Every finding on record at Sharpview Residence and Rehabilitation Center

Based on observation, interview, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1medication cart (200 Hall Nurse Cart) reviewed for pharmacy services . LVN A failed to ensure the 200 Hall Medication Nursing Cart was locked when not under direct supervision of authorized staff ON 5/27/26 at 10:26 AM. This failure could place residents at risk of adverse reactions to medications and misappropriation of medications.Findings included: Observation on 05/27/26 at 10:26 AM revealed the 200 Hall medication cart was unlocked and unattended. In an interview on 5/27/26 at 10:30 with CMA A, it was revealed that the unattended medication care was assigned to LVN A. CMA A initially thought LVN A was giving care to a resident in the area. However, after looking in several rooms, LVN A was not located on the floor. CMA A stated carts should be locked when unsupervised to prevent unauthorized access to the carts' contents. She said unlocked carts could place residents at risk of injury. In observation and interview on 05/27/26 at 10:40 AM, LVN A arrived back on the 2nd floor (200 Hall). LVN A stated she had to run downstairs (100 hall) and she thought she had locked her cart. LVN A stated she had in-service training two weeks ago on abuse and neglect, and on securing medication carts. LVN A stated the adverse effect of leaving a medical cart unattended and unlocked could have resulted in a resident accessing medication or other items that could result in serious harm or have an adverse drug reaction if they consumed medications from the cart. LVN A stated the medication cart had 4 drawers and contained a locked narcotics box inside. She stated needles were located in the top drawer of the cart and a resident could have opened it and harmed themselves. The medication cart contained the following items: Drawer 1- OTC medications, syringes, prescription medication, > 30 lancets (a device with a small needle used to prick fingers to collect blood for blood sugar monitoring.), >100 pen needles (needles attached to insulin pens).Drawer 2- liquid OTC and RX Only medications, solid form Resident prescription medications.Drawer 3- Inhalation solutions, inhalers, and topical creams An interview on 05/27/26 at 11:14am with the DON revealed that she made random rounds throughout day ensuring carts were locked and attended. She stated the nurse's medication cart should never have been unlocked. She stated she had never counseled LVN A because she was a good nurse, and typically very careful. The DON stated the adverse effect of an unlocked and unattended car was a resident could have gotten hold of the needles, vitamins, medication, which could have placed the resident at risk of harm. Record review of the undated facility policy Medication Storage revealed the following, General GuidelinesAll drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature and controls.C. During the medication pass, medications must be under the direct observation of the person administering medications or not in the medication storage area cart.

Based on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (CR #1) of 4 residents reviewed for tracheostomy care.-LVN A failed to provide emergency tracheostomy (surgical hole in the windpipe to assist with breathing when the usual way is blocked) reinsertion for CR #1 after the resident accidentally removed their tracheostomy on 04/27/2025. LVN A did not use an obturator (an instrument used to guide the cannula (tubing that allows oxygen to go through the windpipe) back into a resident's opening (the surgical hole in the windpipe also called a stoma) during reinsertion) and did not know what it was or how to use an obturator. LVN A had to provide oxygen to CR #1 by placing the resident's cannula directly into the opening until emergency services arrived and transported CR #1 to the hospital. An IJ was identified on 07/25/2025. The IJ template was provided to the facility on [DATE] at 3:29PM. While the IJ was removed on 07/29/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not IJ due to need for ongoing monitoring.This failure placed residents at risk of improper tracheostomy care which could lead to respiratory distress and failure, physical and emotional injuries and potentially death. Record review of CR #1's face sheet dated 07/24/2025 revealed a [AGE] year-old resident originally admitted on [DATE] with medical diagnoses including acute respiratory failure with hypoxia (difficulty breathing), pulmonary embolism (blood clot in the lung), hypertension (high blood pressure), and type 2 diabetes mellitus (high blood sugar). CR #1 was her own RP. CR #1 was discharged on 04/27/2025 to the hospital. Record review of CR #1's Comprehensive MDS dated [DATE], reflected her BIMS score was a 12 indicating she was moderately cognitively impaired related to thinking and memory skills. CR #1 had a walker and wheelchair. CR #1 required setup assistance in eating, oral and toileting hygiene, and dressing and showering and was independent with personal hygiene. Record review of CR #1's care plan last reviewed 04/22/2025 revealed she had a tracheostomy related to acute respiratory failure, with interventions including keeping extra trach tube and obturator at bedside, if tube cannot be reinserted, monitor/document for signs of respiratory distress, if able to breathe spontaneously, elevate HOB 45 degrees and stay with resident, and obtain medical help immediately.Record review of CR#1's progress notes dated 4/27/2025 at 10:29am, reflected Resident was performing self trach care, when trach dislodged due to her not holding trach in place while changing ties (strap or collar used to hold a tracheostomy tube in place to prevent movement). LVN A attempted to reinsert, unsuccessful, applied O2 @3L/NC, O2 sat 98%. Cleaned area and applied dsg, tol well. Notified MD, and DON. Record review of CR#1's change in condition assessment dated [DATE], reflected she had change in condition due to trach dislodged, assessed, unable to reinsert, cleaned area, cover with dsg, applied o2, 3l/nc, 02 sat 98%.Record review of CR#1's respiratory training sheet with the RT and signed on 4/21/25, reflected CR #1 had training on sterile procedures on 4/21/25 and refused training on how to manually provide 100% via ambu bag (a handheld device used to provide oxygen to residents not breathing adequately) and how to do tracheal suctioning. In an interview with LVN A on 07/24/2025 at 4:03pm, she said that a resident could provide their own suctioning if the respiratory therapist assessed them and approved. LVN A said on 4/27/25, an aide called LVN A to CR #1's room because CR #1's trach came out. CR#1 told LVN A that CR #1 was doing her trach ties and forgot to hold them and the trach popped out and by the time LVN A got to CR #1's room her opening was closing and LVN A tried to reinsert CR#1's trach but was unsuccessful. LVN A placed oxygen on her opening and was able to re-establish CR #1's airway and calm the resident down. LVN A called CR #1's doctor to notify them and sent CR #1 to the hospital. LVN A said CR #1 was being trained on changing her collar. At the time, CR#1 was breathing fine and was over 95% oxygen sat on room air and CR #1 was not in respiratory distress. LVN A said nurses were able to do trach care and that her last inservice on trach care was when she was hired in 2024 and in April 2025. If there were any issues with a resident's trach she would stabilize them, get them on oxygen, call for some help and then 911. If she had any questions, she would call the DON or the RT. A later interview with LVN A on 04/25/2025 at 11:00am, revealed she said she was downstairs when an aide called her to assist CR #1, and CR #1's opening was closing by the time she got to her side. The CNA (she did not remember who the CNA was) notified LVN A as soon as it happened. CR #1 had a tote next to her bed with a trach care kit, extra disposable trach ties, cannula and suction. LVN A was not sure if reinsertion was covered in trach training. LVN A was not sure what an obturator was and did not know if it was by CR#1's bedside at the time of the incident.In an interview with the DON on 04/25/2025 at 8:38am, she said nurses were able to do trach care and the RT did training and scheduled to come to the facility once a week and as needed. The DON said that residents could do it themselves and the facility would want residents to be able to do that when residents discharge from the facility. The DON wanted staff to be present when residents were performing trach care on themselves. If a trach came out, a resident should have an obturator in their room so staff could reinsert the trach. Trachs could be reinserted successfully, depending on how long the trach had been out. A negative outcome if a resident's trach came out would be respiratory distress and needing to call 911. In an interview with the RT on 07/25/2025 at 9:39am, the RT said she provided training based on what the DON wanted, with all the respiratory competencies. Sometimes residents wanted to do it themselves so the RT would teach, do return demonstration, educate nurses and tell the DON when residents chose to do it themselves, otherwise she educated residents to use the call light to get assistance for trach care. The RT trained residents until they were comfortable doing it themselves. The RT said CR#1 was given supplies that she needed and that the RT had no concerns with return demonstration on CR#1's trach care and the RT saw CR#1 perform trach care 3-4 times. CR#1 was verbally educated on what to do if the tube was removed, including trying to put it back in and calling 911 if she could not do it herself. The RT was unaware of the facility protocol on reinserting the trach. CR#1 refused to return demonstration on how to use the ambu bag and tracheal suctioning because she said she didn't need that much suctioning. The RT said she did in-services with staff and the DON would have the documentation. The RT said if residents did not reinsert their trach correctly, they could get an infection, cause irritation and bleeding and possibly remove from tissues from suctioning. The RT said there were no residents doing self-care right now. In an interview with LVN F on 07/25/2025 at 9:10am, she said she had residents on a trach and provided trach care. LVN F said the RT came in the last month and showed her how to provide trach care. If a trach came out, nurses should give the resident constant air to ensure they were breathing, secure the oxygen, and raise the oxygen level so that the resident was comfortable and then call 911. LVN F said she was not trained on reinserting the trach. The RT brought a dummy during training, and everyone practiced putting in the inner cannula but were not taught to use the obturator. The resident should have a suctioning machine, extra oxygen tanks, cleaning trays, extra inner cannulas and tubings and ambu bag by their bedside. LVN F said if a resident's trach came out and anyone tried to place it back in, it can put infection into the person. In an interview with LVN C on 07/25/2025 at 9:10am, she said she did trach care for residents and had trach training in the last 30 days, including for reinserting the trach. LVN C said residents should have their call light nearby, have a suction machine and extra trach kits in the room and ensure residents' airways were open at all times. If a resident's trach came out, LVN C would try to maintain patency (remaining open and unobstructed) for oxygen flow and immediately call for 911. LVN C had a training on putting the trach in, and the RT educated them on maintaining an open airway and then trying to replace it, and if not able to nurses should put oxygen over the resident's airway. Residents should always have a trach kit near their bedside. In a later interview on 07/25/2025 at 11:33am, LVN C said that she was never taught how to reinsert the trach. LVN C said if the hole was not patent and closed it could restrict the airway and residents could stop breathing if they did not get air.In an interview with CR #1 on 07/25/2025 at 1:43pm via telephone, she said she was able to do a lot of trach care herself and that the RT at the facility educated CR #1 on trach care but that the RT was only at the facility once a week and the nurses did the best they could with trach care. CR #1 said that she was trying to place the strap back on but did not know the tracheostomy tube going into her opening was short, and when she accidentally pulled too hard on one side of the strap the entire tubing came out. CR #1 said that day was a blur because a lot went on, but CR #1 remembered getting an aide's attention and that aide went to get a nurse who tried to put the trach back in and calmed her down when she was panicking. CR #1 said she did not remember how long it took the nurse to arrive but that it took a while. CR #1 said she was breathing fine when the ambulance came. Attempted interview with CR #1's Physician A on 07/28/2025 at 10:16am, and a voicemail was left. NP A called back on 07/29/2025 at 11:03am and said that he worked with Physician A at the facility. NP A was informed when CR #1's trach was dislodged and she was sent out to the hospital. NP A knew CR #1 was doing trach self-care and that she refused nurses assisting with suctioning. NP A expected nurses to document when residents refused care. The RT at the facility would do resident education on trach care. NP A said most nurses would not really be equipped with trach reinsertion and if there was an RT on site respiratory care would be much easier and that he did not know if nurses were trained on emergency trach situations such as reinsertion and that would be a question for the facility. NP A said if it were up to him, even if the nurse was able to successfully reinsert CR #1's trach, NP A would send the resident out anyway to ensure that everything was in place with the trach. NP A said there was a pulmonologist who came to the facility.Record review of the facility's Tracheostomy Policy copyrighted 2021 read in part, .2. The facility will provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, tracheostomy care and/or suctioning .5. The facility will ensure staff responsible for providing tracheostomy care including suctioning are trained and competent according to professional standards of practice. This policy had no guidance on trach reinsertion. Record review of the facility's Emergency Response to Accidental Tracheostomy Decannulation (Cannula removed) policy, undated, read in part, Accidental decannulation is a medical emergency that requires immediate and competent intervention. The primary responsibility of the nurse is to assess the resident's respiratory status, maintain a patent airway, and activate the appropriate emergency response. The specific actions taken will depend on the age of the tracheostomy stoma (opening) .4. Essential Bedside Equipment .Obturator for the current tracheostomy tube size The policy reviewed the procedure for reinsertion including, If the stoma is mature (mature being a stoma in place 7 or more days, and immature being less than 7 days old) and you have been trained and deemed competent in tracheostomy tube reinsertion, proceed with the following steps. If you are not trained, follow the protocol for an immature stoma and await assistance. 1. PREPARE THE NEW TUBE:o Open the package for the spare tracheostomy tube (same size preferred, use smaller size if difficulty is encountered). o Insert the obturator into the outer cannula. o Apply a small amount of water-soluble lubricant to the tip of the tube Record review of the facility's Competency Expiration and Revocation Policy for Tracheostomy Self-Care, undated, established clear guidelines for the expiration, renewal and revocation of resident competency in performing tracheostomy self-care, such as initial competency being valid for 90 days from the date of assessment and reassessed following any hospital discharge or significant change in physical or cognitive status and when revocation of competency would happen. The Administrator was notified on 07/25/25 at 3:21 PM an Immediate Jeopardy situation (IJ) was identified due to the above failure. The Administrator was provided the IJ template on 07/25/2025 at 3:29PM and a Plan or Removal (POR) was requested. The facility POR was accepted on 07/27/2025 at 7:19AM and indicated:Tag Cited: F-695S483.25(i) - Respiratory/Tracheostomy Care and SuctioningIssue Cited: Failure to Provide Adequate Tracheostomy Care due to LVN A failing to provide tracheostomy care consistent with professional standards of practice when CR #1's tracheostomy was removed during care. 1. Identification of Residents Affected or Likely to be Affected:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 7/25/25) The DON or designee(s) evaluated all current residents with a tracheostomy for adverse outcomes due to the alleged deficient practice. Concerns were not identified. The DON and Nursing Supervisors audited the medical record for all current residents with a tracheostomy to ensure the presence of physician's orders and resident specific care plan interventions for the care of their tracheostomy, no concerns noted. The DON or designee assessed all current residents with a tracheostomy to ensure that any needed tracheostomy care equipment and supplies were at the bedside, no concerns noted. Resident CR#1 discharged home from the hospital. Resident was discharged to the hospital on [DATE] and discharged home from the hospital on [DATE]. LVN A was provided educational counseling by the DON regarding the Emergency Response Trach Policy. LVN A demonstrated understanding of the policy through verbal explanation of procedures, return demonstration of emergency trach reinsertion using a mannequin. RT was provided educational counseling by the DON regarding the Emergency Response Trach Policy. The RT demonstrated understanding by accurately explaining the policy content, conducting a mock in-service session with the DON present, and documenting her plan to provide return demonstrations and report non-compliance to the DON in real time. Residents will be required to complete a competency test before performing self trach care by utilizing the Resident Self Care Competency Plan which was updated 7/25/25. DON will be responsible to complete with all new residents who will be providing their own tracheostomy care. Facility currently does not have residents providing their own tracheostomy care. Plan includes:o Initial Assessment of Capabilityo Skills Demonstration Checklisto Documentation and Care Plan Inclusiono Ongoing Monitoringo Competency Expiration and Revocation Policy2. Actions to Prevent Occurrence/Recurrence:The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 7/25/25) The facility's policies and procedures on Emergency Response Trach Policy reviewed with the facility Medical Director, no changes to the policy were made and the Medical Director felt it was appropriate. The Director of Nursing (DON) provided education to licensed nursing staff on Respiratory/Tracheostomy Care and Suctioning, as well as on the facility's Emergency Response Tracheostomy Policy. No direct care licensed nurse is permitted to work until they have completed this mandatory training. Additionally, all newly hired direct care licensed nurses will receive this education during orientation and prior to working an assigned unit: o Emergency Response Trach Policyo following the individualized interventions in each resident's care [NAME] obtaining physician's orders for tracheostomy careo ensuring tracheostomy care equipment/supplies are readily available at the bedside.o Competency checks were performed for licensed nurses on duty and nurses who are not on duty on 7/25/25 will be completed prior to their first shift. To demonstrate understanding, each nurse will be required to verbally explain the key components of the Emergency Response Tracheostomy Policy, ensuring they can articulate the appropriate steps and rationale behind each procedure. Additionally, nurses must successfully perform a return demonstration of emergency tracheostomy procedures using a simulation mannequin. This includes proper suctioning technique, the use of an obturator, and the reinsertion of a dislodged tracheostomy tube. These steps confirm both cognitive and practical competency before the nurse is permitted to provide direct patient care. Upon identification, the DON or designee will immediately address and remedy any audit deficiencies with the licensed nursing staff. This process is currently in place; however, the DON will complete audits more frequently, three times per week (entered the number of times per week but was asked to remove as it goes into the POC) . A QAPI PIP was implemented to track and report on above audit findings. The findings will be presented at the monthly QAA meeting for a minimum of three months. After the initial three months, the QAA Committee will make a determination regarding the continued frequency of audits and subsequent reporting, with audits continuing at least monthly to sustain compliance.The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following:On 07/27/2025 at 7:19AM IJ Monitoring began.Observations of Residents #1, #2 and #6 on 07/25/2025-07/29/2025, revealed residents were in their rooms with no distress. There were trach kits in their room by the bedside which had obturators. In an interview with LVN F on 07/27/2025 at 9:30am, she said she worked nights (10p-6a) and sometimes morning shift (6a-2p) and stated having training on 07/25/2025 and 07/26/2025 on trach reinsertion, including return demonstration. Nurses were responsible for ensuring residents had enough trach care supplies by their bedside in case of emergency situations. LVN F said an obturator was used to enlarge the resident's stoma and to guide the outer cannula and nurses must use a gel on the obturator to guide the outer cannula to avoid damaging the resident's tissue. In an interview with the RT on 07/28/2025 at 9:55am via phone, she said the DON provided in-service for the RT on what to do if the trach was dislodged and how to stabilize the resident. The RT then did a mock return demonstration on a dummy (human model used for training) . The RT said she did education for the nurses who were able to reiterate the training and perform the return demonstration. The RT reviewed the trach policy, went over what to do with residents with mature or immature stoma (opening) , reporting any incident of dislodgement to the doctor and sending residents to the hospital if they have an immature stoma. The RT also went over monitoring residents' breathing through breathing patterns, watching for accessory muscles (other muscles used to breathe) to gauge stabilized breathing, and getting oxygen saturation levels. The RT reviewed how to use the various types of obturators, placing the lubricant on the obturator before insertion, when to use the ambu bag, getting a nonrebreather (oxygen mask used to deliver high levels of oxygen in emergency situations) on the resident and how to place dressing on a resident's opening. The RT said she would do competencies for staff once a year and trach care as needed and when the DON requested any training or education.Interview with LVN B on 07/27/2025 at 10:12am, revealed LVN B worked morning (6a-2p) and afternoon (2p-10p) shifts and received training on trach reinsertion and had return demonstration on the dummy, along with reviewing the emergency trach policy on the step-by-step process for reinsertion. LVN B said he completed his competencies with the DON. He was able to state what an obturator was used for which was to guide the outer cannula into the resident's stoma. Nurses should apply a gel on the obturator before insertion to protect the resident's skin. LVN B stated nurses were responsible for checking on bedside supplies every shift. Interview with RN M on 07/27/2025 at 1:00pm, revealed RN M worked morning shift (6a-2p) and stated she receiving trach reinsertion training and competencies and that an obturator was used to guide the outer cannula into a resident's stoma and would make sure to use the gel on the cannula for easy insertion and not to hurt the resident. If she was unable to reinsert the cannula, she would make sure the resident's airway was established, secure trach ties to keep the flow of oxygen in place and call 911. RN M stated nurses were responsible for checking on bedside supplies every shift. Interview with LVN C on 07/27/2025 at 2:10pm, revealed LVN C worked morning shift (6a-2p) and explained how to reinsert a trach and stated receiving training on 07/25/2025 on the obturator which was used to expand a resident's stoma so that she could guide the outer cannula in. LVN C said that she was also trained on using the gel from the trach kit on the obturator so that it provided lubrication and for easier reinsertion. LVN C stated nurses were responsible for checking on bedside supplies every shift. In an interview on 07/27/25 at 2:32 p.m., RN N said she worked at the facility for 8 years and that she was in-serviced on 07/25/2025 on how to do trach care using sterile technique and how to change the trach collar. RN N said she was educated on replacement of extubated cannula, how to check tracheostomy supply at the bed side each shift and to ensure supply in case of emergency. RN N was also educated on how to use the obturator to reinsert the extruded (forced out) cannula. She said she did return demonstration using the mannequin. She said in the event of emergency after the resident was situated, she would notify the resident's physician, DON and responsible party. She said during the emergency she would call for help. RN N said she would assess the resident while she reinserted the cannula and if the size 6 was big then she would use the smaller size 4. She said if the stoma was new and she met with resistance she would stop and placed oxygen on the resident stoma and close the ostomy (opening) with gauze and have another nurse communicate with 911 and the doctor. RN N said if she was off and came back to work, she would review the resident record, from assessment, orders, MAR and progress notes. She said at the end of the education there was a written test. RN N said they reviewed the facility policy on tracheostomy. Interview on 07/27/25 at 11:03 p.m., revealed RN B worked at the facility for six years and said she had in-service on tracheostomy on 07/25/2025 from the DON. RN B said she was educated on trach care, such as suctioning, changing the trach collar, assessment and administering breathing treatment if needed. She said she was all reeducation on trach emergency(decannulation) . She said if the trach was new and the cannula came out she would try to reinsert it with the obturator after applying gel, and if the cannula met with resistance stop and bag the resident and call 911 to prevent further damage to the site. RN B said if it was an old trach and after the obturator was inserted then insert the cannula and if met with resistance stop and step down to a smaller size and assess the resident while providing care and call for assistance. RN B would then assess for color, breath sounds, and oxygen saturation. RN B said after the resident was stabilized, the nurse would notify the doctor, management and responsible party and follow the doctor's order. Then document on the progress note. She said the nurse could find out information about the resident on the orders, MAR and assessment and report during shift change. RN B said she was in serviced on the facility policy on trach care and trach emergency. Interview on 07/27/25 at 11:19 p.m., revealed LVN D worked at the facility for a month, and he had an in-service on how to take care of a resident with a trach during an emergency when the cannula was pulled out of the trach. LVN D said the nurse should call for help and try to reinsert the canula by using the obturator to help expand the air way but do not force it. When inserting the canula if you were met with resistance do not force but down grade to a low number if it was an old trach, but if it was a new trach do not proceed but apply oxygen to the resident and put a cover on the trach and call 911. LVN D said before and during the emergency call for help and another nurse would be calling the doctor, ambulance and DON. LVN D said they were retrained on the trach policy, and they had a copy of the policy at the nursing station. He did a return demonstration. LVN D said he would find out about his residents with a trach during shift change, progress notes, orders, MAR and assessment. He said after the emergency he would document and notify the DON, RP and physician if they had not been notified and that he took a written test. Interview on 07/27/25 at 11:33 p.m., revealed LVN J worked at the facility for a year and said she was trained on 07/26/2025 when she came to work before starting her shift. LVN J was reeducated on trach care: suctioning, change of trach collar, and in the event of an emergency (decannulation). LVN J said to call for help and reinsert the cannula using the obturator and if it was an old trach and you met any resistance stop and use a smaller size cannula. If it was a new trach stop, apply oxygen and call 911. While helping the resident LVN J would call for help, and continue insertion and assessing the resident's O2 sat, skin color and breathing. LVN J said she would call the doctor, DON and RP and document. LVN J said she did return demonstration and had a written test on the in-service. LVN J said she could find information about care provided for the resident or how to provide care for the resident from the orders, assessment, MAR, progress note and during shift change report. Interview with LVN A on 07/28/2025 at 10:26am, revealed LVN A worked morning shift (6a-2p) and received training on emergency situations like when a trach was dislodged, suctioning, oxygenation, neb treatments and concentrators (neb treatments being a machine that delivers mist for residents to breathe and concentrators being the machine that delivers oxygen to a resident) . If a trach came out, she would get a trach kit, retrieve the obturator and lubricate the end, insert the cannula in the opening, take it out, put in a new inner cannula, secure the ties, get oxygen saturations and check for rate of breathing and lung sounds. Checking for lung sounds was important to make sure the resident's airway was clear and nothing was damaged. LVN A was educated on the difference between immature and mature stomas. LVN A did a return demonstration and completed her competencies. The RT and nurses were responsible for making sure supplies were in the room. LVN A would look at a resident's orders, hospital records and care plans for more information on how to care for their trach. Interview with the DON on 07/28/2025 at 10:45am, revealed the DON received training from the RT and completed her competencies. The DON watched suctioning, trach care, education on the respiratory system's anatomy. The DON trained staff on trach care equipment and making sure it was easily available; equipment consisted of suction kit, trach care kit, ambu tag, trach ties, extra split gauze, and having two trach kits with two different sizes at the bedside with obturators in the kit. The DON educated and demonstrated for staff on establishing the airway/circulation/breathing by grabbing a new trach kit (inner cannula, obturator, outer cannula). She took the kit and demonstrated with her hands how to insert it, apply lubricant, giving gentle pressure to insert it, and once inserted use trach ties to secure it. Nurses should then check for oxygen saturation, apply oxygen and start assessment by reviewing a resident's mental status (facial expression), check for breath sounds, monitor O2 sats, and if ordered give breathing treatment, check skin color, position resident in high position to increase airway, monitor resident breathing (evenly, unlabored or labored), check if residents were using the right abdominal muscles to breathe, document in their notes and notify the physician, family and the DON. When the DON evaluated current residents with a trach, she found they were breathing well. The DON and RT looked at care plans and orders and added procedures in the care plan for some residents. The DON completed competencies for the nurses and the RT was going to do weekly competencies. The DON conducted supply screenings and found sufficient trach supplies by residents' bedsides. The DON conducted training for LVN A on how to establish an airway using an obturator, reviewed respiratory system anatomy, supplies and trach policies. LVN A did return demonstration and verbal explanation with no concerns. The DON was going to continue to monitor the plan by continued training and competencies by having staff demonstrate and verbalize the process of reinsertion, their understanding of the respiratory system, trach size and type. Nurses could look in residents' orders for trach size, type of suctioning, and how old their tracheostomy was. Regarding the IJ, she said if nurses did not know how to re-establish airway, residents could have hypoxia, change in respiratory status or needed supportive systems to re-establish baselines. Residents could become confused, lethargic or pass away from not being able to breathe. Interview with the Administrator on 07/28/2025 at 12:34pm, revealed she informed the Medical Director of the IJ on 07/25/2025 around 4:00pm and reviewed the emergency policy with him and did not make any changes. She also reviewed the checklist and observation for staff in training. The DON and RT reviewed current residents with trach's medical records and found no concerns. The Administrator said the IJ came about because the nurses could not explain what an obturator was and that it was due to a lack of knowledge. LVN A told the Administrator she could not remember what an obturator was called and that she did not do well under pressure. The Administrator said nurses would be trained upon hire and every quarter even if the facility did not have a resident with a trach. The DON and ADON were going to monitor supplies and train nurses. The facility was going to monitor for trach care training for three months to ensure the plan was being followed. The Administrator said that harm could come to a resident if their trach was out and nurses did not follow trach care procedure and that all nurses on the floor were trained before starting their shift.Attempted interview with the pulmonologist on 07/29/2025 at 12:13pm, and a voicemail was left. The pulmonologist did not return the phone call as of exit. Record review of Resident #1's care plan and orders dated 07/28/2025, reflected his care plan had changes including ensuring trach ties were secured, monitor oxygen settings, and p[TRUNCATED]

Based on observation, interview, and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 3 residents (Resident #8) reviewed for coordination of PASARR and assessments. -The facility failed to conduct the PASARR Level I assessment Form 1012-Mental Illness/Dementia Resident Review for Resident #8 until 7/24/25.-The facility failed to request, submit and coordinate the PASARR assessment and screening in the Simple LTC portal to ensure therapeutic services (physical, speech and occupational) were completed for Resident #8.This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility. Record review of Resident #8's facility face sheet dated 7/28/25 revealed a [AGE] year-old-female with an admission date of 10/2/24. Her diagnoses included unspecified dementia (unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety) (a condition where a patient exhibits dementia symptoms but the specific type and severity are not identified, and the dementia is not accompanied by behavioral disturbances, psychotic symptoms, mood disorders, or anxiety), and schizoaffective disorder (onset date 12/5/25)(Schizoaffective disorder is a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania).Record review of Resident #8's admission MDS assessment dated [DATE] revealed the Section A1500 Preadmission Screening and Resident Review (PASARR). The question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition was answered no. The BIM score was 3 indicating she was severely impaired cognitively. Resident #8 was coded in Section I - Active Diagnoses, I4800 to have Non-Alzheimer's Dementia. Record review of Resident #8's Significant Change MDS assessment dated [DATE] revealed the Section A1500 Preadmission Screening and Resident Review (PASARR). The question, Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition was answered no. The BIM score was blank, and she was coded to be severely impaired in section C1000- Cognitive Skills for Daily Decisions. Resident #8 was coded in Section I - Active Diagnoses, I4800 to have Non-Alzheimer's Dementia and I6000 to have Schizophrenia.Record review of Resident #8's care plan with a review start date of 6/19/25 and target completion date of 6/25/25 revealed a care plan to address ADL self-care performance deficit r/t dementia, impaired mobility, impaired cognitive function and impaired thought processes r/t dementia.Record review of Resident #8's quarterly MDS dated [DATE] revealed BIMS of 3 out of 15 indicated severely impaired cognition. further review of the MDS revealed the resident was dependent on the staff for all ADL care.Record review of Resident #8's care plan with a review start date of 6/19/25 and target completion date of 6/25/25 revealed a care plan to address ADL self-care performance deficit r/t dementia, impaired mobility, impaired cognitive function and impaired thought processes r/t dementiaRecord review of Resident #8's care plan dated 12/09/25 revealed Resident #8 used psychotropic medications related to Behavior management for impulsive behavior, agitation, repeat words, difficult to redirect. Interventions included: Administer psychotropic medications as ordered by physician and monitor for side effects and effectiveness Q-SHIFT (every shift). Attempted telephone interview on 07/27/25 at10:50 a.m., MDS B, the phone rang for 2 minutes, and she did not pick up. A second attempt was made on07/28/25 at 11:51 a.m., MDS B was called, and she did not pick up the call and a message were unable to be left. Interview on 07/28/25 at 12:09 p.m., MDS B said she was the MDS nurse at the facility for four years. MDS B said Resident #8 came to the facility with a negative PASARR level 1 and some months later she had a mental diagnosis, and it was missed because they did not reassess the resident and enter the assessment into the portal for LIDDA to come out and see Resident #8. MDS B said Resident #8 would have missed services which could have been beneficial for the resident. MDS B said they had a plan to correct the mistake moving forward by reviewing all resident diagnosis to prevent the incident from reoccurring. Interview on 07/24/25 at 2:05 p.m., MDS A said she was one of the two MDS coordinator. MDS A said Resident #8 was not admitted to the facility with a positive PASARR. MDS A said Resident #8 had a mental diagnosis of schizoaffective in December 2024 and the IDT team should have notified the MDS team about the new diagnosis and that the diagnosis was missed, and Resident #8 was not reassessed. MDS A said this could affect Resident #8 because they did not receive the services because the resident was not assessed. MDS A said she had Form1012 and was waiting for the doctor to sign the form. Interview on 07/24/25 at 2:37 p.m., the Administrator said the MDS coordinator was responsible for assessing and reassess the resident when a resident had a new mental diagnosis, and they would be able to explain the process better. she said if the assessment was not done time, it could affect the resident because the resident may not get the services required. Interview on 07/24/25 at 3:09 p.m. the ADON said the MDS nurse had remote access to the resident information, and they could see when a resident had new diagnosis, and they were responsible for reassessing the resident when a resident had a new metal diagnosis. The ADON said because the resident was not reassessed the resident did not get the services which could have helped with care of the resident mental health. Interview on 07/26/25 at 10:52 a.m., The DON said she completed the clinical section for Resident #8 in the computer and the SW completed her section and MDS had access to the data. The DON said the MDS team had not been in the building for the past year. She said she had seen the MDS nurse in the building and that anybody could put the diagnoses in the face sheet and the MDS team was responsible for updating face sheet and they could see a resident's diagnosis. The DON said the MDS nurse had access to the resident information, and they were part of the IDT team, and they were responsible for reassess the resident for PASSAR services. The DON said if the resident was not reassessed when the resident had a diagnosis of mental illness the resident would not get the services needed for the resident mental health and other services. Interview on 07/27/25 AT 1:01 p.m., the SW said she was not responsible for scheduling the meeting with LIDD and the MDS was responsible for the PASARR assessment. The SW said the nursing team was responsible for updating the face sheet with resident diagnoses. The SW said the MDS team had remote access to the resident information and could see the diagnoses and could reassess the resident for PASARR. Residents should have been reevaluated to make sure the resident got services needed for the resident's mental health. Record review of the PASARR Level I assessment (Form 1012-Mental Illness/Dementia Resident Review) dated 7/24/25 revealed that the Social Services Director conducted the assessment on 7/25/25. Further review revealed that Resident #8's date of onset for schizoaffective disorder was on 12/5/24.Record review of the PASARR Level I assessment (Form 1012-Mental Illness/Dementia Resident Review) dated 7/24/25 revealed that the physician signed the assessment on 7/25/25. Further review revealed that Resident #8's date of onset for schizoaffective disorder was on 12/5/24. Resident Assessment - Coordination with PASARR Program, dated copyright 2024 read in part. This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. a. PASARR Level I - initial pre-screening that is completed prior to admission.Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include.A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR.

Based on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 4 residents (Resident #25) reviewed for significant medication errors.- LVN S failed to administer medication as ordered to Resident # 25 when she injected insulin Lispro 5 units subcutaneously (below the top skin layer) and all the insulin was not administered to the resident. This failure could place residents at risk of hyperglycemia, and potential hospitalization.Record review of Resident #25's face sheet dated 07/24/25 revealed a 51year old male was initially admitted to the facility on [DATE] and readmitted [DATE]. His diagnoses included: diabetes mellitus with hyperglycemia (persistently high blood sugar), dysphagia (difficulty swallowing), and metabolic encephalopathy (brain dysfunction due to chemical imbalance in the body).Record review of Resident #25's quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 indicating intact cognition. Record review of Resident #25's care plan revision date 11/09/23 revealed Resident #25 had type 2 diabetes mellitus. Interventions: administer diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Monitor/document, report PRN any s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd pain, Kussmaul breathing (deep, rapid and consistent breathing when the body was responding to metabolic acidosis) acetone breath (smells fruity), stupor (state of reduced responsiveness when resident's consciousness is significantly impaired), coma.Record review of Resident #25's order summary report for July 2025 read in part .insulin lispro Injection Solution 100unit/ml (Insulin Lispro) Inject 5 unit subcutaneously with meals related to type 2 diabetes mellitus with hyperglycemia, hold if blood sugar less than 150 Active date 03/26/2025.During insulin medication observation on 07/23/25 at 1:00 p.m., Resident #25's blood sugar level was 314 mg/dL. LVN S drew up five units of lispro insulin and verified it with another nurse. When LVN S administered the insulin to Resident #25, she did not pinch the Resident's skin on the left back arm, and she did not angle the needle at a 45-degree angle. LVN S pushed the needle straight into Resident #25's arm, pushed the plunger of the syringe, and LVN S did not wait to ensure the insulin was administered entirely to Resident #25 before she pulled the needle out of the Resident's arm. LVN S stated she had finished insulin administration. The Surveyor asked LVN S to push the syringe plunger forward, and a substantial amount of insulin dropped out of the needle (three drops).During an interview on 07/23/25 at 1:06 p.m., LVN S said she should have pinched the skin and made sure she administered the insulin to the SUBQ . LVN S stated that she should have pushed the plunger of the syringe and held it in place on Resident #25's arm for approximately 10 seconds to ensure she administered all the insulin to the resident. She said Resident #25 did not get all the prescribed dose of the medication because four drops of insulin came out of the needle after the insulin was administered to the resident. LVN S stated that insulin was a very critical medication, which was why another nurse verified it. LVN S said Resident #25's blood sugar could remain elevated because the appropriate dose was not administered. LVN S said she would notify the physician, DON, and RP that she did not administer all the insulin. LVN S stated that she had a skills check, which included medication administration, and insulin was part of the administered medication. LVN S said the ADON and DON monitored the nurses during rounding.During an interview on 07/24/25 at 11:50 am the DON said LVN S did not follow the proper insulin medication administration because she should have pinched the skin and angled the needle at 45 degrees to ensure the medication was administered to the subcutaneous layer of skin and once LVN S pushed the plunger of the syringe she should have held the plunger in place and the needle in Resident #25's arm for 10 seconds which would have allowed the insulin left in the syringe to enter Resident #25's subcutaneous layer of skin and the resident would have gotten his full dose. The DON said if Resident # 25 did not get the medication as prescribed, Resident #25's blood sugar would remain high, and it could lead to health complications. The DON said LVN S had a skill check-off, which included medication administration, and the nurse managers monitored the nurses during random rounds. The DON stated that LVN S notified Resident #25's physician about the insulin administration error, and he issued an order to monitor the resident and recheck Resident #25's blood sugar as scheduled. LVN S notified the resident's representative.Record review of the facility undated medication administration policy read in part .medication are administered . as ordered by physician and in accordance with professional practice.Record review of the facility undated administration of injection policy read in part . Injections are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice.Record review of administering from lispro insulin from a vial Instructions for Use revised: July/2023, Step 10: Insert the needle into your skin. Step 11: Push down on the Plunger to inject your dose. The needle should stay in your skin for at least 5 seconds to make sure you have injected all of your insulin dose.insulin-lispro-vial-us-ifu.pdf.

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on the resident's comprehensive assessment for 1 (Resident #9) of 5 residents reviewed for quality of care. -Resident #9 was found with a skin tear on 07/24/2025 after surveyor intervention . LVN B, CNA G and CNA V cared for Resident #9 and did not document the skin tear prior to 07/24/2025.This failure could lead to residents not receiving timely wound interventions and could cause further wound deterioration, infection and decline in health. Record review of Resident #9's face sheet dated 07/26/2025 revealed a [AGE] year-old male originally admitted on [DATE] and last re-admitted on [DATE] . His medical diagnoses included dysphagia (difficulty swallowing), type 2 diabetes mellitus (high blood sugar), dysphagia following cerebral infarction (difficulty speaking following a stroke, which is when there is a loss of blood to the brain), hypertension (high blood pressure), and pressure ulcers of the sacral region (lower back area) and bilateral heels, and spinal stenosis (narrowing of the spinal canal, putting pressure on the spinal cord or nerves). Record review of Resident #9's Quarterly MDS dated [DATE], reflected Resident #9 had a BIMS (short interview to gauge cognitive intactness) score of 8, indicating the resident was moderately cognitively impaired on skills related to thinking and problem-solving. Resident #9 was coded for a wheelchair and was totally dependent on staff for all ADLs including toileting, oral and personal hygiene, dressing and showering and eating as well as bed mobility such as rolling left and right, sitting to lying and bed-to-chair transferring. Record review of Resident #9's skin assessment on 07/22/2025 reflected he had three areas under monitoring and treatment which were his sacral wound and bilateral heel wounds. There was nothing documented for the inner right leg. During observation and interview with LVN A on 07/24/2025 at 1:30pm, LVN A said she was the temporary wound care nurse as the other wound care nurse was on vacation. LVN A said she had not started on wound care on 07/24/2025, and that she did not know about Resident #9's leg prior to surveyor intervention. A request for a complete wound care list was made to LVN A. LVN A had not produced a list as of exit. Observation of Resident #9's inner right leg revealed one quarter-sized circle halfway between the knee and ankle, which was pinkish in color with a skin tear on the lower right rim with white exposed skin. Resident # 9 said I don't know yet when asked if he was in pain. Resident #9 did not appear to be in distress or discomfort during observation. Record review of Resident #9's July 2025 MAR dated 07/24/2025, reflected Resident #9 was not receiving treatment for his wound on his right inner leg. Record review of Resident #9's active Physician Orders dated 07/25/2025, reflected he had an order with a start date of 07/25/2025 for cleanse rt inner lower leg with NS, pat dry, apply calcium alginate, cover with dry dressing daily and prn one time a day wound care. Order was after surveyor intervention.Record review of Resident #9's care plan dated 07/24/2025, reflected he was care planned for skin issues and pressure ulcers, with interventions including monitor for skin breakdown. Resident #9 was also care-planned for having a communication problem related to expressive aphasia and late effects of CVA with being conscious of resident in groups, encourage resident to continue stating thoughts, adaptive communication equipment message board, call light within reach.Record review of Resident #9's change in condition assessment done on 07/24/2025 and after surveyor intervention reflected Resident #9 had a skin wound or ulcer, other vitals like oxygen and temperature were within normal range. Interventions already in place included repositioning resident Q2H (every two hours) and padding, wedges, cushioning and pillowing to alleviate stress tissues and promote circulation. give pain meds scheduled and PRN (as needed).Record review of the facility's in-service on 07/24/2025, reflected the DON conducted in-service on staff regarding reporting skin abnormalities to the charge nurse and using stop and watch method. It was signed by nursing staff, including LVN B, CNA G and CNA V . During interview and observation of Resident #9 on 07/22/2025 at 3:04pm, Resident #9 was sitting in his chair and appeared comfortable and well-groomed. Resident #9 said things were good, but did not answer further questions and shrugged his shoulder and nodded. Resident #9 had flaky skin on his legs, and there appeared to be healed circular skin on his left leg. A later observation of Resident #9 on 07/24/2025 at 9:33am, revealed he was lying in bed, pillows elevated both side of his head, and his legs were out from under the sheets with pillows cushioning both legs. He appeared comfortable in bed, with no distress, in a pleasant mood and well-groomed. In an interview with LVN B on 07/24/2025 at 2:49pm, he said that aides and nurses could report skin issues to the wound nurse. LVN B said today 07/24/2025 was the first time he saw the skin issue after being informed by the surveyor. Nurses can assess skin, but skin assessments were the responsibility of the Wound Care Nurse. During observation and interview with the DON on 07/24/2025 at 2:51pm, she said was not aware of the area before surveyor intervention. The quarter-sized wound had a layer of skin that was peeling and exposed outer edge on the lower right side. The DON told LVN A to call the resident's doctor and family and get labs to make sure there were no changes in condition. The DON said the facility was going to call the wound care doctor to get a treatment order. The DON believed the wound was an old wound that reopened. In an interview with the Director of Rehab on 07/24/2025 at 3:30pm, he said Resident #9 had ongoing physical therapy from 05/14/2025 to present. None of his staff reported any skin concerns to him, but if they saw something, he expected his therapists to report skin issues to the resident's floor nurse. The Director of Rehab said if staff did not provide repositioning care to residents, they could develop pressure ulcers. In an interview with CNA V on 07/25/2025 at 9:17am, she said she worked with Resident #9 on 07/21/2025 and gave him a bed bath. She gave him a bed bath which was cleaning his genital area. CNA V did not see any issues with his skin that day, and she did not notice any new wounds in his inner right leg. CNA V said on 07/23/2025 she gave Resident #9 a full body bed bath with another aide and did not see the old wound opened up. CNA V said LVN A just told her on 07/25/2025 that Resident #9 had an old wound that reopened. CNA V said she repositioned Resident #9 every two hours or one hour. Repositioning was done to help prevent wounds. In an interview with LVN C on 07/25/2025 at 9:58am, she said she was Resident #9's nurse on 7/21/2025 and 7/22/2025. LVN C did not receive skin issue reports during those two days and LVN C did not see anything new with the inner leg wounds. LVN C knew about Resident #9 being prone to wounds on skin Interventions for wounds would be providing an air mattress, hydration, relieving pressure and applying lotion. On 07/21/2025 LVN C assisted with bath time and saw the aide apply lotion to Resident #9's body. If she saw new wounds she would address them immediately with the resident's doctor, get treatment orders and enter them into the system and communicate with the incoming nurse, then call the resident's family, notify the physician or NP and tell the DON. LVN C said aides should reposition residents every two hours and that LVN C monitored aides for repositioning and helped if she saw residents sliding in their chair. In an interview with CNA G on 07/25/2025 at 10:41am, she said she did not work with Resident #9 that week, but in the past she would change, reposition and give baths for Resident #9. CNA G said she would let her nurse know if residents had new wounds and would document bruises and skin issues in the resident's online medical records portal.A later interview with the DON on 07/28/2025 at 10:45am , revealed the DON called the wound care nurse LVN A said there was pinkish tissue, and it was open. The DON then established wound care and started in-servicing on reporting the incidents and that the ADON did in-services on pinkish skin. The DON said wounds not addressed could lead to signs of infection. THE DON was going to send in-services on skin.Record review of the facility's policy on Provision of Quality Care, undated, read in part, 1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 2. A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan. 3. Responsibility for interventions on the care plan will be clearly identified. 4. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices.Record review of the facility's policy on Skin Assessment, undated, read in part, 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury .4. Considerations for a resident with darkly pigmented skin:a. It is not always possible to identify redness on darkly pigmented skin.b. Indicators of early pressure damage:i. Localized heatii. Edema (swelling)iii. Bogginess (soft or wet feeling in a tissue or area of the body)iv. Induration (thickening or hardening of the skin)

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including adminstering drugs and biologicals to meet the needs for each resident for 1 (Resident #105) of 4 residents reviewed for medication administration. LVN F did not correctly check Resident #105's g-tube placement before medication administration.LVN F did not stir the medications before administering it through the g-tube.LVN F left a substantial amount of medication residue in the medication cups after Allopurinol 100 mg give 0.5 tablet and Amoxicillin-Pot Clavulanate tablet 500-125 mg were administered through a g - tube to Resident #105.These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Record review of Resident #105's face sheet dated 07/22/25 revealed an [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included: gastrostomy status (a tube is surgically inserted into the stomach), dysphagia (difficulty swallowing), and acute kidney failure (a rapid decline in kidney function that occurs over days or weeks).Record review of Resident #105's admission MDS assessment dated 0717/25 revealed the resident had memory problems. Further review revealed the resident was dependent on staff for all ADL care and had a G -tube. Record review of Resident #105's order summary report for July 2025 read in part . enteral feed order every shift related to gastrostomy status Flush enteral tube with 30ml water pre/post medication administration and 5-10 ml water between each medication active date 07/16/2025. Allopurinol Oral Tablet 100 MG (Allopurinol) Give 0.5 tablet enterally one time a day related to gout active 07/10/2025. Amoxicillin-Pot Clavulanate tablet 500-125 MG give 1 tablet via G-Tube three times a day for bacterial infection, aspiration and UTI for 10 days active date 07/21/2025.Record review of Resident #105's MAR for July 2025 read in part Allopurinol Oral Tablet 100 MG (Allopurinol) Give 0.5 tablet enterally one time a day related to GOUT ordered date 07/10/25. Amoxicillin-Pot Clavulanate Table 500-125 MG Give 1 tablet via G-Tube three times a day for bacterial infection, aspiration and UTI for 10 Days ordered date 07/21/25.During medication observation on 07/23/25 at 7:10 a.m., LVN F crushed Allopurinol Oral Tablet 100 MG, give 0.5 tablet enterally one time a day, and Amoxicillin-Pot Clavulanate Tablet 500-125 MG, give 1 tablet via G-Tube three times a day, and poured each medication into two separate medication cups. LVN F placed the crushed medication cups and two water cups on the bedside table and pushed it to the bed of Resident #105, who was lying on her back with the head of the bed elevated. LVN F stopped the feeding and pulled 10 cc of air, then pushed the air into Resident #105's g-tube . She poured 10 ml of water on each of the medications, and she did not stir the medication . LVN F poured the first medication and flushed with 5 mL, then administered the second medication and flushed with 5 mL, stating she had finished the medication administrations. LVN F reconnected the feeding and unstopped the feeding. The two medication cups had substantial medication left in them after she administered the medications.During an interview on 07/23/25 at 7:35 a.m., LVN F stated that she should not have pushed air into the g-tube because she could have caused an air embolism for Resident #105. LVN F said she should have aspirated the gastric content, checked for the residual, and returned the content while she listened with her stethoscope. LVN F said she used 5 ml of water to flush before, in between, and after medication administration because she was not sure of how much water to use . LVN F stated that she forgot to stir the medication and stated she rinsed the medicines from the portion cups, then administered the remaining medication from the cup to Resident #105 , but this was not observed by the surveyor. She said Resident #105 did not receive the recommended dose because medication was left in the cups . LVN F said the medication would not provide the therapeutic effect for the reason the physician ordered the medication. LVN F said she had a skill check on medication administration through a G-tube, and the nurse manager monitored the nurse during random rounds. LVN F said she would notify the DON and the physician that she did not administer the recommended medication doses. During an interview on 07/24/25 at 9:50 a.m., the DON said the proper way to check for residual before medication administration was to pull up the gastric content and check the amount, and with a stethoscope, listen to the bowel sound while LVN F pushed back the stomach content. The DON said pushing 10 cc of air could cause air embolism for Resident #105. The DON said LVN F should follow the physician's order on how to flush the G tube before and after medication administration. The DON stated LVN F should have flushed with 30 ml of water before and after medication administration. The DON stated LVN F should have stirred the medication and ensured the medication was dissolved before she administered the medication, rinsed the medication cup, and ensured she administered all the medication. The DON stated the medications would not provide the desired therapeutic level because LVN F did not administer medications as prescribed.During an interview on 07/27/2025 at 10:30am with Resident #105's NP, she said she checked in with Resident #105's physician who said that they were aware of the missing dose of medication and that the physician told nurses who continue monitoring Resident #105. Record review of the facility undated policy on medication administration via G tube read in part . it is the policy of this facility to ensure the safe and effective administration of medication via enteral feeding by utilizing best practice guidelines. explanation and guidelines. #3. medication should be crushed and mixed with purified or sterile water. Record review of the facility undated medication administration policy read in part .medication is administered . as ordered by physician and in accordance with professional practice.

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 6%, based on 2 errors out of 31 opportunities, which involved 1 (Resident #105) of 4 residents reviewed for medication errors. - LVN F left a substantial amount of medication residue in the medication cups after Allopurinol 100 mg give 0.5 tablet and Amoxicillin-Pot Clavulanate tablet 500-125 mg were administered through a g - tube to Resident #105.- LVN F did not stir the medications before administering it through the g-tube.These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings included: Record review of Resident #105's face sheet dated 07/22/25 revealed an [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included: gastrostomy status (a tube is surgically inserted into the stomach), dysphagia (difficulty swallowing), and acute kidney failure (a rapid decline in kidney function that occurs over days or weeks).Record review of Resident #105's admission MDS assessment dated 0717/25 revealed the resident had memory problems. Further review revealed the resident was dependent on staff for all ADL care and had a G -tube. Record review of Resident #105's order summary report for July 2025 read in part . enteral feed order every shift related to gastrostomy status Flush enteral tube with 30ml water pre/post medication administration and 5-10 ml water between each medication active date 07/16/2025. Allopurinol Oral Tablet 100 MG (Allopurinol) Give 0.5 tablet enterally one time a day related to gout active 07/10/2025. Amoxicillin-Pot Clavulanate tablet 500-125 MG give 1 tablet via G-Tube three times a day for bacterial infection, aspiration and UTI for 10 days active date 07/21/2025.Record review of Resident #105's MAR for July 2025 read in part Allopurinol Oral Tablet 100 MG (Allopurinol) Give 0.5 tablet enterally one time a day related to GOUT ordered date 07/10/25. Amoxicillin-Pot Clavulanate Table 500-125 MG Give 1 tablet via G-Tube three times a day for bacterial infection, aspiration and UTI for 10 Days ordered date 07/21/25.During medication observation on 07/23/25 at 7:10 a.m., LVN F crushed Allopurinol Oral Tablet 100 MG, give 0.5 tablet enterally one time a day, and Amoxicillin-Pot Clavulanate Tablet 500-125 MG, give 1 tablet via G-Tube three times a day, and poured each medication into two separate medication cups. LVN F placed the crushed medication cups and two water cups on the bedside table and pushed it to the bed of Resident #105, who was lying on her back with the head of the bed elevated. LVN F stopped the feeding and pulled 10 cc of air, then pushed the air into Resident #105's g-tube . She poured 10 ml of water on each of the medications, and she did not stir the medication . LVN F poured the first medication and flushed with 5 mL, then administered the second medication and flushed with 5 mL, stating she had finished the medication administrations. LVN F reconnected the feeding and unstopped the feeding. The two medication cups had substantial medication left in them after she administered the medications.During an interview on 07/23/25 at 7:35 a.m., LVN F stated that she should not have pushed air into the g-tube because she could have caused an air embolism for Resident #105. LVN F said she should have aspirated the gastric content, checked for the residual, and returned the content while she listened with her stethoscope. LVN F said she used 5 ml of water to flush before, in between, and after medication administration because she was not sure of how much water to use . LVN F stated that she forgot to stir the medication and stated she rinsed the medicines from the portion cups, then administered the remaining medication from the cup to Resident #105 , but this was not observed by the surveyor. She said Resident #105 did not receive the recommended dose because medication was left in the cups . LVN F said the medication would not provide the therapeutic effect for the reason the physician ordered the medication. LVN F said she had a skill check on medication administration through a G-tube, and the nurse manager monitored the nurse during random rounds. LVN F said she would notify the DON and the physician that she did not administer the recommended medication doses. During an interview on 07/24/25 at 9:50 a.m., the DON said the proper way to check for residual before medication administration was to pull up the gastric content and check the amount, and with a stethoscope, listen to the bowel sound while LVN F pushed back the stomach content. The DON said pushing 10 cc of air could cause air embolism for Resident #105. The DON said LVN F should follow the physician's order on how to flush the G tube before and after medication administration. The DON stated LVN F should have flushed with 30 ml of water before and after medication administration. The DON stated LVN F should have stirred the medication and ensured the medication was dissolved before she administered the medication, rinsed the medication cup, and ensured she administered all the medication. The DON stated the medications would not provide the desired therapeutic level because LVN F did not administer medications as prescribed.During an interview on 07/27/2025 at 10:30am with Resident #105's NP, she said she checked in with Resident #105's physician who said that they were aware of the missing dose of medication and that the physician told nurses who continue monitoring Resident #105. Record review of the facility undated policy on medication administration via G tube read in part . it is the policy of this facility to ensure the safe and effective administration of medication via enteral feeding by utilizing best practice guidelines. explanation and guidelines. #3. medication should be crushed and mixed with purified or sterile water. Record review of the facility undated medication administration policy read in part .medication is administered . as ordered by physician and in accordance with professional practice.

Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety for 1 (Freezer A) of 1 freezer observed for food storage.-There were 3 packets of onion soup base which had best used by dates of 07/11/2025 in Freezer A. This failure could put residents at risk of food contamination and illness due to being served food past the best used by date. Observation of Freezer A on 7/22/2025 at 8:25am, revealed there were 3 5.4 oz. packets of onion base soup powder dated best if used by 07/11/2025 and labelled 11-12 in black ink pen.During observation and interview with the Dietary Manager on 7/22/2025 at 8:25am, the Dietary Manager said those packets should be thrown away and that everyone in the kitchen was responsible for checking for dates. The Dietary Manager was observed throwing all 3 packets into the trash can. The Dietary Manager said there was no harm or risks to residents if the food was expired and still on the shelves because the kitchen would not cook and serve those foods to residents. The Dietary Manager said the facility did not have a policy on expired food and that they were to throw away items past the expired dates on the package.In an interview with the DON and Administrator on 07/22/2025 at 4:41pm, the DON said residents could get an upset stomach if they ate expired food and could get diarrhea or nausea too. The Administrator said the Dietary Manager should be in charge of expiration dates and that the culinary team was trained on handling food and that the DON was aware the team had a rotating schedule regarding food to ensure food served was fresh. A policy was requested covering expired foods, and the Food Storage policy was provided.Record review of the facility's Food Storage policy approved on 12/01/2011 read in part, All food will be stored according to the state and Federal Food Codes . The policy did not cover expired food.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Hall A) of 3 halls observed for infection control.-There was a trash bag with white and blue linen left outside Resident #12's room by the doorway on the floor.This failure could place residents at risk of contagious diseases and spread of illness when infection control protocols are not followed. Observation and interview in Hall A on 7/23/2025 at 3:40pm, revealed there was a trash bag on the floor outside Resident #12'sroom. The bag was tied up and contained white and blue linen. MA V saw the bag and took it and walked it down the hall to the trash room. MA V said that it did not belong there, and she did not know who put it there.In an interview with LVN B on 7/23/2025 at 3:41pm, he said the trash bag should not have been on the floor and he did not know who placed it on the floor. He said leaving the bag on the ground could spread infection and be an infection control issue. He said he had received training on infection control since working at the facility.In an interview with the DON on 07/28/2025 at 10:45am, she said tied bags of sheets should not be on the floor and nothing should go on the floor but feet. The DON said whatever was on the floor would be carried on the bag, like infection and that staff were in-serviced on infection control. She said Housekeeping was also in-serviced on enhanced barrier precautions when going into rooms, how to carry linen and handwashing. Record review of the facility's in-services for staff, on 07/08/2025 reflected the ADON conducted an in-service on handling linen and wearing gloves in the hallway. It was signed by MA V and LVN B .

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for five of six residents, (Resident #5, Resident #10, Resident #13, Resident #136 and Resident #186) and three of four staff (LVN A, LVN B, CNA A, RN A) reviewed for infection control and prevention, in that: 1. Resident #186's pressure sore treatment was not done with the clean technique. 2. CNA A did not perform hand hygiene before or after Resident #10 nor Resident #13's incontinence/indwelling catheter care. 3.4. LVN did not follow proper technique in cleaning accu-check machine between Resident #136 and Resident #5. These failures placed residents at risk for the development and transmission of infectious diseases, urinary infections, respiratory infections, hospitalization s and death. Findings included: Record review of Resident #186's facility admission record dated 6/14/2024 revealed an admitted [DATE]. Resident #186 was an [AGE] year-old male with diagnoses that included dysphagia (difficulty swallowing), tracheostomy status ((also called a tracheostomy) is a procedure where a hole is made at the front of the neck. A tube is inserted through the opening and into the windpipe (trachea) to help you breathe) and gastrostomy status (a surgical opening into the stomach for nutritional support or gastric decompression). Record review of Resident#186's baseline care plan dated 5/29/2024 revealed care plans for tracheostomy care, suctioning and skin risk-pressure ulcer at sacrum. Record review of Resident #186's care plan, dated 06/12/24 11:31 am reflected: -Resident #186 is at risk chronic pain r/t Wound at sacrum: Resident #186 will display a decrease in behaviors of inadequate pain control: irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, and groaning through the review date. Record review of Resident #186's Admission MDS dated [DATE], revealed that the Brief Interview for Mental Status was blank. Section GG for ADL's revealed Resident #186 was total dependent on staff. Observation of Resident #186's pressure ulcer on 6/12/24 at 1:01 PM, performed by RN A, she cleaned the stage 2 pressure ulcer to the sacral area stage 2, RNA poured normal saline on 4 x4 gauze, with gloved hand she cleaned, RN A cleaned the wound in a circular form around the wound. In an interview with RN A on 6/12/24 at 1:18 PM regarding cleaning Resident #186's pressure ulcer, RN A said she always cleaned the pressure wound in a circular motion and she had in-services on wound cleaning, and she could not remember when she had in-services on wound care. In an interview with the DON on 6/12/24 at 4:30 PM regarding the cleaning pressure ulcer wounds she said, nurses were supposed to clean pressure ulcer from the center outward. Record review of Resident #10's face sheet revealed an [AGE] year-old resident who was originally admitted to the facility on [DATE]. Her medical diagnoses included cerebrovascular disease (variety of medical conditions that affect the blood vessels of the brain and the cerebral circulation), type 2 diabetes mellitus, hyperlipidemia (high levels of fat in the blood), hypothyroidism (the thyroid gland does not produce enough hormones), Anxiety Disorder, Malignant Neoplasm of Female Breast, Hypertension (high blood pressure), Hemiplegia and Hemiparesis following cerebral infarction (stroke) affecting left non-dominant side, dysphagia (difficulty swallowing), and generalized muscle weakness. Record review of Resident #10's quarterly MDS dated [DATE], the resident's BIMS (brief interview that measures cognitive intactness) score was a 14, indicating she was cognitively intact. Further review showed the resident was always incontinent of urine and bowel. Record review of Resident #10's care plan dated 05/22/2024, her focus areas included: -I have bowel incontinence, dated 11/28/2023. Interventions included: checking resident every two hours and assisting with toileting as needed, provide bedpan/beside commode, provide peri care after each incontinent episode, take resident to toilet each day to try to establish a bowel pattern: I have an ADL self-care performance deficit r/t Hemiplegia and Hemiparesis affecting Left non-dominant side s/p cerebrovascular attack, Interventions included: Toilet use, with the resident being totally dependent on one staff for toilet use. Record review of Resident #13's face sheet revealed an [AGE] year-old who was originally admitted to the facility on [DATE]. Her medical diagnoses included Type 2 diabetes mellitus (high glucose in the blood), urinary tract infection, immunodeficiency due to conditions classified elsewhere, inflammatory Poly arthropathy, retention of urine, vascular dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #13's admission MDS dated [DATE], the resident's BIMS (brief interview that measures cognitive intactness) score was blank, indicating she was cognitively intact. BIMS score of blank meaning Resident #13 was severely impaired. Resident #13 was always continent of urine using indwelling catheter and incontinent bowel. Record review of Resident #13's care plan revised 05/08/2024 revealed resident was care-planned for the following: Resident #13 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Activity intolerance, impaired balance. -Interventions for Toilet Use: The resident is totally dependent on (x 1) staff for toilet use, Resident #13 has bowel incontinence r/t immobility, poor gait & balance -Interventions: Check resident frequently and assist with toileting as needed, Provide peri care after each incontinent episode Record review of Resident #13's MAR (Medication Administration Record) for May 2024 revealed resident was on Macrobid (medication used for urinary tract infection for 7 Days) and she just completed on 5/18/24. Observation of Resident # 13's Foley catheter care on 06/11/24 at 08:52 AM was lying in bed, with eyeglasses on, she had indwelling catheter. Further observation on 6/11/24 at 10:00AM, CNA A was at bedside to perform incontinent / indwelling catheter care, don gloves but did not wash hands., CNA A placed indwelling, Foley catheter on the bed with 50cc of yellow urine in the bag and urine along the tubing, she wipe resident, groin, and perineal area, she did not open the labia to cleaned, she cleaned the tubing, she repositioned resident on her left side, then pulled down the brief from the back, Resident #13 had large bowel movement (BM), CNA A then change gloves, did not washed hands or use hand sanitizer and picked a cleaned gloves from her uniform pocket, cleaned in/between the buttocks, she did not cleaned around the buttock did not change gloves, then placed a clean brief on Resident #13. Observation on 6/11/24 at 10:25 AM Resident #10 was lying in bed, CNA A washed hands and donned (put on) clean gloves, using the wet wipes, CNA A cleaned Resident #10's groin, and did not open the labia to clean. CNA A repositioned to the left side, Using the wet wipes, CNA A cleaned in between buttocks, she did not clean the around the buttocks. The CNA A picked up cleaned brief put it on Resident #10 without changing gloves. CNA A used the same gloves throughout the procedure. Interview with CNA A on 6/11/24 at 11:30 AM, regarding Resident #10's incontinent and indwelling catheter care, she said she started working December 2023, and she thought she did a good job. C.NA A was off duty and was not picking telephone calls. During an interview with the DON on 06/13/2024 at 2:25 PM., the DON stated that during the incontinent care of a female resident, Staff should wipe the peri area, then open the labia and clean downward and clean the indwelling catheter in a circular motion. The DON said she was going to start incontinence care skills checks. DON said the ADON and they do incontinent monitoring. The DON stated that if staff performed peri care deviating from policy, residents risked possible urinary infections. The DON did not have policy for incontinent and Foley catheter care. In an interview on 06/13/2024 at 2:35 PM, the Administrator stated her expectation was that incontinent care and hand washing were always done to prevent infection. Interview with ADON on 6/13/24 at 4:15 PM she said Resident#13 just completed Macro antibiotic bid on 5/18/24 for UTI (urinary tract infection). Record review of Resident #5's face sheet revealed [AGE] year-old resident who was originally admitted to the facility on [DATE]. Her medical diagnoses included type 2 diabetes mellitus without complications (high levels of fat in the blood), morbid (severe) obesity due to excess calories, diabetic neuropathy, unspecified psychosis not due to a substance or known physiological condition. Record review of Resident #5's admission MDS dated [DATE], the resident's BIMS (brief interview that measures cognitive intactness) score was a 15, indicating she was cognitively intact. Record review of Resident #5's Care plan revealed he had an ADL self-care performance deficit r/t impaired mobility New Goal The resident will improve current level of function through the review date. Record review of Resident #5's physician's order dated 05/14/2024, revealed accu-check before each meal. Record review of Resident #136's face sheet revealed [AGE] year-old resident who was originally admitted to the facility on [DATE] readmitted [DATE]. Her medical diagnoses included type 2 diabetes mellitus without complications (high levels of fat in the blood), morbid (severe) obesity due to excess calories ( excess weight gain) multiple myeloma (blood cancer) not having achieved remission. Record review of resident #136's quarterly MDS dated [DATE], the resident's BIMS (brief interview that measures cognitive intactness) score was a 08, indicating she was moderately cognitively intact. Record review of Resident #136's Care plan I have an ADL self-care performance deficit r/t impaired mobility New Goal The resident will improve current level of function through the review date. - Record review of Resident #136's physician's order dated 03/28/2024, revealed accu-check before each meal. Observation on 6/11/24 at 4:19 PM of Resident #136's care blood glucose (BG) done by LVN B, LVN B picked up accu-check from the medication cart to Resident #136's room, she used the lancet and struck Resident #136's finger and drop blood on blood glucose strip. BG was 142mg/dl. Observation on 6/11/24 at 4:33 PM, LVN B did not wipe down the accu-check machine, between Resident #136's and Resident #5's BG checks. LVN B checked Resident #5's BG was 213mg/dl. In an interview with LVN B on 6/11/24, at 4:38 PM she was very sorry for not wiping the accu-checks in-between the Resident #136 and Resident #5. It could cause contamination. She said she had in-services on infection control. In an interview with DON on 6/12/24 at 5:00PM regarding accu-check machine cleaning during blood glucose checks. DON said LVN B were supposed to clean the accu-check machine between residents BG checks to prevent infection. DON said she would be conducting in-services on accu-check. Record review of undated policy for Hand Hygiene revealed: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 3. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. 4. Hand hygiene technique when using an alcohol-based hand rub: a. Apply to palm of one hand the amount of product recommended by the manufacturer. b. Rub hands together, covering all surfaces of hands and fingers until hands feel dry. c. This should take about 20 seconds. 5. Hand hygiene technique when using soap and water: a. Wet hands with water. Avoid using hot water to prevent drying of skin. b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f. Use clean towel to turn off the faucet. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. b. Bar soap is approved for a resident's personal use only. Keep bar soap clean and dry in protective containers (i.e. plastic case or bag). Record review of undated policy for catheter care revealed Catheter Care Under Policy Explanation . #9. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. Record review of the facility policy undated for clean dressing change: Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and /or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy explanation and compliance guidelines: 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound). Pat dry with gauze. 32422

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure expired foods were discarded. 2. The facility failed to ensure foods were labeled and dated. 3. The Facility failed to ensure food was stored in designated areas at all times. 4. The facility failed to thaw frozen ,d+[DATE] lb. rolls of frozen ground beef. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on [DATE] at 8:15 AM revealed the following. 1. A Plastic Container of Pureed sausage saved from breakfast dated [DATE] use by date [DATE] 2. A Plastic container of Sour cream dated [DATE] no use by date 3. A Plastic Container of ,d+[DATE]lb ground beef submerged in water with temperature of 78.8 degrees Fahrenheit , the ground beef Temperature was 67.4 degrees Fahrenheit. 4. Several boxes food on floor kitchen, walk in refrigerator, in freezer and in storeroom. 5. Scoop left in flour bin. 6. Sugar bin and thickener bin not covered. Interview with the Dietary Food Service Manager on [DATE] at 8:25 AM she stated the leftover food stored in the refrigerator should have been used or discarded prior to use by date, she further stated that all food shall be stored 6 inches off the floor. She also stated that the proper thawing of frozen meat water should be running with a temperature of 70 or below degrees Fahrenheit and the meat should have at temperature of 41 degrees or lower. The Dietary Food Service Manager in-serviced the Dietary staff on Thawing and Cooling Procedure and a post test on [DATE]; Procedure on Expired Products on [DATE]; Procedure on Dietary Leftover Food and Procedure on dating /opening products on [DATE]. Record review of facility's policies and procedures for Food Safety for Residents dated 2022 read in part .cover, label with name, date stored and Record review of facility's policies and procedures for Food Storage dated 2022 read in part .store all items at least 6 inches above the floor with adequate clearance between goods and other contamination.

32422 Based on observation, interview and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, for oxygen therapy for two of two residents (Resident # 29 and Resident #186) reviewed for respiratory care. -The facility failed to follow the physician orders for Resident #29's oxygen administration. -The facility failed to provide tracheal care and suctioning according to professional standards for Resident #186. These deficient practices could result in the resident's not receiving the care and services ordered by the physician and a decline in health status and oxygen deprivation. Findings included: Record review of Resident #29's facility admission record dated 06/11/2024 revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Resident #29's medical diagnoses included Alzheimer's Disease, dementia, hyperosmolality (a serious complication of diabetes that causes very high blood sugar and dehydration), hypernatremia (high concentration of sodium in the blood), hypertension (high blood pressure), acute kidney failure, and dysphagia (difficulty swallowing). Record review of Resident #29's quarterly MDS assessment, dated 04/11/2024 revealed a BIMS (Brief Interview for Mental Status) was not completed due to the resident being rarely or never understood. Further review showed Resident #29 was receiving oxygen therapy at the facility. Record review of Resident #29's care plan last reviewed on 05/22/2024 revealed she was on supplemental oxygen for Respiratory Failure. Interventions included: administering oxygen per doctor's order, receiving monitoring for symptoms of respiratory distress and report to doctor as needed, and being provided extension tubing or portable oxygen apparatus as needed. Record review of Resident #29's order summary report dated June 2024 revealed on 02/14/2023 she had an order to apply continuous O2 sat (saturation) at 2L (liters) per minute every shift for SOB (shortness of breath). On 12/01/2022 Resident #29 had an order to check O2 sat every shift and as needed. Further review revealed her oxygen saturations for June 2024 were within normal range. During an observation on 6/11/2024 at 9:33am, Resident #29's concentrator was set on 1.5L. Resident #29 was sleeping in bed and appeared comfortable and not in respiratory distress. During an observation on 6/11/2024 at 3:44pm, Resident #29's concentrator was set on 1.5L. Resident #29 was lying in bed and did not appear to be in respiratory distress. During an observation on 6/12/2024 at 10:02am, Resident #29's concentrator was set at 1.5L. She was sleeping in bed, no discomfort or respiratory distress was noted. Her humidifier was dated 06/12/2024. Resident #186 Record review of the facility admission record dated 6/14/2024 revealed an admitted [DATE]. Resident #186 was an [AGE] year-old male with diagnoses that included dysphagia (difficulty swallowing), tracheostomy status ((also called a tracheotomy) is a procedure where a hole is made at the front of the neck. A tube is inserted through the opening and into the windpipe (trachea) to help you breathe) and gastrostomy status (a surgical opening into the stomach for nutritional support or gastric decompression). Record review of Resident #186's care plan revealed a care plan to address Tracheostomy Status: Resident #186 has a tracheostomy r/t traumatic subdural hemorrhage with loss of consciousness: Resident # 186 will have no abnormal drainage around the trach site through the review date. 06/12/24 11:31 AM Resident #186 was at risk chronic pain r/t Wound at sacrum: Resident #186 will display a decrease in behaviors of inadequate pain control: irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, and groaning through the review date. Record review of Resident # 186's Admission MDS dated [DATE], revealed the BIM score was blank. Resident was documented to be total dependent for all ADL's. Record review of Resident #186's physician orders for June 2024 with a start date pf of 5/29/2024 revealed the following orders: -Change Shiley (Shiley inner cannulas that twist to lock in place are reusable) 6 disposable inner cannula at bedtime for Patent airway. -Change trach tie as needed. -Change trach tie at bedtime every Monday, Wednesday and Friday for maintenance and infection control. -The resident is on Enhanced Barrier Precautions regarding tracheostomy care/wound care: Use a gown and gloves for high-contact resident care. If there is a risk of splash or spray, use a face shield as needed. Every shift for prevention spread of infection. Don gloves and gown before high contact resident care. Remove gown and gloves and handwash/sanitize hands, before exiting the room and before providing care to another resident. -Trach care every 12 hours for maintenance/infection prevention. -Tracheal suction every 6 hours for Patent airway. -Clean the sacrum wound with normal saline, pat dry, and apply med honey and calcium alginate. Cover with 4 x 4 form dressing. Every day shift for wound with a start date of 6/2/2024. -Wash wound with NS, pat dry. Apply calcium alginate to wound bed, cover with dry dressing, one time a day for wound. Record review of Resident #186's care plan, no date provided revealed a care plan to address Tracheostomy Status: Resident #186 has a tracheostomy r/t traumatic subdural hemorrhage with loss of consciousness: Resident #186 will have no abnormal drainage around the trach site through the review date. 06/12/24 11:31 am Resident #186 is at risk chronic pain r/t Wound at sacrum: Resident #186 will display a decrease in behaviors of inadequate pain control: irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, and groaning through the review date. Record review of Resident #186's Treatment Administration Record for June 2024 revealed tracheal suction every 6 hours for patent airway was provided on 6/1/2024 through 6/13/2024. Observation on 6/11/2024 at 10:00 am, revealed Resident #186 lying in bed, trach in place, oxygen was in place, resident appeared to be asleep. Observation of Resident #186 on 6/12/2024 at 1:15 PM, resident was observed lying in bed with the head at a 30-degree angle. Resident #16's oxygen concentrator read 3.5L/min. Observation on 06/12/2024 at 1:26 PM revealed Resident #186 was in bed with audible moist breath sounds. Respiratory Therapy (RT) was at bedside observing tracheostomy care, LVN A stated resident was not usually this moist and they changed the resident's inner cannula every day. LVN A set up a clean field on the bedside table, checked oxygen saturation checked and it was 99%. She changed gloves without washing hands or using hand sanitizer, grabbed the sterile suction catheter kit tray, opened it, then doff gloves without washing hands, picked up the sterile gloves, don sterile gloves then picked up normal saline at Resident #186's bed side, poured it in the tray. LVN A picked up the suction tubing from the sterile suction kit connected it to the suction machine at Resident #186's bed side. LVN A then used the sterile gloved right hand to removed oxygen mask on Resident #186's trach, then inserted suction catheter into the tracheostomy tube x 2 times, then rinsed tubing with normal saline LVN A donned clean gloves, picked up Trach Care Kit without changing gloves. LVN A opened the sterile Trach Care Kit, using the same gloves picked up sterile 4x4 gauze, brush and sterile gloves placed on the bedside table. LVN A, using the same gloves, removed tracheostomy inner canula, then picked a syringe 10 ml normal saline (NS) covered with plastic wrap, LVN A unwrapped NS the rinsed tracheostomy inner cannula x 2 times, then re-inserted it to trach site. In an interview on 06/12/2024 at 1:54 PM, LVN A stated she did not wash her hands during trach care or do suctioning right. She stated she should have used sterile technique throughout, and she had last in-service on tracheostomy care in 1 month ago and not suctioning tracheostomy with cleaned technique could result infection or cardiac arrest. She stated she works with Resident #186 most of the time. In an interview with RT on 6/12/24 at 2:00 PM regarding tracheostomy care she observed LVN A performed , she said LVNA did not maintained sterile technique and she had in-services with LVN A about a month ago with return demonstration. RT said she was to retrain all the staff and she thought she was just nervous. In an interview on 06/12/2024 at 5:45 PM, when Surveyor described the observed trach care, suctioning for Resident #186, the DON stated tracheostomy care should be done using sterile procedure. The DON said the last in-services on tracheostomy was last month. The DON said LVN A always worked with Resident #186, and she was going to have more training with the nurses on tracheostomy care and not maintaining sterile technique could result in respiratory tract infection. During an interview on 6/12/2024 at 10:02am with RN A, she stated that Resident #29 was her resident, and that Resident #29 gets continuous oxygen. RN A said she checks Resident #29's oxygen every hour and checks the humidifier daily. RN A said that in the last few days she noticed Resident #29's concentrator dipping after she sets it to 2L per physician order, but she has not told the DON yet. She said Resident #29's oxygen saturation levels have been normal in the last few days. RN A said that she reads the oxygen level by looking down at the machine from a standing position, not sitting directly in front of the machine. RN A had in-services the previous week on how to care for residents on oxygen therapy. Interview with the DON on 6/12/2024 at 2:25pm, she said none of her nurses have told her about oxygen concentrator issues, but that she would look into it. The DON said her expectations for her nurses are that they follow procedures correctly. If residents do not get the right amount of oxygen therapy as prescribed by their physicians, it could cause them distress and they would not be able to breathe properly. She said her staff had an in-service on oxygen and respiratory therapy the previous week and that she will do an in-service on how to accurately read the oxygen concentrator immediately. Record review of the facility policy entitled Oxygen Administration dated copyright 2022, read in part, Oxygen is administered under orders of a physician .The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as when to administer such as continuous or intermittent .equipment setting for the prescribed flow rates. Record review of the facility policy and procedure entitled Tracheostomy Care dated copyright 2021, read in part . Policy: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Record review of the facility policy and procedure entitled Tracheostomy Care-Suctioning, dated , read in part . Policy: The facility will ensure that residents who need respiratory care, including tracheal suctioning, are provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Tracheal suctioning is performed by a licensed nurse to clear the throat and upper respiratory tract of secretions that may block the airway.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 9% based on 3 errors out of 32 opportunities, which involved 3 of 9 residents (Resident #29, Resident #14 and Resident #6) reviewed for medication errors. 1. RN A did not administer Sodium Chloride (a prescription medicine used to replenish lost water and salt in your body due to certain conditions like low salt syndrome) to Resident #29 as ordered by the physician. 2. MA A did not administer Losartan Potassium ( a drug used to lower blood pressure) to Resident #14 as ordered by the Physician. 3. RN B did not administer Valproic Acid ( a drug works by lowering seizures) to Resident #6 as ordered by the physician. These failures could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications. Findings included: Record review of Resident #29's face sheet revealed a female admitted on [DATE]. Her diagnoses sodium deficiency displacement of other gastrointestinal prosthetic devices ( tube surgically inserted in stomach used to feeding and medication administration), implants and grafts, Alzheimer's disease( a brain disorder that slowly destroys memory and thinking skills, eventually affecting a person's ability to perform simple tasks), cerebral infarction ( death of brain tissue due to a lack of blood flow to the brain), acute respiratory failure with hypoxia ( lack of oxygen to the brain). Record review of Resident #29's quarterly MDS assessment dated [DATE] revealed a BIMS score of blank out of 15 which indicated severely cognitive impairment. She needed extensive assistance of 1-2 staff for ADLs. Record review of Resident #29's Physician Order Report for 08/28/2023 revealed an order for Sodium Chloride oral tablet Give 1 gram via peg-tube two times a day. Record review of Resident #29's MAR revealed Sodium Chloride oral tablet Give 1 gram via peg-tube two times a day. Scheduled time was for 9:00 AM and 5:00 PM In an observation and interview on 6/11/24 at 8:55 PM RN A prepared and administered Sodium Chloride 500 mg 1 tablet from the bottle. RN A then crushed Sodium Chloride 1 tablet and dilute in water and administered with other medication via GT . In an interview on 6/13/24 at 10:00 Am with RN regarding not giving Sodium Chloride as ordered by the doctor, she said she did not check the order well and she should have given 2 tablets. She said she had in-services on medication administration, and she had been working on and off for the facility for 7 years. She knew not giving the medication correctly could result in having medication error and the medication would not be effective. 2. Rrecord review of resident #14's face sheet revealed a female admitted on [DATE]. her diagnoses type 2 diabetes mellitus ( high blood glucose) with diabetic neuropathy ( nerve problem), chronic kidney disease, stage 3 morbid (severe) obesity due to excess calories ( excess fat due too much food consumption), anemia in other chronic diseases classified elsewhere, bipolar disorder ( abnormal mood swing), essential (primary) hypertension ( high blood pressure). Record review of Resident #14's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated no cognitive impairment. She needed extensive assistance of 1-2 staff for ADLs. Record review of Resident #14's Physician Order Report for 01/12/2024 revealed an order for Losartan Potassium Oral Tablet 25 MG (Losartan Potassium) Give 1 tablet by mouth one time a day for Hypertension Hold for SBP< 110, DBP< 60, HR <60. Observation on 6/12/24 at 8:05 AM, MA A did not administered Losartan Potassium Oral Tablet 25 MG with other medications she administered to Resident #14. MA A initialed Losartan Potassium Oral Tablet 25 MG with other medications given at 8:00 AM In a telephone interview on 6/13/24 at 2:30 PM, MA A said was off duty and thought she did administer all medication to Resident #14, she said she got was in-serviceds on medication. 3. Record review of Resident #6's face sheet revealed a female admitted on [DATE]. Her diagnoses type 2 diabetes mellitus ( high blood glucose) gastrostomy infection, epilepsy ( seizure), without type 2 diabetes mellitus with diabetic neuropathy ( nerve pain), unspecified status epilepticus, aphasia ( unable to talk), severe intellectual disabilities, chronic kidney disease, dysphagia(difficulty swallowing) Record review of Resident #6's quarterly MDS assessment dated [DATE] revealed a BIMS score was blank out of 15 which indicated severely cognitive impairment. She needed extensive assistance of 1-2 staff for ADLs. Record review of Resident #6s Physician Order Report for 03/07/2024 revealed an order for 3/7/24 Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 10 ml via G-Tube every 12 hours for Seizure. Observation on 6/12/24 at 8:18 AM, RN B poured Valproic Acid Oral Solution 250 MG/5ML 12 ml in a medication cup and others medication via G-Tube. In an interview with RN B on 6/13/24 at 10:00 AM, regarding not administering Valproic Acid Oral Solution 250 MG/5ML 10 mls as ordered by the physician's she said would be more careful . In an interview on 6/13/24 at 12:38 PM the DON said the staff should read the MAR and blister packet before medication administration to Residents. She said she expected nursing staff to ensure the medication order and inventory matched because the correct dosage needed to be provided to the resident. In an interview on 6/13/24 at 12:46 PM the Administrator said he expected nursing staff to follow the physician orders. Record review of facility's policy on Medication Administration undated: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state , as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on observation, interview and record review the facility failed to obtain laboratory services to meet the needs of its residents for 1 of 5 residents (Resident #29) reviewed for laboratory services. The facility did not obtain CBC levels for Resident #29 following orders on 6/6/2024. This failure could place residents at risk of not receiving treatment and services to meet their needs. Findings included: Record review of Resident #29's facesheet dated 06/11/2024 revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Resident #29's medical diagnoses included Alzheimer's Disease, dementia, hyperosmolality (a serious complication of diabetes that causes very high blood sugar and dehydration), hypernatremia (high concentration of sodium in the blood), hypertension (high blood pressure), acute kidney failure, and dysphagia (difficulty swallowing). Record review of Resident #29's quarterly MDS assessment, dated 04/11/2024 revealed a BIMS (a brief interview to gauge a resident's cognitive intactness) was not completed due to the resident being rarely or never understood. Record review of Resident #29's doctor visit summary dated 04/17/2024 revealed she was in a vegetative state. Record review of Resident #29's medical chart, her last CBC labs with differential (a lab that counts a person's different types of cells to give their healthcare providers a picture of their overall health) was on 02/08/2024, 01/25/2024, and 10/12/2023. Record review of Resident #29's MAR and TAR for June 2024 captured 06/11/2024 at 3:05pm, resident had a Lipid (fat) panel including CBC scheduled for 06/06/2024, which read, one time only for lab until 06/07/2024. The order for 6/7/2024 was initialed by RN B. The MAR and TAR further stated Resident #29 was receiving Eliquis Tablet 2.5 MG (medication given to prevent blood clots) via G-tube (a tube connected to a person's stomach through which medicine, nutrition and hydration can be given. She was also scheduled for anticoagulant monitoring via low platelet count. During an observation on 6/11/2024 at 3:44pm, Resident #29 was lying in bed and did not appear to be in respiratory distress. Resident #29 did not respond to questions. During an observation on 6/12/2024 at 10:02am, Resident #29 was sleeping in bed, no discomfort. Interview with on 6/14/2024 at 11:00am with RN B, she stated that Resident #29 was her resident. Resident #29 had a CBC test scheduled for 6/24/2024 in her orders but RN B was unaware of the test ordered on 6/6/2024. She said she did not remember the earlier order dated 6/6/2024 nor signing for that order on 6/6/2024. Interview with the DON on 6/13/2024 at 4:09pm, the DON was shown Resident #29's lab orders for 6/6/2024. She said there was a lab order for 6/24/2024 but not for 6/6/2024. When asked why there would be two orders in the system, the DON replied that the two orders placed on 6/6/2024 and 6/24/2024 could be routine labs done for long-term care residents or in preparation for residents' doctor's visits. The DON would need to look into the lab order placed on 6/6/2024, as she needs to look for the original labs in the system. The facility did not provide the lab results by the end of survey.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 1 of 4 residents (Resident #1) reviewed for pharmacy services, in that: -The facility failed to ensure Resident #1was monitored during medication administration. This failure could place residents at risk of not receiving their medications, chocking and respiratory distress. Findings included: Record review of Resident #1's admission face sheet dated 10/19/23 revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted [DATE]. Her diagnoses included cerebrovascular disease (a result of disrupted blood flow to the brain), diabetes mellitus (metabolic disease involving Hight blood glucose levels) dysphagia (impairment or difficulty in swallowing), hypertension (blood is pumping with more force than normal through arteries) and seizures (a burst of uncontrolled electrical activity between brain cells). Record review of Resident #1's Quarterly MDS assessment, dated 08/31/23, revealed the BIMS score was 10, which indicated moderate impaired cognition. Further review of the MDS revealed he required limited to extensive assistance with one to staff assist with all ADL. Record review of Resident #1's care plan initiated 09/08/21 and revealed the following: Resident #1 has a seizure disorder: intervention: give medication as ordered. Monitor/document for effectiveness. Resident #1 has cerebral vascular accident. Intervention: monitor and document ability to chew and swallow. If resident is presenting with problem, obtain order for speech therapy to evaluate. Resident #1 has constipation related to limited mobility and the use of pain medication. Intervention: administer medications for the side effects of constipation, keep physician informed of any problem. During an observation and interview on 10/19/23 at 11:04 a.m., Resident #1 had three medications in her mouth toward the back of her tongue and two in the medication cup. Resident #1 placed the medication cup with the two pills inside the trash can. She was drinking water and moving her head backward and forward, but she could not swallow the medication. Then, Resident #1 brought the medicine to the front of her mouth, crushed the pills with her teeth, and drank water three times. Resident #1 was in the room by herself and was not observed by any staff while taking her medications. During an observation and interview on 10/19/23 at 11:22 a.m., LVN V said she was Resident # 1 nurse and MA M should not have left Resident #1 to take her medication unattended. LVN V said the aide did not follow the five rights of medication administration. LVN V took the medication cup from the trash and said the medication in the cup was for constipation. LVN V said Resident #1 could choke on her pill and cause respiratory distress; if she did not take her medication as ordered, the medicine would not be effective. LVN V said the floor nurse should monitor the medication aides and make sure the medication was administered properly. LVN V said the nurse managers monitored the nurses by making random rounds. During an interview on 10/19/23 at 11:26 a.m., LVN D said she reported to Resident # 1's doctor, FM, and the DON. LVN D said MA M would be in serviced, and she would be suspended pending investigation. LVN D said another MA would be placed in the hall to pass medication. During an Interview on 10/19/23 at 11:30 a.m., MA M said she should have stayed with Resident #1 when she was taking her medication. MA M said Resident #1 may not have taken all her medications, which could cause the medicine not to be effective or choke on the pills, which could cause respiratory distress. MA M said Resident #1 takes a long time to take her medication, and she stays with her because she takes her medication slowly. MA M said she should have told LVN V to monitor the resident when she left the room. She said she had skills check off on medication administration and storage. During an interview on 10/19/23 at 3:50 p.m., the ADON said MA M should have stayed with Resident #1 when she administered the medication and monitored the resident as she swallowed the medicines to prevent the incident of not taking all her medication and Resident #1 placed two pills in the trash. The ADON said since Resident #1 did not take medicine as ordered, there could be side effects; if it was blood pressure medication or blood thinner, the resident could have a stroke, heart attack, and blood clot, and the resident could choke, which causes respiratory distress. The ADON said the charge nurse monitors the medication aide by making rounds during medication administration. The ADON said the nurse managers monitor the nurses by making random rounds. The ADON said she made rounds before the incident. During an interview on 10/19/23 at 4:41 p.m., the DON said her expectation for MA M was to stay at the bedside until Resident #1 finished swallowing her medications. DON said MA M should wait until Resident #1 swallowed her medicines for safety and the medication was administered properly. DON said there was a potential for aspiration, and Resident #1 could get sick and have respiratory changes. DON stated if one of the medications Resident #1 did not take was her blood pressure, it could cause elevated blood pressure. DON said if a time-release medication were chewed by Resident #1, it would change the absorption rate, and it could have advised rate because it could change the therapeutic rate in Resident's blood. DON said none of the nurses or medication aides had told her that it takes Resident #1 a while to take her medication. DON said she would review Resident #1 medication and see if any of her medication could be changed to crushable or liquid form. The DON said after the incident happened, the following steps were taken : MA M was suspended. Another medication aide was to take over the floor. The doctor to review Resident #1 medications, and the doctor said to call the pharmacy for recommendations and call her back for approval. The DON said she was waiting for the pharmacy to call her with the recommendations, and when she called the doctor for approval, she would ask the doctor or the NP (nurse practitioner) to come and see and assess Resident #1. Record review of the facility policy on pharmacy services Copyright 2023 the compliance store, LLC. Read in part . compliance guidelines: #1 the facility will provide pharmaceutical services include . administering of all routine drugs .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that: -The facility failed to ensure food items with an expired use by date were removed from the refrigerator. -A food item was not cooled properly before being placed in the walk-in refrigerator and was 100 degrees Fahrenheit when tested with a thermometer. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease. Findings include: Observation of the facility's kitchen and interview on [DATE] between 8:30 am and 8:40 am with the Dietary Cook A revealed a container of cooked macaroni with a use by date of [DATE] in the walk-in refrigerator. Observed on [DATE] at 8:35 AM revealed a container of breakfast pork sausage with a temperature of 100 degrees Fahrenheit when tested , in the walk-in refrigerator. Interview with the Dietary Cook A on [DATE] at 8:35 AM, she stated that the container of cooked macaroni should have been used or discarded prior to the used by date. Interview with the Dietary Cook A on [DATE] at 8:40 AM, she stated that she did not follow the facility's proper procedure to cool the breakfast pork sausage prior to storing the food in the walk-in refrigerator. Dietary Cook A was not able to articulate the proper cooling procedure. Interview with the Dietary Manager on [DATE] at 9:00 AM she said that she was responsible for training staff on labeling and storage requirements ensuring dietary requirements were met. A form will be used where the staff will document the food temperature from the steam table and document time to cooling food rapidly prior to storing in the walk in refrigerator therefore food temperature is not on the danger zone ( Cold food with a temperature of 40 degrees F or lower and hot food with a 135 degrees Fahrenheit or higher) to be in the safe temperature zone. Record review of facility's Policy Food Safety Requirements dated 2022 Read in part .c. Preparation of food, including thawing, cooking, holding, and reheating. C. Refrigerated Storage .Practices to maintain safe refrigerated storage include: ii Placing hot food in container (e.g.Shallow pan) that permit the food to cool rapidly. iv Labeling, dating, and monitoring refrigerated food including, but not limited to leftovers, so it is used by its use-by date or/discarded.

Based on observation, interviews, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments for one (Nurse Medication Cart West Hall) of four medication carts observed for storage of medications. The facility failed to ensure the Nurse Medication Cart West Hall was secured when unattended. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: Observation of West Hall during tour on 04/16/2023 at 9:31 AM revealed West Hall Nurse Medication Cart parked in the hall at room [ROOM NUMBER] unlocked and unattended. No residents or visitors were in the hall. One staff member was observed three rooms away passing ice. Continued observation at 9:36 AM revealed LVN A returned to the West Hall Nurse Medication Cart from room [ROOM NUMBER]. In an interview on 04/16/2023 at 9:37 AM, LVN A stated she left the medication cart because she heard a resident needed help. LVN A stated she was thinking of resident safety. LVN A stated she did not intend to leave the medication cart unlocked. LVN A stated the medication cart was to be locked at all times when left unattended. The LVN stated the staff working on the cart was responsible for locking it. LVN A stated the risk of the unlocked medication cart was someone could remove a medication off the cart they should not have. Observation on 04/16/2023 at 9:38 AM during an inventory of Nurse Medication Cart West Hall accompanied by LVN A revealed: Left side of medication cart: -Drawer #1: Vitamins, stool softener, acidophilus, iron folic acid, zinc, fish oil, melatonin, vitamin B1, Tylenol, Aspirin, glucose monitoring supplies; -Drawer #2: Resident's individual medication packets, liquid Dilantin (antiseizure medication); -Drawer #3: Respiratory medication and respiratory treatment supplies, Lidocaine topical patches; -Drawer #4: Alcohol wipes, medication administration supplies; Right Side of Cart: -Drawer #1: Insulin, glucose monitoring supplies; -Drawer #2: Locked narcotic box with medications for nine residents; -Drawer #3: Locked narcotic box with medications for two residents; -Drawer #4: Liquid medications Colace, protein supplement, Miralax. In an interview on 04/18/2023 at 9:10 AM, the DON stated her expectations were for the medication carts to be locked when left unattended. The DON stated it was the responsibility of the staff working on the medication cart to ensure it was locked prior to leaving it. The DON continued and stated a risk of an unlocked medication cart was that someone could move a medication off the medication cart they should not have access to. The DON stated to prevent this from occurring again she will in-service and impress on the staff the risk of not locking a medication cart. She stated there was no reason for not locking it before walking away. In an interview on 04/18/2023 at 9:46 AM, the Administrator stated she expected all medication carts to be locked when unattended. The Administrator stated the risk of not locking a medication cart was a medication can be removed. She stated the only person supposed to have access to the medication carts were the nurses or medication aides. Record review of the facility's policy titled Medication Storage dated 2022 read in part It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufactures' recommendations and sufficient to ensure proper sanitation, temperature, light, ventilations, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls .

Based on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 (Resident #8) of 3 resident reviewed for respiratory care. -The facility failed to follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure placed residents who received oxygen therapy at risk of respiratory complications. Findings included: Record review of Resident #8's face sheet revealed a [AGE] year-old -female was admitted to the on 05/16/2011 and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's annual MDS dated [DATE] revealed BIMS at 06 indicating severely impaired cognition. It also revealed resident required extensive assist with 2 to 3 staff assistance for ADL care. Further review of the resident MDS did not mention the resident was on oxygen. Record review of Resident#8's care plan dated 02/08/22revealed the resident had shortness of breath related to [CONDITION(S)] disease of the nervous system, intervention: oxygen per medical doctor order. Record review of Resident#8's clinical physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 8's TAR (treatment administration record) for February 2022 read: use oxygen at 2 liters via nasal cannular every shift for shortness of breath/wheezing start date 02/20/21 Observation and interview on 02/08/22 at 11:19 a.m., with RA A, who was attending to the resident, said the oxygen concentrator was set at 4 liters and she did not adjust the concentration setting. She said the nurses set the oxygen levels on the machine. Resident #8 was observed lying on her back and she did not respond to any greetings. Observation and interview on 02/08/22 at 12:43 p.m., with LVN D, she said the oxygen was set at 4L, and it is at the correct level. She said the order in the chart read 2 to 4 liters, and somebody made a mistake when it was entered in the computer. She said the nurse who received the oxygen order writes it and transcribes it to the treatment administration record. Observation and interview 02/08/22 at 12: 45 p.m., with LVN D, revealed the doctor's order was written to be administered at 2 liters on the physician order. LVN D then said it was her fault, She should have checked the setting on the oxygen concentrator and made sure oxygen was set according to the doctor's order which was 2 liters when she made rounds. She said oxygen should not be increased or decreased without a doctor's order. She said not administering the oxygen according to the doctor's order could harm the resident's respiration. She said she did skills checks on oxygen before working with a resident with oxygen. Observation and interview on 02/08/22 at 12:57 p.m., with ADON, she looked up the oxygen order on the computer and said the oxygen order was written on 02/19/2021 for at 2L. she said the nurses are responsible for writing orders from the doctor and transcribing the order to the treatment administration record. Observation and interview on 02/08/22 at 1:00 p.m., with ADON, she said the O2 was at 4L instead of 2 L. She stated her expectation for the nurses was to do rounds and check the setting on the 02 concentrators and make sure the setting on the concentrator matched the physician order. She said the setting must not be changed without a doctor's order because it is considered a medication. ADON stated that giving the resident more oxygen than what was ordered could cause a negative side effect because oversaturation of oxygen has a negative effect on the resident, such as oxygen toxicity. Interview on 02/09/22 at 10:28 a.m., the DON she said oxygen is considered medication and it should be administered per the doctor's order. She said it could have an adverse reaction. It can cause the opposite effect; instead of increasing the oxygen circulation, it will cause the opposite effect, and it may cause harm to the resident. She said the nurses had skills check before working with the resident; also, LVN D was in - service on oxygen administration and monitoring. She said the nurse should check the oxygen setting during rounds to make sure oxygen is set according to the doctor's order. The DON stated she and ADON trained the nurses, and they monitor nurses randomly daily. The DON said she would retrain the nurses, and the resident would be assessed, and her doctor would be notified too. She also said the resident doctor was notified by the ADON after she interviewed the surveyor on 02/08/22 about 1:15 p.m. and the doctor gave order to monitor the resident. Interview on 02/10/22 at 8:52 a.m., with RN E she said she was the nurse who worked on the night on 02/07/22, and LVN D took over from her on the morning of 02/08/22. She said she did not change the setting on the oxygen concentrator, but it was on 2 liters when she checked but did not remember what time it was. She said she had skills check off on oxygen during floor orientation. Record review of the undated facility policy on oxygen administration read . to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues . Procedure . #1. Check physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 24 residents (Resident #31) reviewed for comprehensive assessments. These deficient practices could affect residents with comprehensive care plans and may result in inadequate care. The findings included: Resident #31 Review of Resident #31's face sheet undated revealed she was a [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #31's care plan dated 11/18/2021 revealed it did not include a focus, goal or interventions for Resident #31's pacemaker. Record review of Resident #31's Re-Admission MDS dated [DATE] revealed in part the following: Section I - Presence of cardiac pacemaker Record review of Resident #31's H&P dated 12/18/2021 revealed the following in part: Single AP (antero-posterior - central position) view of the chest is provided. Left chest wall pacer device . Record review of Resident #31's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 2/10/2022 at 3:05 p.m. with the DON said resident care plans should be comprehensive and include specific medical diagnosis. The DON said Resident #31's pacemaker status should be included in her care plan so the pacemaker could be monitored. The DON said Resident #31's pacemaker status should have been identified by all staff that assisted in her admission on 12/22/2021. The DON said it must have been missed the pacemaker because she was not aware Resident #31 had a pacemaker. The DON said we should talk to Resident #31's cardiologist or primary care physician. The DON said it is important to monitor Resident #31's pacemaker because Resident #31 has heart failure and if the pacemaker is not functioning properly it could affect Resident #31 negatively. Record review of admissision progress note dated 12/22/2021 documented by admitting nurse revealed it was not documented that Resident #31 had a pacemaker. Interview was attempted on 2/11/2021 at 1:10 p.m. with Resident #31's admitting nurse, a voicemail was left and there was not a return phone call. Record review of facility policy Comprehensive Care Plan and Care Plan Meetings not dated revealed the following in part: Purpose: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preference and goals and address the resident's medical, physical, mental and psychosocial needs. .This community will help develop and implement a comprehensive person-centered care plan for each resident that includes: c. Services are furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . 2. The comprehensive care plan will be developed by the Interdisciplinary Team using the MDS is assess the resident's clinical condition . The services provided or arranged by the community, as outlined by the comprehensive care plan, must: Meet professional standards of quality and the services provided or arranged by the facility .

Based on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 24 resident's (Resident #31) reviewed for resident call system, in that: The facility failed to ensure Resident #31's had a working call light. This failure could have placed residents at risk of being unable to obtain assistance when needed. The findings include: Review of Resident #31's face sheet undated revealed she was [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included presence of cardiac pacemaker, heart failure, [CONDITION(S)] (condition of being overweight to a degree that is dangerous to one's health), respiratory failure, [CONDITION(S)] (diseases that cause airflow blockage and breathing-related problems). Record review of Resident #31's Re-Admission MDS dated [DATE] revealed she had a BIMS of 7 which indicated she was severely cognitively impaired. Record review of Resident #31's care plan dated 11/18/2021 revealed the care plan did not address the call light. Observation and Interview on 2/11/2022 at 9:20 a.m. revealed Resident #31's firmly pressed her call light button, and it did not signal. The call light did not light up or signal at the site of the call light plug, the light above the resident door, or at the nurse's station call light indicator. Resident #31 said she tried to notify the staff by pushing her call light that she wanted to get up out of bed and go to the dining room for an activity. Resident #31 said she had pushed the call light about 20 minutes ago and there was no response from staff. She said she was ready to get out of bed. Resident #31 pressed the call light in surveyor's presence and the call light system did not light up in the room or at the nurse's station. Interview on 2/11/2022 at 9:25 a.m. with CNA P said she was assigned to Resident #31's hall. CNA P said she was not aware Resident #31 call light was not functioning. CNA P said she does not monitor if the call lights were functioning properly and that was maintenance's responsibility. She said it was important for the call light system to function properly to notify staff when a resident needed assistance. Interview on 2/11/2022 at 9:28 a.m. with RN G said she was prn and was not aware Resident #31's call light was not working. RN G said she had not been trained or told to monitor call lights and if they were working properly. She said they check on residents a least every 2 hours and they can use the call light if they need assistance. RN G said it was important for the call light to function and alert staff by lighting up so resident will not go without assistance. Interview on 2/11/2022 at 9:52 a.m. with Maintenance Director said he checked to ensure the call lights were working properly, but was not on a specific schedule. He said he has sometimes incorporated checking the call lights on Monday's but not consistently every Monday. He said he checked the maintenance log and did not see a work order request for any call lights. He said the residents use the call lights for assistance and the call light should be in working condition. The Maintenance Director said he was responsible to ensure the call light system was functioning. Interview on 2/11/2022 at 10:15 a.m. with the DON said the Maintenance Director was responsible for ensuring the call light systems were working properly in the building. The DON said the call light function when pressed by the residents was to ensure they were assisted when needed. The DON said there was not a specific schedule of when call lights were checked to ensure they were working. She said the facility did not have a specific policy on call light maintenance. Record review on 2/11/2022 at 9:30 a.m. of the maintenance log binder (12/2021 - 2/11/2022) at the East Nurses station revealed there was not a work order request for Resident #31's non-functioning call button. Record review of undated facility policy Call Lights revealed the following in part: Purpose: Ensure the safety of our residents. Procedure: Providing a safe environment for our residents is key. 1. Answer call lights promptly.

Based on observation, interview, and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 (CR #1 and #2) of 7 residents reviewed for pain, in that: -CR #1 complained of pain and swelling in right arm for four days and the facility failed to follow physician's orders [REDACTED].#1 sent to the hospital and was diagnosed with [REDACTED]. -CR #2 had unrelieved pain that was delayed in being treated effectively by staff not assessing the pain or following physician's orders [REDACTED].#2 was transferred to the hospital to receive effective pain management and diagnostic tests not conducted at the facility as orderd. After administrative review on [DATE], it was determined that additional information was needed and a Surveyor returned to the facility on [DATE]. These failures placed all residents who experience pain at risk of inadequate therapeutic outcomes, a decline in health and hospitalization s. Findings included: CR #1 Record review of CR #1's face sheet revealed he was an [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. He died in Hospice care on [DATE]. Record review of CR #1's admission MDS dated [DATE] revealed he had a BIMS of a 9 which indicated he had moderate cognitive impairment. No routine or PRN pain management was noted on the MDS. He needed ,[DATE] person extensive staff assistance with bed mobility, transfers, eating, toilet use and personal hygiene. Record review of CR #1's [DATE] MAR indicated [REDACTED]. There was an X in each box indicating pain level was not assessed. Record review of CR #1's MAR for [DATE] revealed -Tylenol extra strength 500mg by mouth one time a day for [MEDICAL CONDITION] given daily [DATE]st-12th and discontinued on [DATE]. -[MEDICATION NAME] Tablet 600mg three times a day for swollen right upper arm x 4 days. Start date of [DATE] and completed on [DATE]. Record review of CR #1's Nurse Progress Note written by RN A, dated [DATE] at 6:13 a.m. read in part . observed patients right elbow area slightly swollen . Noted area painful as patient states my arm hurt . Able to move right arm per passive range of motion . Record review of facility 72-hour summary/nurse report from [DATE] at 9:00 a.m. identified a nurse note on [DATE] for CR #1, read in part x-ray pending, order to start [MEDICATION NAME] x 4 days, and physician will assess tomorrow . There was no nurses note related to CR #1's continued pain or swelling to the right arm. Record review of a phone order dated [DATE] for CR #1 that read in part . right elbow X- ray, reason pain . Record review of a phone order dated [DATE] for CR #1 that read in part . right elbow X- ray, reason swelling and pain .outpatient imaging . Record review of CR #1's physician progress notes [REDACTED]. History of present illness: Patient discovered to have a swollen and warm right elbow over the weekend. He is noted to have reduced ROM and now requires help with feeding, pain is noted with movement . Physical exam: right elbow swollen, reduced passive and active ROM, pain with movement, does not seem to be in pain with palpation of elbow . treatment plan: [REDACTED]. Record review of CR #1's phone order for CR #1 dated [DATE] phone order revealed MD ordered a stat chest x-ray. Record review of CR #1's Nurse Progress Note dated [DATE] at 9:08 p.m. by ADON B read in part . patient has altered mental status, and lethargic . Right elbow has begun to swell again following completion of [MEDICATION NAME] . Record review of emergency room Medical Screening dated [DATE] for CR #1 revealed he had a right upper extremity doppler ultrasound that showed [MEDICAL CONDITION] in the right brachial vein. The X-ray of the right arm showed a healing [MEDICAL CONDITION] and a [MEDICAL CONDITION]. Interview on [DATE] at 10:40 a.m. with ADON, she said RN B told her CR #1 had swelling to his arm. The ADON said she saw CR #1's arm and it was swollen. She said they informed CR #1's Family Member and the Family Member thought the pain may have been due to arthritis. Interview on [DATE] at 11:04 a.m. with CNA A, she said she told LVN A that CR #1's right arm was swollen on [DATE]. She said if she touched it he would make a noise and pull his arm back. She said she told LVN A several times that CR #1 was complaining about pain to his arm, but she was not sure if LVN A followed-up. She said if she touched under his arm, he would say it hurts. Interview on [DATE] at 4:23 p.m. with RN A said she was the nurse on duty overnight. She said her last round she was told by CNA D that CR #1's arm looked swllen. RN A said she touched his arm and he said my arm as if it hurt him. I told the ADON (no longer employed at the facility). RN A said she gave him pain medication. I could not document the pain level because the system did not allow me to. Interview on [DATE] at 5:26 p.m. with ADON, a copy of CR #1's care plan was requested and was not provided by exit. Interview on [DATE] at 6:07 p.m. with the Administrator, he said the electronic charting system was not set up to have nurses input the level of pain at the time of giving medications. Interview on [DATE] at 3:12 p.m. with RN B (wound care nurse), she said she seen CR #1 for a skin assessment in early [DATE] and identified that he had pain with PROM and localized swelling to right elbow. She said he had no redness or discoloration. RN B said signs of a fracture would be limited mobility, pain, change in tissue color, possible recent fall, change in bone alignment and skin may be warm to touch. She said signs of a [MEDICAL CONDITION] are pain, decreased pulse sensation, change in skin color and swelling. She said CR #1 did not have signs of a [MEDICAL CONDITION] because there was no localized swelling or tenderness. She said she informed the floor nurse of her findings and documented them on her skin assessment. She said the floor nurse should have documented this information on the 24-hour report. Telephone Interview on [DATE] at 3:54 p.m. with CR #1's physician, she said she remembered she was notified by nursing on [DATE] that CR #1 had pain with ROM. She said she assessed the resident and he had some swelling and pain with ROM, but he looked comfortable and no pain when sitting up in wheelchair undisturbed. She said signs of a [MEDICAL CONDITION] are swelling, pain and redness. She said CR #1 had no signs or symptoms of a [MEDICAL CONDITION]. She said a [MEDICAL CONDITION] in the arm would not cause concern for [MEDICAL CONDITION] emboli. She said she ordered an x-ray to his elbow because of swelling and tenderness with passive range of motion. She said the resident was very old and frail and they would have a field day with him, referring to the hospital. CR #2 Record review of CR #2's face sheet revealed he was a [AGE] year old male admitted and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #2's quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating moderate impaired cognition. He needed limited help of 1 staff for bed mobility, extensive help of 1 staff with dressing, toileting, personal hygiene, and locomotion in the facility using a wheelchair. Record review of CR #2 Medication Review Report revealed orders for: .Pain assessment every shift using the verbal pain scale order date of [DATE]. .[MEDICATION NAME] Tablet ,[DATE] mg ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth every 4 hours as needed for pain. Order date [DATE]. [MEDICATION NAME] Tablet ,[DATE] mg ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth every 8 hours for pain. Order date [DATE]. Record review of CR #2's Order Summary Report read in part . [MEDICATION NAME] Tablet ,[DATE] mg ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth every 6 hours as needed for pain . effective date [DATE] . Record review of CR #2's Care Plan read in part: . Acute pain right abdomen & right flank aspect r/t kidney stones . Interventions: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain, grimacing and/or guarding . Monitor/document for side effects of pain medication. Observe for constipation, new onset or increase agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness, and falls. Report occurrences to the physician . initiated [DATE] . Record review of CR #2's Nurse Progress Note dated [DATE] by LVN C at 9:00 p.m. read in part . complaints of abdominal pain rate ,[DATE] on verbal scale. Abdominal assessment done and observed the following . Abdomen distention . complain of pain upon touch during palpation . New order for stat KUB and stat abdominal ultrasound . Record review of CR #2's Nurse Progress Note by RN B dated [DATE] at 10:42 p.m. CR #2 transferred to hospital related to abdomen pain that is not well managed by pain med. Record review of CR 2's Nurse Progress Note by LVN A dated [DATE] at 9:20 a.m. read in part . returned from ER . diagnosed with [REDACTED].Treated with [MEDICATION NAME] while in ER . Follow up with urologist and PCP . urology appointment set up . pain management in progress and well tolerated . Ultrasound of the abdomen order was received from MD . Observation and Interview on [DATE] at 12:58 p.m. with CR #2. He was alert to surroundings and his situation. He admitted he did get forgetful at times and asked the surveyor for her name a couple times throughout the conversation. He rubbed at his right side of abdomen during the conversation and said he had pain in his abdomen that was very annoying. He said he had a recent hernia surgery. CR #2 pulled his shirt up and observation of a healed mid abdominal incision and a small reddened open area on the right lower abdomen. The abdomen appeared to be slightly more distended on the right side then the left side. He rubbed his hand around the mid to lower abdomen and said that was where he had pain. He rated his pain a 6 ½ to 8 on a ,[DATE] pain scale. He said pain medications helped the pain, but the pain never went away. He said he received a pain med around 10:00 a.m. by LVN A but the medication had not helped. Interview on [DATE] at 1:30 p.m. with LVN A, she said she had given CR #2 pain medication that morning because he complained of abdominal pain. She said CR #2 received [MEDICATION NAME] 1 tablet for a pain of 7 but unsure when she gave the medication. She said the pain medication was effective. She said he was forgetful at times and did not remember when he received his pain med. LVN A said she had not done an abdominal assessment on CR #2. Interview on [DATE] at 1:51 p.m. with ADON, she said CR #2 had a hernia surgery in January. She said the resident was always forgetful and always complained of pain. Surveyor asked if pain was objective or subjective and she said pain was what the resident said it was, but CR #2 would constantly ask for a pain med because he forgot when he last received them. Observation and Interview on [DATE] at 7:05 p.m. of CR #2, he was lying in bed alert and orientated to his surroundings. CR #2 greeted surveyor on first name basis when entering. He said he was still having pain in his stomach and he was not feeling well. He rated his pain a 7 ½ to 8 on a pain scale of ,[DATE]. He had some facial grimacing, rubbing at the right side of abdomen, and his abdomen appeared more distended from the day before. Interview on [DATE] at 7:15 p.m. with LVN D, she said she recently had an in-service related to pain. She said she was to follow up on a resident's pain ,[DATE] hours after pain med given. She said if a resident had concerns of new pain she would notify the doctor. She would document on the MAR pain and the effectiveness of the pain medication. Surveyor had told LVN D of CR's pain. She said she gave CR #2 pain meds around 2:00 p.m. and followed up around 4:00 p.m. to check the effectiveness. LVN D said CR #2 complained of pain often because he of his dementia. She then went back to completing her other nursing tasks she was doing before surveyor stopped her. Observation and Interview on [DATE] at 7:30 p.m. LVN D went into CR #2's room and asked the resident about his pain. The resident reported a pain of 7 ½ to 8 on a pain scale of ,[DATE]. He said the pain had worsened. Observation of LVN D gave CR #2 [MEDICATION NAME] 10- 325mg, 1 tablet at 7:35 p.m. She said she had to multi task and prioritize which was more important when doing her nursing tasks. Observation and Interview on [DATE] at 7:42 p.m. with LVN D and RN C completed an abdominal assessment on CR #2. RN C initiated by lifting residents shirt and began to push on abdomen. CR #2 complained of pain and had facial grimacing and told the nurses that the pain felt like it was inside his stomach. He pointed to the right lower part of his abdomen and told them that his pain had worsened in his stomach and said I'm sick and abnormal. I don't enjoy dealing with all this. LVN D listened to his stomach and reported bowel sounds were normal. The nurses talked with the resident and told him that they would call the doctor because of his pain. The nurses explained the abdominal assessment was good. LVN D said she was going to contact the doctor about CR #2's pain. Surveyor asked if LVN D had any further concerns she would report to the doctor and she replied no. She said she would make a progress note. Observation and Interview on [DATE] at 12:28 p.m. of CR #2, he was lying in bed asleep. He easily awoke when knocked on door. He could not remember the surveyor. He said he had right sided abdominal pain of a 7.5 on a pain scale of ,[DATE] and he had some facial grimacing. He said he could not remember what they had done for him the night before related to his pain and he requested to be left alone. Observation of his abdomen appeared round and distended. Observation and Interview on [DATE] at 5:01 p.m. of CR #2. He was lying in bed awake and alert to his surroundings. He was complaining of pain in his right abdomen but not too bad. He rated his pain a 6. CR #2 was rubbing the right side of his stomach. He said the pain had gotten a little better, but now was having pain in back and top of head. He said he could not remember if he had told the nurse staff. Interview on [DATE] at 5:20 p.m. with ADON, she said CR #2 had no pain today, she said she had checked on him twice. Interview on [DATE] at 3:25 p.m. with RN A she said she had a recent in-service by the previous DON on pain assessment/ pain management which included resident assessment for pain before pain medications are given and follow up in a half hour to an hour to assess the resident's pain. She said if the medication was noneffective report to the physician such as if the resident still had pain after medications were given. She said a resident could not go over 2 days in pain without a follow-up with the physician. She said it was her duty as a unit manager to make sure the orders were followed through as well as the floor nurses. Record review of the facility's undated Resident Assessment Pain Assessment and Management policy read in part . General Guidelines . 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident . 3b. Effectively recognizing the presence of pain . 3d. Addressing the underlying causes of the pain . 3g. Monitoring for the effectiveness of interventions . 5. Conduct a comprehensive pain assessment . whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain . 6. Assess the resident's pain and consequences of pain at least each shift for acute pain . Monitoring and Modifying Approach . 1. Re-assess the resident's pain . 3. Monitor the resident by performing a basic assessment with enough detail . Reporting: report the following information to the physician or practitioner . 1. Significant changes in the level of resident's pain . 3. Prolonged, unrelieved pain despite care plan interventions .

Based on interview and record review, the facility failed to provide radiology services to the resident and have an agreement to obtain these services from a provider or supplier that was approved to provide these services under Medicare for 2 (CR #1 land CR #2) of 7 residents reviewed for radiological services, in that: -CR #1's physician ordered an x-ray for CR #1's arm after swelling and complaints of pain from the resident. The facility did not obtain the x-ray for four days due to not having a contract with a radiology company to provide this service. CR#1 was sent to the hospital and was diagnosed with [REDACTED]. -CR #2's physician ordered abdominal ultrasound on [DATE] and on [DATE] that were not completed until [DATE]. CR #2 had consistent complaints of pain to his right side which required him to be transferred to the hospital. After administrative review on [DATE], it was determined that additional information was needed and a Surveyor returned to the facility on [DATE]. These failures could affect all residents who required diagnostic services to assist the physician to [DIAGNOSES REDACTED]. Findings included: CR #1 Record review of CR #1's face sheet revealed he was an [AGE] year-old male admitted on [DATE]. His [DIAGNOSES REDACTED]. He died in Hospice care on [DATE]. Record review of CR #1's admission MDS dated [DATE] revealed he had a BIMS of a 9 which indicated he had moderate cognitive impairment. He needed ,[DATE] person extensive staff assistance with bed mobility, transfers, eating, toilet use and personal hygiene. Record review of CR #1's Nurse Progress Note dated [DATE] at 6:13 a.m. written by RN A, read in part . observed patients right elbow area slightly swollen . Noted area painful as patient states my arm hurt . Able to move right arm per passive range of motion . Record review of facility 72-hour summary/ nurse report identified a nurse note on [DATE] read in part . x-ray pending, order to start [MEDICATION NAME] x 4 days, and physician will assess tomorrow . Many attempts have been made to talk to staff at the diagnostic center, no luck . Record review of CR #1's weekly skin assessment dated [DATE] read in part . right elbow with localized swelling . passive range of motion with tenderness . X-rays pending and new medication from MD . Record review of a phone order dated [DATE] for CR #1 that read in part . right elbow X- ray, reason swelling and pain. Outpatient imaging. Record review of CR #1's physician progress notes [REDACTED]. History of present illness: Patient discovered to have a swollen and warm right elbow over the weekend. He is noted to have reduced ROM and now requires help with feeding, pain is noted with movement . Physical exam: right elbow swollen, reduced passive and active ROM, pain with movement, does not seem to be in pain with palpation of elbow . treatment plan: [REDACTED]. Record review of phone order dated [DATE] for CR #1 revealed MD ordered a stat chest x-ray. Record review of CR #1's Nurse Progress Note dated [DATE] at 2:40 p.m. by LVN A read in part .new order stat chest x-ray at outpatient imaging . Outpatient imaging sent resident back for order clarification . rescheduled for next available [DATE] . Record review of CR #1's Nurse Progress Note dated [DATE] at 9:08 p.m. by ADON B read in part . patient has altered mental status, and lethargic . Right elbow has begun to swell again following completion of [MEDICATION NAME] . Pending chest x-ray scheduled for Monday. Resident sent to ER . Record review of emergency room Medical Screening dated [DATE] for CR #1 revealed he had a right upper extremity doppler ultrasound that showed [MEDICAL CONDITION] in the right brachial vein. The X-ray of the right arm showed a healing [MEDICAL CONDITION] and a [MEDICAL CONDITION]. Interview on [DATE] at 10:05 a.m. with Administrator, he said he was not sure how Resident #1 received the fracture to his elbow. He said there were several attempts to schedule a mobile x-ray to come to the facility starting on [DATE]. He said the company that they usually used had gone bankrupt. He said another local X-ray provider was taking too long. He said a different management company took over the facility and further delayed securing a contract with a mobile x-ray service. He said CR #1 was sent out to an outpatient imaging center but returned because the order needed to be clarified by the doctor. CR #1 was sent to the hospital for a chest x-ray on [DATE] and he also received a x-ray to his right elbow which revealed the fractures. Record review of email sent to the Administrator dated [DATE] at 10:42 a.m. from the mobile x-ray company read in part . Subject - Radiology service . I'm working on getting pricing approval. Once completed I can send you a contract for radiology services. How are you handling exams now? . Interview on [DATE] at 10:40 a.m. with ADON, she said RN B told her CR #1 had swelling to his arm. She said the MD came on that Wednesday ([DATE]). She said she transcribed an order given by the MD to get an x-ray. She said they had a problem with getting a mobile x-ray company to come to the facility. She said she tried a different x-ray provider, but they took too long. She said she tried on [DATE] and [DATE] without success to get an x-ray company to come to the facility, before she looked for an outpatient hospital for the x-ray. CR #1 was scheduled for the outpatient x-ray on [DATE] but was sent back to the facility because the outpatient clinic wanted the order clarified by the MD. She said the order was clarified but the next available appointment was [DATE]. She said the residents' elbow swelled even more. Interview on [DATE] at 11:42 a.m. with CR #1's MD, she said she was told about CR #1's swollen arm. She said she gave an order for [REDACTED]. She expected the x-ray to be completed within 24 to 48 hours. Interview on [DATE] at 2:28 p.m. with LVN A, she said she was told by CNA A that CR #1 had pain in his right arm. She said the facility did not have a contract with a mobile x-ray unit at that time. She said CR #1 should have been sent out to get the x-ray. She said there was a problem with the MD x-ray order when CR #1 went on [DATE] to get an x-ray of his arm. CR #1 was sent back to the facility without getting a x-ray. She said CR #1 went to the ER before the scheduled x-ray appointment on [DATE]. Interview on [DATE] at 3:22 p.m. with the Administrator, he said they should have followed the MD orders and sent CR #1 to an out-patient imaging center for an x-ray to his elbow as soon as possible. He said when they did send him, there was a problem with the order according to the imaging center, which was out of our control, and the MD was needed to clarify the order. Interview on [DATE] at 4:32 p.m. with CNA C, he said he saw CR #1's arm was swollen, and he said he told the ADON. He said there was a problem with the mobile x-ray company coming out. He said CR #1 would wince if his arm was touched. Interview on [DATE] at 5:26 p.m. with ADON, a copy of CR #1's care plan was requested and was not provided by exit. Interview on [DATE] at 12:30 p.m. with LVN A, she said a routine x-ray was to be done within the same day and a stat within 4 hours. If the mobile x-ray company could not follow through she would send the resident to an outpatient or ER. She said CR #1 had pain to his right elbow. She said she had given him routine Tylenol and notified the doctor and an x-ray was ordered. She said she also had the CNA place a pillow under his arm for comfort. LVN A said she had trouble getting the mobile x-ray company out to the facility and she had tried for a couple days. She said she notified the previous ADON about not getting the x-ray. She said later the resident was having some respiratory issues and the doctor ordered a stat chest x-ray. She said the resident was sent to an outpatient imaging but returned because the order needed to be clarified. Telephone Interview on [DATE] at 3:54 p.m. with CR #1's physician, she said she remembered she was notified by nursing on [DATE] that CR #1 had pain with ROM. She said she assessed the resident and he had some swelling and pain with ROM, but he looked comfortable and no pain when sitting up in wheelchair undisturbed. She said she was aware the facility was having trouble with the mobile x-ray company and she felt an outpatient x-ray would be a better choice than sending the resident to the hospital. She said the resident was very old and frail and they would have a field day with him. She said she expected stat x-rays to be done that day and routine x-rays were generally done by the next day. She said it was very rare to send a resident out for imaging. CR #2 Record review of CR #2's face sheet revealed he was a [AGE] year old male admitted on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #2's quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating moderate impaired cognition. He needed limited help of 1 staff for bed mobility, extensive help of 1 staff with dressing, toileting, personal hygiene, and locomotion in the facility using a wheelchair. Record review of CR #2's Care Plan read in part . (CR #2) has surgery site at mid gastric with J-P drain relate to hernia repair surgery, [MEDICAL CONDITION] of abdomen wall . initiated [DATE] . Interventions . Monitor mid gastric surgery incision for sign of pain, drainage, odor, skin color change (sign of infection) report to physician . initiated [DATE] . Acute pain right abdomen & right flank aspect r/t kidney stones . Interventions: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain, grimacing and/or guarding . Monitor/document for side effects of pain medication. Observe for constipation, new onset or increase agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness, and falls. Report occurrences to the physician . initiated [DATE] . Record review of CR #2 Medication Review Report revealed orders for: Abdominal KUB stat order date of [DATE]. Abdominal ultrasound stat order date of [DATE]. Record review of CR #2's Nurse Progress Note by LVN C dated [DATE] at 9:00 p.m. read in part . complaints of abdominal pain rate ,[DATE] on verbal scale. Abdominal assessment done and observed the following . Abdomen distention . complain of pain upon touch during palpation . New order for stat KUB and stat abdominal ultrasound . Record review of CR #2's Nurse Progress Note by RN B dated [DATE] at 10:42 p.m. CR #2 transferred to hospital related to abdomen pain that is not well managed by pain med. Record review of CR 2's Nurse Progress Note by ADON dated [DATE] at 9:20 a.m. read in part . returned from ER . diagnosed with [REDACTED]. Follow up with urologist and PCP . urology appointment set up . Ultrasound of the abdomen order was received from MD . Record review of CR #2's Nurse Progress Note by LVN A dated [DATE] at 10:33 a.m. abdominal ultrasound, order noted and carried out . Record review on [DATE] of CR #2's ER hospitalization paperwork revealed a [DIAGNOSES REDACTED]. Recommend following up with urologist in ,[DATE] days . CT Abdomen/ pelvis without contrast identified revealed punctate non-obstructing right renal stone . Record review of CR #2's abdomen ultrasound completed on [DATE] at 6:29 p.m. Conclusion: prominent fatty liver. Noted on report called to doctor at 6:30 p.m. on [DATE], no new orders. Observation and interview on [DATE] at 12:58 p.m. with CR #2. He rated his pain a 6 ½ to 8 on a ,[DATE] pain scale. He said pain medications helped the pain, but the pain never went away. He said he received a pain med around 10:00 a.m. by LVN A but the medication had not helped. Interview on [DATE] at 5:20 p.m. with ADON, she said CR #2 had no pain today, she said she had checked on him twice. She was unable to find the results of the resident's ER visit or stat KUB results. She said CR #2's abdominal ultrasound was just completed and did not have results. She said she reviewed the hospital paperwork and she had no concerns. Interview on [DATE] at 6:13p.m. with LVN C said CR #2 was sent out to ER for a KUB on [DATE] but had no results. She said CR #2's abdominal ultrasound was done. Surveyor reviewed the stat order for abdominal ultrasound on [DATE] with LVN C and she said that the order had been changed to routine. She said the doctor was notified and gave approval for ultrasound to be done on [DATE]. She said she a follow up order should have been written by the nurse who called the doctor, but will make sure a late entry note was documented about the order change. Interview on [DATE] at 3:25 p.m. with RN A said she was stepping into the ADON position and nurse manager position because there was no ADON or DON working at the facility. She said she was in-serviced on a new diagnostic company because the other company went bankrupt. She said a stat x-ray was to be done within 4 hours and a routine x-ray was to be done within the same day or at least 24 hours. She was unsure who was to follow up on orders to make sure they were completed. She said she would have to ask, left the room and returned momentarily. She said it was her duty as a unit manager to make sure the orders were followed through as well as the floor nurses. She said nurses had a couple different ways of entering an order for [REDACTED]. She said the nurse who ordered the test would discuss and document on the computer for next shift as a communication between nurses. Interview on [DATE] at 5:05 p.m. with the administrator. He explained that they had a diagnostic company that went out of business and currently have a contract with another imaging company that was started on [DATE]. He said nurses received training on mobile diagnostic protocol and who to notify if they had concerns. He said if the mobile diagnostic testing did not come out in the time frame necessary the facility also had a contract with an out-patient hospital imaging. Record review of facility in-services for January and February 2020 revealed no in-services related to following physician orders [REDACTED]. Record review of facility's Change of Condition reporting and diagnostic testing revision date of ,[DATE] read in part .The center will notify the resident's physician . whenever there is a significant change in the resident . there is a change in the resident's condition that although not significant is prudent to report using good nursing judgement . The nurse will 1. Assess the resident's condition . 2. Notify the physician of the change of condition . 4. Document . The DON/ ADON or designee will provide oversight as needed whenever there is significant change of condition noted in a resident . Record review of facility's Physician order [REDACTED]. Written orders . c. Carry out the orders as appropriate (i.e. schedule lab) . Physician order [REDACTED]. Confirm that other orders were carried out as appropriate .