injection, inject into the skin four times daily before meals and at bedtime. Novolog Subcut. (subcutaneous) if blood sugar: 0-120= 0 units, 121-150=2 units, 151-200=4 units, 201-250=5 units, 251-300=6 units, 301-350=8 units, 351-400=10 units, 401-450=12 units & call MD (Medical Doctor). Greater than 450=Call MD. According to the Nursing 2011 Drug Handbook, by Wolters Kluwer/Lippincott Williams & Wilkins, copyright 2011, insulin aspart (Novolog) when administered subcutaneously, has an onset of 15 minutes, peaks at 1-3 hours, and the duration is 3-5 hours. On 1/31/12 the MAR documented resident #1 was to receive 30 units of Novolog insulin with breakfast (rather than the 3 units as ordered by the physician), and sliding scale Novolog insulin according to the result of the blood sugar testing to be completed with meals and at bedtime. During an interview with surveyor # on 2/15/12 at 10:15 a.m., WC-A (Ward Clerk) indicated that upon resident #1's admission on 1/31/12 she transcribed the physician orders [REDACTED]. WC-A indicated she transcribed the orders as written, including the Novolog insulin at breakfast to be 3 Units, as ordered. WC-A stated she then provided the physician orders [REDACTED]. During a telephone interview with surveyor # on 2/15/12 at 9:15 a.m., RN-B verified WC-A provided her with the transcribed admission orders [REDACTED]. RN-B stated the morning Novolog insulin was appropriately documented as 3 units as ordered. RN-B stated she "locked" the orders into the computer. RN-B stated the facility has a "double" check system in which the orders need to be verified by another nurse and double "locked" into the computer. RN-B indicated she printed off the "Chrono" orders which are a chronological listing of the physician orders [REDACTED]. RN-B stated she asked RN-C to verify the orders, and double lock the orders and generate the MAR. During a telephone interview with surveyor # on 2/15/12 at 8:42 a.m., RN-C verified RN-B provided her with the "Chrono" listing of physician orders [REDACTED]. RN-C stated she reviewed the transcribed physician order [REDACTED]." RN-C stated she misread the order to be 30 units of Novolog with breakfast rather than 3 units. RN-C stated she changed the order in the computer from 3 to 30 units, but had not verified the original order noted on the hospital discharge summary. Surveyor # asked why RN-C why she thought the transcribed order was 30 units instead of 3 units, RN-C stated she thought the U was a zero. It should be noted that the transcribed order was fully written as 3 Units and not abbreviated to be 3 U. RN-C was not able to explain why she did not recognize if she thought the U was a zero then the order would have read 3U "nits". RN-C was not able to explain why she had not verified the original physician order [REDACTED]. RN-C stated after she changed the order in the computer, amended the chrono sheet, locked the order in the computer, and asked LPN-D (Licensed Practical Nurse) to "double lock" the order in the computer. During a telephone interview with surveyor # on 2/15/12 at 9:35 a.m. LPN-D verified that on 1/31/12 RN-C called her and asked her to double lock resident #1's physician orders [REDACTED].#1's medical record. LPN-D verified she was not familiar with resident #1 and had not reviewed any of the orders noted by the physician. LPN-D stated she was working on another unit when her supervisor (RN-C) called her and asked her to double lock the orders. LPN-D stated she did indeed double lock the orders, (which included 30 units of Novolog insulin with breakfast), but had not actually verified the orders were correct. When surveyor # questioned the rationale behind having a second nurse lock the orders, LPN-D stated it was a double check system to ensure the orders were correct. LPN-D verified she had not completed the verification, and stated she was in a "hurry" and assumed the orders were correct. The MAR documented the following: 2/1/12 at 7:30 a.m., resident #1's blood sugar was 189. Resident #1 was provided 30 units of Novolog insulin, and an additional 4 units of sliding scale Novolog insulin for a total of 34 units. (According to the physician admission orders [REDACTED]. 2/1/12 at 11:30 a.m. resident #1's blood sugar was 54. The resident progress notes dated 2/1/12 at 12:55 p.m. indicated RN-E had contacted the NP (nurse practitioner) regarding the low blood sugar, and an order to hold the next scheduled dose of Novolog was received. A Late Entry documented on 2/6/12 at 11:30 p.m., noted the following: "Late Entry 2/1/12 @ 1130 (a.m.): BS (blood sugar) checked 54. Resident's skin warm and dry. Sitting in his w/c (wheelchair), alert and oriented. Denies HA (headache) or N/V (nausea/vomiting). No tremors. Asymptomatic. Resident given OJ (orange juice) and a sandwich." Late Entry 2/1/12 @ 1145 (a.m.): BS rechecked 67. Remains asymptomatic. Sitting in his w/c eating. Alert and oriented. Page sent out to...APNP (Advanced Practice Nurse Practitioner). Late Entry 2/1/12 @ 1155 (a.m.): Rechecked BS 98. Late Entry 2/1/12 @ 1200 (p.m.): NP aware of Resident's blood sugars of 54/67/98. New order to hold scheduled Novolog Insulin for noon..." During a telephone interview with surveyor # on 2/15/12 at 10:54 a.m. RN-E verified on 2/1/11 she provided resident #1 with the 34 units (as noted above). RN-E stated she administered the insulin according to what was documented on the MAR, which included 30 units of scheduled and the sliding scale based upon the result of the blood sugar. RN-E stated sometime after the breakfast insulin had been administered, resident #1's wife, informed her resident #1 "felt funny" and he felt as though his blood sugar was low. RN-E tested resident #1's blood sugar and noted it to be low at 54. RN-E stated she provided resident #1 orange juice and a snack and continued to monitor until the blood sugar rebounded. RN-E verified she informed the NP of the blood sugar results and received an order to hold the next scheduled dose. RN-E stated resident #1 was not displaying any outward signs of [DIAGNOSES REDACTED] (i.e. confusion, sweating, etc.) and that resident #1 had informed her he felt his blood sugar was low. During an interview with surveyor # on 2/15/12 at 1:20 p.m. resident #1 recalled the morning of 2/1/12. Resident #1 stated he has been diabetic since the age of 17, and is very familiar with how he feels in relation to his blood sugar. Resident #1 stated he can tell when his blood sugar is low. Resident #1 stated on 2/1/12 after the breakfast insulin, he felt like his blood sugar was low as he "couldn't think" straight. Resident #1 indicated he alerted his wife who was visiting, and the nurse was notified. Resident #1 verified the nurse checked his blood sugar, and it was low. A snack was provided, and his sugar began to rise again. Resident #1 stated he did not realize that staff had given him more than 30 units of insulin that morning. Resident #1 stated he has never taken that much insulin, but did not question the nurse when she administered the insulin. Resident #1 stated he did not pay attention and was not informed how much insulin was provided. Resident #1 stated he figured the nurses would give the correct amount. The MAR documented on 2/2/12 at 7:30 a.m. resident #1's blood sugar was 306. Resident #1 received 30 units of scheduled Novolog, and 8 units of sliding scale for a total of 38 units. (According to the physician admission orders [REDACTED]. The MAR documented on 2/3/12 at 7:30 a.m. resident #1's blood sugar was 207. Resident #1 received 30 units of scheduled Novolog, and 5 units of sliding scale for a total of 35 units. (According to the physician admission orders [REDACTED]. A 2/4/12 statement written by FM-F (Family Member), who is resident #1's wife, documented the following regarding the events of 2/3/12: The statement indicated on 2/3/12, FM-F left the facility with resident #1 at 10:15 a.m. for a physician appointment. Before FM-F and resident #1 left the city of Manitowoc, resident #1 began feeling like his blood sugar was low. FM-F had "Little Debbie" peanut butter bars which she provided to resident #1. Resident #1 began eating the peanut butter bars, and indicated he needed more things with sugar. FM-F proceeded to open three sugar packs which resident #1 put into his mouth and drank coffee to wash it down. Resident #1 then began eating graham crackers and was "getting worse as sweat poured off him profusely." FM-F provided resident #1 with orange soda which he began drinking. Resident #1 proceeded to eat two more peanut butter bars and a couple of small candy bars, then began eating more graham crackers. FM-F indicated she and resident #1 lived seventeen miles from the facility, and passed by their home on their way to the physician's office. FM-F stopped at their home to pick up more food and the blood sugar monitor. FM-F indicated she checked resident #1's blood sugar at 11:17 a.m. and it was 36, after all of the sugar he had consumed. FM-F stopped at a gas station and picked up orange juice and more candy for resident #1 to eat, and his blood sugar level began to level out. FM-F indicated resident #1's clothes were "soaked" from all of the sweating. FM-F indicated they arrived at the physician's office, and the surgeon evaluated resident #1's surgery site and they left. On the way back to the facility, FM-F stopped at their home to obtain more test strips and resident #1's blood sugar was 136 at that time. Upon return to the facility, FM-F questioned how much insulin resident #1 had received in the morning on 2/3/12. After the facility began investigating it was noted a medication error had occurred, and resident #1 had received 30 units of scheduled insulin rather than the 3 units ordered. During an interview on 2/15/12 with surveyor # at 1:20 p.m., FM-F and resident #1 verified the events documented within FM-F's written statement. Resident #1 verified he had experienced profuse sweating and could not concentrate, and could feel his blood sugar was low. Resident #1 and FM-F verified they are both very familiar with managing resident #1's diabetes, including monitoring the blood sugar. Resident #1 and FM-F verified the reading of 36, as noted above. FM-F stated if she had not been prepared with snacks readily available in the vehicle, and being so familiar with managing low blood sugars, she felt the outcome could have been much worse. FM-F and resident #1 indicated by the time they arrived at the surgeon's office, resident #1 was feeling better. FM-F and resident #1 verified the surgeon only evaluated the surgical site and was not his primary physician. During the telephone interview with surveyor # on 2/15/12 at 9:15 a.m., RN-B verified that on 2/3/12 when FM-F and resident #1 returned from the physician's appointment and questioned the insulin dosage she began investigating what had occurred. RN-B verified resident #1 had received the wrong insulin dosage on 2/1/12, 2/2/12, and 2/3/12. RN-B verified RN-C changed the dose to 30 units of Novolog insulin with breakfast instead of the 3 units ordered by the physician. RN-B stated if RN-C thought the transcribed order read 30 units, she should have checked that order with the hospital discharge summary to verify before changing the order in the computer which generates the MAR. On 2/15/12 at 9:15 a.m. surveyor # completed a telephone interview with RN-I. RN-I verified she provided resident #1 with the scheduled 30 units of Novolog insulin on 2/2/11 and 2/3/11 as documented on the MAR. RN-I stated the nurses passing the medications refer to the MAR for administration dosages, and administer the dosage printed on the MAR. RN-I stated the facility system of having the orders verified and locked by two separate nurses prior to printing the MAR is to prevent medication errors. RN-I stated it was her understanding that the two nurses are supposed to verify the orders were correct on the Chrono prior to printing the MAR by reviewing the original order to ensure transcription errors had not occurred. On 2/15/12 at 10:25 a.m. surveyor # interviewed DON-G (Director of Nursing). DON-G verified the transcription error noted above. DON-G verified resident #1 had received 30 units of scheduled insulin on 2/1/12, 2/2/12, and 2/13/12, but should have received only 3 units of scheduled insulin. DON-G stated RN-C should have verified the original physician order [REDACTED]. DON-G stated LPN-D should have verified the orders against the original orders before completing the double lock verification. This failure to ensure the procedures were followed to ensure the accurate dispensing and administration of medications created a finding of Immediate Jeopardy, which began on 2/1/12. The Immediate Jeopardy was removed and the deficient practice corrected by 2/4/12 after the facility implemented a systemic plan that included the following actions: ~All resident physician orders [REDACTED]. ~Implemented a new policy where supervisors must verify all new physician orders; and ~Retrained all staff on the new policy. On 2/15/12 at 10:25 a.m. surveyor # interviewed DON-G (Director of Nursing). DON-G verified after investigating this error, the facility inserviced all licensed staff regarding [DIAGNOSES REDACTED], transcription of orders, verification of orders, and the double lock system. DON-G stated the facility completed audits of all physician orders [REDACTED]. Noncompliance remained at the lower scope and severity level of D (potential for more than minimal harm that is not immediate jeopardy/isolated) because an additional medication error was identified that occurred after 2/4/12. 2) On 2/15/12, surveyor # reviewed resident #2's medical record. According to the "Hospital's Patient Medication List" dated 2/12/12, resident #2 had physician orders [REDACTED]. Surveyor # reviewed resident #2's medication administration record. The medication administration record indicated on 2/12/12 at 1630 (4:30 p.m.), resident #2's blood sugar was 228. The medication administration record did not contain any documentation that the extra five units of Novolog Flexpen 70/30 was administered as directed by the physician's orders [REDACTED]. On 2/15/12 at 9:20 a.m., surveyor # interviewed RN-H regarding the insulin administration for blood sugars greater than 180. RN-H reviewed the medical record and verified the extra five units of Novolog Flexpen 70/30 was not administered to resident #2 as directed by the physician.