Every finding on record at Signature Healthcare of Ridgely Rehab&Wellness CTR

Based on policy review, observation, and interview the facility failed to ensure infection control practices to prevent the spread of infection when 4 of 4 nurses (LPN #1, LPN #3, LPN #4, and LPN #6) (Licensed Practical Nurses) failed to perform hand hygiene during medication administration. The findings include: 1. Review of the facility policy titled, Handwashing/Hand Hygiene, dated 3/1/2023, revealed .This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub .or .soap and water for the following situations .Before and after direct contact with residents .Before preparing or handling medications .After contact with a resident's intact skin .After contact with objects .After removing gloves .Hand hygiene is the final step after removing and disposing of personal protective equipment .The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . 2. Observation on the 300 Hall during medication (med) administration on 8/22/2023 at 5:07 PM, revealed LPN #1 placed a Novolog insulin pen on a tissue barrier on the med cart. LPN #1 stated, I'm going to have to put a one time order in . LPN #1 entered the order on the laptop on her med cart, closed the laptop, wrote the open date and time on the insulin pen, entered Resident #27's room, donned gloves, and administered Resident #27's insulin. LPN #1 failed to perform hand hygiene prior to donning gloves and administering Resident #27's insulin injection. 3. Observation on the 100 Hall during med administration on 8/23/2023 at 9:18 AM, revealed LPN #4 retrieved a lidocaine patch from the med cart and entered Resident #28's room. LPN #4 lowered the head of Resident #28's bed, donned gloves, removed the patch from Resident #28's lower back, disposed of the patch and put gloves in the trash can, donned gloves, and placed the new lidocaine patch on Resident #28's back. LPN #4 failed to perform hand hygiene prior to donning and after doffing gloves. 4. Observation on the 200 Hall during med administration on 8/23/2023 at 9:37 AM, revealed LPN #3 opened the med cart, retrieved a bottle of Vitamin B tablets, removed a tablet from the bottle, placed the tablet in a pill cutter, cut the tablet, removed the tablet with her bare hands, and placed it in the pill cup. 5. Observation and interview on the 100 Hall during med administration on 8/24/2023 beginning at 9:17 AM, LPN #6 removed each of Resident #2's medications from the med cart and stated, We have no D3 [vitamin D3] in the drawer. I will have to go see if there's any in the med room . LPN #6 placed the pill cup containing Resident #2's medications in the top drawer of the med cart and locked the cart. LPN #6 went to the med room, opened a cabinet, and moved medication bottles around with her hands looking for a bottle of vitamin D3. LPN #6 returned to the med cart, unlocked the med cart, removed Resident #2's medications from the med cart, went to Resident #2's room and administered Resident #2's medications. LPN #6 did not perform hand hygiene prior to removing medications from the med cart, after going to the med room, or prior to administering Resident #2's medications. 6. During an interview on 8/25/2023 at 6:18 PM, the Director of Nursing (DON) was asked when should hand hygiene be performed during medication pass. The DON stated, A lot .before handling anything with the elderly .when entering the patient room, after administering meds and exiting the room. The DON confirmed that hand hygiene should be completed prior to donning and after doffing gloves. The DON was asked should staff remove a medication from the pill cutter with their bare hands. The DON stated, No.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 4 staff members Licensed Practical Nurse (LPN #3) left medications unattended at the resident's bedside and when in 3 of 5 (100 Hall Medication (Med) Cart, 200 Hall Med Cart, and 300 Hall Med Cart) medication storage areas had an expired and open and undated medications. The findings include: 1. Review of the facility's policy titled, Medication Storage, dated 1/2021, revealed .Medications and biologicals are stored properly .to maintain their integrity and to support safe effective drug administration .In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medication .are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access .Outdated, contaminated .medications .are immediately removed from stock .and reordered from the pharmacy .if a current order exists . Review of the facility's policy titled, Medication Administration, dated 1/2021, revealed .Medications are administered .in accordance with .good nursing principles and practices .Check expiration date .no expired medications will be administered to a resident .Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date .The nurse shall place a 'date opened' sticker on the medication if one is not provided .and enter the date opened .Certain products .have specified shortened end of use dating, once opened, to ensure medication purity and potency . 2. Observation and interview at the 300 Hall Med Cart on 8/22/2023 at 5:41 PM, revealed an opened, undated 10 milliliter (ml) vial of Lidocaine 1 percent (%), an opened, undated Symbicort 80/4.5 micrograms (mcg) inhaler and an opened, undated Combivent Respimat 20 mcg/100 mcg inhaler, and an exceeded for use Spiriva Respimat 2.5 mcg inhaler. LPN #1 confirmed there was no open date on the Lidocaine, Symbicort, and Combivent, and the Spiriva Respimat dated 5/28/2023 had exceeded its expiration date. LPN #1 was asked how long the Spiriva Respimat is good after opened. LPN #1 stated, 60 days 2. Observation and interview at the 100 Hall Med cart on 8/23/2023 at 9:32 AM, revealed an opened, undated bottle of Moxil Ophthalmic solution/Vigamox 0.5% [an antibiotic used to fight bacterial eye infections]. LPN #4 confirmed the eye drops were not dated when opened. 3. Observation and interview in the resident's room on 8/23/2023 beginning at 9:37 AM, revealed LPN #3 entered Resident #19's room with his medications on a tray, placed them on his over bed table in front of the resident and stated, I did not get water. LPN #3 left Resident #19's meds on his over bed table and returned to the med cart. LPN #3 mixed Resident #19's Clear lax [a laxative that provides relief from constipation] in water and returned to Resident #19's room. LPN #3 stated, Let me admit to my mistake. When I left to get the Miralax [Clearlax] I should have taken this tray [containing Resident #19's meds] with me. 4. Observation and interview at the 200 Hall Med cart on 8/23/2023 at 10:00 AM, revealed an open and undated bottle of Insulin Glargine [glucose lowering medication]. LPN #3 was asked was there an open date on the insulin. LPN #3 stated, It's not. LPN #3 confirmed the bottle of insulin should have an open date on it. 5. During an interview on 8/25/2023 beginning at 6:37 PM, the Director of Nursing (DON) was asked should medications be dated when opened. The DON stated, Yes. The DON was asked should the Spiriva with an open date of 5/28/2023 still be in the med cart. The DON stated, No. The DON confirmed nurses should not leave medications unattended and out of sight at the resident's bedside.

Based on policy review, observation, and interview, the facility failed to ensure staff changed gloves and sanitized their hands while going back and forth from dirty to clean dishes, when 2 of 3 (Dietary Staff #1 and #2) dietary staff members were observed in the dish room going from dirty to clean areas, then back to dirty, without changing gloves or washing hands. The facility had a census of 64 and 63 residents received a tray from the kitchen. The finding include: 1. Review of the facility policy titled Warewashing dated 9/2017, revealed .Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware . 2. Observation in the Kitchen dish area on 8/22/2023 at 9:17 AM, revealed Dietary Staff #1, with gloved hands started on the dirty side, rinsed, and loaded dishes into the dish machine, then unloaded the dish machine and distributed the clean dishes without changing her gloves and washing her hands. This was observed during two rounds of loading and unloading the dish machine. Dietary Staff #1 failed to remove her gloves and perform hand hygiene. 3. Observation in the Kitchen dish area on 8/23/2023 at 9:10 AM, Dietary Staff #2, with gloved hands, grabbed a rack from the dirty side of the dish machine, rinsed, then unloaded the rack into the dish machine. She went on to unload the clean dishes from the clean side of the dish machine and began placing them on racks on the clean side without removing her gloves and washing her hands During an interview on 8/23/2023 at 9:15 AM, Dietary Staff #2, was asked if she should be going back and forth between the clean dishes and dirty dishes without washing her hands. Dietary Staff #2 stated, No ma'am, but I don't know how else to do it because there is no time to stop. 4. During an interview on 8/23/2023 at 9:15 AM, the Dietary Manager confirmed that staff should not be going back and forth between the dirty dishes and clean dishes without washing their hands.

Based on policy review, medical record review, observation, and interview, the facility failed to accurately assess residents for the Brief Interview for Mental Status (BIMS) score and pressure ulcers for 3 of 18 residents (Resident #13, #28, and #41) reviewed for accuracy of assessments. The findings include: 1. Review of the facility's policy titled, Resident assessment dated [DATE], revealed .The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity .The assessment process includes direct observation and communication with the resident, resident's family or legal guardian, as well as communication with licensed and non-licensed direct care staff members .On comprehensive assessments the Care Area Assessment and comprehensive Care plan will be completed in accordance with the RAI [Resident Assessment Instrument] manual .The Assessment Coordinator will be responsible for ensuring that all required resident assessments are completed and submitted to CMS' [Centers for Medicare and Medicaid] QIES [Internal Quality Improvement and Evaluation System] Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines outlined in the RAI Manual . 2. Review of the medical record revealed Resident #13 was admitted to facility on 5/2/2023, with diagnoses of Diabetes, Neurogenic Bladder, Retention of Urine, Dementia, Hypertension, Congestive Heart Failure, and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #13 had a BIMS score of 3 which indicates severe cognitive impairment. Section M Skin Conditions .Unhealed Pressure Ulcers/Injuries . [was answered] Yes .Current Number of Unhealed Pressure Ulcers /Injuries at Each Stage [blank]. 3. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses of Dementia, Anxiety, Overactive Bladder, Peripheral Vascular Disease, and Meniere's Disease. Review of the annual MDS dated [DATE], revealed .Section C Cognitive Patterns .Should Brief Interview for Mental Status (BIMS) (C0200-C0500) be conducted . [was answered] Yes .BIMS Summary Score [blank] . During an interview on 8/25/2023 at 1:44 PM, the MDS Coordinator was asked should a comprehensive MDS have a BIMS score or the Cognitive Skills for Daily Decision Making coded and do you see one for Resident #28. The MDS Coordinator stated, No, but the top of the section is yes [C0100] then the BIMS [C0500] should be completed . 4. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses of Acquired Absence of Right leg Above Knee, Diabetes, Pressure Ulcer of Right Hip, Stage 2, and Cerebral Infarction. Review of the quarterly MDS dated [DATE], revealed Resident #41 had a BIMS score of 15, which indicated cognitively intact.Section M Skin Conditions .Unhealed Pressure Ulcers/Injuries . [was answered] Yes .Current Number of Unhealed Pressure Ulcers /Injuries at Each Stage [blank] . During an interview on 8/25/2023 at 2:05 PM, the MDS Coordinator was shown Section M and asked what you used to determine there was a pressure ulcer. The MDS Coordinator stated, .wound orders. The MDS Coordinator was asked if she marked yes, the resident had a pressure ulcer should she have followed up to determine if the resident truly had a wound. The MDS Coordinator stated, I did and there wasn't one on the wound report. The MDS Coordinator was asked did she follow through to see if the resident had a pressure ulcer. The MDS Coordinator stated, No I didn't go ask anybody. The MDS Coordinator was asked when there were wound orders but no assessment for a wound did that raise a red flag to her. The MDS Coordinator stated, No . The MDS Coordinator was asked if there was a problem with inconsistencies in documentation wouldn't that have prompted her to check and be sure the resident had a pressure ulcer. The MDS Coordinator stated, I didn't know I should go check her foot I've never been told that I have to go check somebody's foot. The MDS Coordinator confirmed that she did not discuss the residents' wounds with the Assistant Director of Nursing (ADON) or the Director of Nursing (DON).

Based on the policy review, medical record review, and interview, the facility failed to resubmit a PASRR after the resident had the addition of a new mental health diagnosis for 1 of 2 sampled residents (Resident #38) reviewed for PASRR. The findings include: Review of the facility's policy titled, Pre-Admission Screening and Resident Review (PASRR), dated 8/1/2018, revealed .PASRR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness (SMI) and/or intellectual disability; 2) be offered the most appropriate setting their needs (in the community, a nursing facility, or acute care settings); and 3) receive the services they need in those settings .Those individuals who test positive at Level I are then evaluated in depth, called Level II PASRR. The results of this evaluation result in determination of need, determination appropriate setting, and a set of recommendations for services to inform the individual's plan of care .An individual is considered to have a serious mental illness if the individual meets the following requirements on diagnosis level of impairment and duration of illness .A schizophrenic, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability .If a significant change in status assessment (SCSA) occurs for an individual known or suspected to have a mental illness .a referral to the State Mental Health or Intellectual Disability/Developmental Disabilities Administration authority for a possible Level II PASRR evaluation must promptly occur as required . Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses of Dementia, Psychosis, Hypokalemia, Anxiety, Paranoid Personality Disorder, Delusions, and Dysphagia. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. Medications received were Antipsychotic, Antianxiety, Antidepressant, Antibiotic, and Diuretic. Resident #38 had a PASSAR completed in 2019, on admission to the facility and had new psychological diagnoses in 2023 which included Delusions, Impulse Disorder and Dementia. Review of the quarterly MDS dated [DATE] revealed Resident #38 had a BIMS score of 2, which indicated severe cognitive impairment. Medications received were Antipsychotic, Antianxiety, and Diuretic. Review of the Care Plan dated 7/5/2023, revealed .Resident has diagnosis of unspecified psychosis and anxiety and is at risk for drug related symptoms: hypotension, gait disturbance, cognitive impairment, behavioral impairment, ADL decline, decreased appetite, abnormal involuntary movements .7/26/2023 .Resident at risk for psychosocial related stress following an elder to elder altercation .APS [Adult Protective Services], ombudsman, police notified of event .head to toe skin assessment performed after altercation .72 hour psychosocial monitoring post altercation . Review of the progress notes dated 7/27/2023 at 1:50 PM, revealed .Elder yelling up and down the hallway for family members who are not here. Yelling for help and when asked what is wrong elder states I need to get home and tell tweety my family sick. or I need to find out where my family is at. Will continue to monitor . Review of the progress notes dated 8/10/2023 at 1:19 PM, revealed .Noted to bump wheelchair into other resident's wheelchairs. She was upset and kept saying that the place is filthy. Not easily redirected . Review of the progress notes dated 8/10/2023 at 2:45 PM, revealed Elder observed this shift, speaking about being scared. Elder kept stating she didn't seem mad at us when we went to bed and i'm afraid she is going to kill the baby. Elder also was stressing about wanting this nurse to stay close to her in case something happened to her . Review of the progress notes dated 8/14/2023 at 19:07 7:07 PM, revealed Elder has no behaviors this AM, at supper elder began to ask about mama and [NAME] and the babies, easily re-directed for supper. No other behaviors noted . During an interview on 8/25/2023 at 10:43 AM, the Director of Nursing (DON) was asked, does the facility identify residents with newly evident or possible serious Mental disease, Intellectual disability, or a related condition after admission to the facility? The DON stated, We have a behavioral portion at the weekly at risk meetings. If there is a new change in psychotropic meds we discuss it. The DON was asked, who is responsible for making the referral to the appropriate state-designated authority when a resident is identified as having an evident or possible Mental disease, Intellectual disability, or related condition? The DON stated, We talk about it in the meeting and if a PASRR is updated it is uploaded into the chart. Not sent to anyone. The DON was asked, if a resident is identified as having newly evident or possible Mental disease, Intellectual disability, or a related condition after admission, what is the facility's process for referring the resident to the appropriate state-designated authority? She stated, We report to doctor and the Psych NP [Nurse Practitioner] and a Social Worker from Behavioral Health that comes in once weekly. The DON was asked, with the new diagnoses of delusional disorder and impulse disorder and the Drug induced Akathisia should the PASSRR have been updated. The DON stated, Yes [named Resident #38] should have had a new PASSR updated. I just started those in June and I am working on getting them caught up on the residents and uploaded in the charts.

Based on policy review, medical record review, and interview, the facility failed to conduct Care Plan meetings for 1 of 8 (Resident #3) sampled residents. The findings include: 1. Review of the facility's policy titled, Comprehensive Care Plans, dated 2021, revealed .The Comprehensive Care Plan is prepared by an interdisciplinary team .care plan should .be updated .At least quarterly . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses of Psychosis, Anxiety Disorder, Mood Disorder, and Schizoaffective Disorder. Review of the medical record revealed the last quarterly Care Plan meeting held for Resident #3 was 3/17/2022. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicates she was cognitively intact. During an interview on 8/22/2023 at 9:48 AM, the Director of Social Services was asked should there have been a care plan meeting since 3/17/2022. The Director of Social Services stated, Yes, not sure why she hasn't had one. The Director of Social Services confirmed that Resident #3 had not had a care plan meeting since 3/17/2022.

Based on policy review, medical review, observation, and interview, the facility failed to ensure weekly wound assessments were completed for 2 of 3 (Resident #1 and #41) residents reviewed for pressure ulcers. The findings include: 1. Review of the facility's policy titled, Skin Integrity Policy, dated 7/11/2022, revealed .Recommend ongoing observation of skin integrity .The Nurse Leader/Wound Nurse shall document all pressure, stasis, surgical incision, or diabetic ulcers in the EMR (electronic medical record) on an ongoing basis or until closed or resident discharged . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Pressure Ulcer Right Buttocks, Pressure Ulcer Right Heel Unstageable, Anxiety, Pressure Ulcer Left Heel Unstageable, Diabetes, Peripheral Vascular Disease, and Polyneuropathy. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact, and had 1 Stage 3 Pressure Ulcer and 2 Unstageable Pressure Ulcers. Review of the Care Plan dated 7/5/2023, revealed .Skin Integrity .have a PRESSURE INJURY to right heel .Created 7/12/2023 .Staff to monitor for s/s (signs and symptoms) of decline and notify MD (Medical Doctor) with changes .Problem Start Date .4/17/2023 .have a pressure injury to left heel .Created 7/12/2023 .Problem Start Date .5/16/2023 .have a pressure injury to right buttock .Created .7/12/2023 .Resident at risk for Pressure Injury(s) . a. Review of the facility's Wound Management Detail Report, dated 4/17/2023, revealed .Date and Time Observed 4/17/2023 .Unstageable .SDTI (suspected deep tissue injury) observed to elder's left heel . Review of the Resident Census record revealed Resident #1 went out to the hospital on 4/17/2023 and returned to the facility on [DATE]. Review of the facility's Wound Management Detail Report revealed Resident #1's left heel was not assessed by the wound care nurse until 5/1/2023, 6 days after Resident #1 returned from the hospital. Review of the facility's Wound Management Detail Report dated 5/1/2023, revealed no decline in the pressure injury to the left heel from the date it was identified on 4/17/2023 and the pressure injury to the left heel remained unstageable. Review of the facility's Wound Management Detail Report revealed the facility failed to assess and document the progress of the wound the week of 5/29/2023, 14 days after the assessment on 5/24/2023. Review of the facility's Wound Management Detail Report dated 6/7/2023, revealed no decline in the pressure injury to the left heel from 5/24/2023 and the left heel remained unstageable. Review of the facility's Wound Management Detail Report revealed the facility failed to assess and document the progress of Resident #1's left heel on the weekly wound assessment tool the week of 6/19/2023, 6/26/2023, 7/3/2023, and 7/21/2023. Review of the Resident Census Record revealed Resident #1 went out to the hospital on 7/12/2023 and returned to the facility on [DATE]. Review of the facility's Wound Management Detail Report dated 7/21/2023 revealed there was no decline in the progress of the wound from the last assessment on 7/3/2023 and the left heel wound remained unstageable. b. Review of the facility's Wound Management Detail Report, revealed, .5/1/2023 .Unstageable-Deep Tissue .DTI (deep tissue injury) R (right) heel . Review of the facility's Wound Management Detail report revealed the facility failed to assess and document the progress of Resident #1's right heel on the weekly wound assessment tool the week of 5/29/2023. Review of the Wound Management Detail report revealed Resident #1's next weekly assessment on 6/7/2023 revealed no decline in the pressure injury to Resident #1's right heel and the pressure injury to the right heel remained unstageable. Review of the Wound Management Detail report revealed the facility failed to assess and document the progress of Resident #1's right heel on the weekly wound assessment tool the week of 6/19/2023, 6/26/2023, and 7/3/2023. c. Review of the facility's Wound Management Detail Report, revealed, .Wound Type .Pressure Ulcer .Wound Location .Right Buttock .Date and Time Identified .6/12/2023 .Unstageable . Review of the Wound Management Detail Report revealed Resident #1's right buttock was not assessed on the week of 6/19/2023, 6/26/2023, and 7/3/2023. Observation in the resident's room during wound care on 8/23/2023 at 10:00 AM, revealed Resident #1 had an Unstageable Pressure Wound to her Left and Right Heel and to her Right Sacrum. During an interview 8/23/2023 at 3:55 PM, the Assistant Director of Nursing (ADON) confirmed Resident #1 had 3 pressure wounds. The ADON confirmed pressure wounds should be assessed at least every 7 days unless the physician orders for them to be assessed differently. The ADON was asked should Resident #1 have weekly assessments of the pressure wound to her buttocks and left and right heel if she was seeing a wound care specialist. The ADON confirmed that the facility should do weekly assessments of the wounds even if they are seeing wound care specialist. The ADON confirmed that no assessments should be missed unless the resident is out of the facility for a hospital stay and upon return, they should be assessed. The ADON confirmed that Resident #1 still had unstageable wounds to her bilateral heels and her right buttock. The ADON confirmed all wounds should be assessed when found, weekly, and when a resident returns from the hospital. During an interview on 8/23/2023 at 5:55 PM, the Director of Nursing (DON) confirmed that all pressure wounds should be assessed every 7 days and it should be documented on the weekly wound management assessment tool. During an interview on 8/25/2023 at 7:34 AM, the DON confirmed the Former ADON was not completing the weekly wound assessment documentation for Resident #1's pressure ulcer to her right buttocks and bilateral heels. 3. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer of Right Hip-Stage 2, Acquired Absence of Right Leg Above the Knee, Diabetes, and Cerebral Infarction. Review of the Wound Management report dated 6/7/2023, revealed .Pressure Ulcer .Left Buttock .Date/Time Identified 03/07/2023 17:36 [5:36 PM] . There was no documentation of pressure ulcer stage. a. Review of the Wound Management report dated 6/7/2023, revealed .Unspecified Ulcer .Right Buttock .Date/Time Identified 03/07/2023 17:39 [5:39 PM] . There was no documentation of ulcer type or stage. b. Review of the Wound Management report dated 6/7/2023, revealed .Wound type .Other .unspecified .Left thigh .distal gluteal fold .Date/Time Identified 05/17/2023 07:58 [7:58 AM . There was no documentation of ulcer type or stage. c. Review of the Wound Management report dated 6/7/2023, revealed .Wound type .Other .unspecified .Left thigh .Date/Time Identified 03/07/2023 17:25 [5:25 PM] . There was no documentation of ulcer type or stage. d. Review of the Wound Management report dated 6/7/2023, revealed .Unspecified Ulcer .Gluteal Fold .left gluteal fold .Date/Time Identified 03/07/2023 17:30 [5:30 PM] . There was no documentation of ulcer type or stage. e. Review of the Wound Management report dated 6/7/2023, revealed .Unspecified Ulcer .Left hip .Date/Time Identified 03/07/2023 17:32 [5:32 PM] . There was no documentation of ulcer type or stage. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #41 had a BIMS score of 15, which indicated he was cognitively intact and had 1 or more unhealed pressure ulcers. Review of the comprehensive Care Plan with a revision date of 6/28/2023, revealed .Skin Integrity .r/t [related to] STAGE II [2] pressure injuries to LEFT BUTTOCK, right buttock and left thigh . Review of the Wound Management report for June 2023 and July 2023 revealed the facility failed to assess and document the progress of Resident #41's left buttock, right buttock, left thigh-distal gluteal fold, left thigh, left gluteal fold, and left hip wound on the weekly wound assessment tool for the week of 6/12/2023, 6/19/2023, 6/26/2023, and 7/3/2023. Review of the medical record revealed treatments were performed as ordered and the wounds did not deteriorate. During an interview on 8/25/2023 at 9:54 AM, the ADON confirmed that Resident #41's weekly pressure ulcer assessments were not completed for the week of 6/12/2023, 6/19/2023, 6/26/2023, and 7/3/2023, and that the wounds had not deteriorated. The ADON was asked should the pressure ulcer assessments be completed on a weekly basis. The ADON stated, Yes. During an interview on 8/25/2023 at 11:36 AM, the Signature Care Consultant confirmed that all pressure wounds should be assessed and documented in the wound management assessment tool every 7 days even if the resident is going out to a wound specialist. During an interview on 8/25/2023 at 12:39 PM, the Family Nurse Practitioner confirmed the facility should assess and document the progression of pressure wounds weekly and document in the wound management tool as part of the resident's medical record.

Based on policy review, observation, and interview, the facility failed to ensure residents were free from significant medication errors when 1 of 4 Licensed Practical Nurses (LPN) #6) failed to obtain a pulse prior to administration of a medication for high blood pressure. The findings include: Review of the facility policy titled, Medication Administration General Guidelines, dated 2007, revealed .Medications are administered in accordance with written orders of the prescriber .Obtain and record any vital signs as necessary prior to medication administration . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Diabetes, Chronic Obstructive Pulmonary Disease, Cerebral Infarction and Presence of Cardiac Pacemaker. Review of the August 2023 Medication Administration Record (MAR) revealed, .bisoprolol fumarate tablet [is used to lower blood pressure] .10 mg [milligram] .Once a day .check heart rate before dose and hold if < [less than] 50 . Observation on 8/24/2023 at 9:32 AM, LPN #6 administered Resident #2's bisopropol 10 mg. LPN #6 failed to obtain a pulse prior to administration of the bisopropol tablet. During an interview on 9:37 AM, LPN #6 was asked why she did not obtain a pulse prior to administering the bisopropol. LPN #6 stated, I did earlier this morning but I should have taken his pulse again before I administered that .he got his vitals taken this morning .right at 7 o'clock. During an interview on 8/25/2023 at 6:18 PM, the Director of Nursing (DON) was asked when there is a physician order to check a pulse prior to medication administration when should the pulse be checked. The DON stated, Directly before administering the medication. The DON was asked would 2 hours before administration of a beta blocker medication be sufficient. The DON stated, No . I would definitely consider that a medication error and the doctor would need to be notified and we would recheck them and follow up and see how they were .

Based on policy review, medical record review, observation, and interview, the facility failed to provide dental services for 1 of 1 (Resident #41) resident reviewed for dental services. The findings include: Review of the facility's policy titled, Dental Services, dated 6/5/2018, revealed .The facility must assist residents in obtaining routine and 24-hour emergency dental care .The facility will provide routine dental services with annual inspection of the oral cavity .The facility will assist the resident in making appointments and arranging for transportation to and from the dentist's office .Nursing Services is responsible for notifying Social Services of a resident's need for dental services . Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses of Acquired Absence of Right Leg Above Knee, Diabetes Mellitus, and Cerebral Infarction. Review of the comprehensive Care Plan with a revision date of 6/28/2023, revealed .I have or am at risk for ORAL/DENTAL complication r/t [related to] no upper teeth and dentures unavailable . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Observation in the resident's room on 8/21/2023 at 2:44 PM, 8/22/2023 at 8:11 AM, 8/23/2023 at 12:00 PM, and 8/24/2023 at 8:03 AM, revealed Resident #41 had no upper teeth. During an interview on 8/21/2023 at 3:15 PM, the Director of Social Services was asked was Resident #41 on the list to see dental services. The Director of Social Services stated, I will check and see. During an interview on 8/22/2023 at 8:40 AM, the Director of Social Services was asked the status of dental services for Resident #41. The Director of Social Services stated, I'm waiting on his orders, 360 [dental services] has to have a doctor's signature. The Director of Social Services was asked were Resident #41's dental issues not addressed the prior day. The Director of Social Services stated, He never said anything about needing it. The Director of Social Services was asked how often she asked the residents about dental and vision services. The Director of Social Services stated, I ask is everything okay .do you need anything. The Director of Social Services was asked did she specifically address the residents' dental and vision needs. The Director of Social Services stated, No. The Director of Social Services was asked did she talk to Resident #41 about seeing the dentist after she was asked about his dental services the previous day. The Director of Social Services stated, No .

Based on policy review, weather website review, medical record review, observation, and interview, the facility failed to ensure a safe and secure environment for 1 of 3 sampled residents (Resident #1) reviewed for elopement/wandering. The facility's failure to ensure a safe and secure environment resulted in Immediate Jeopardy when Resident #1, a vulnerable severely cognitively impaired resident with dementia and confusion, exited the facility unsupervised and without staff knowledge. Resident #1 was found outside the building in the front parking lot, approximately 143 feet from the exit door, seated in her wheelchair. The resident was last seen in the Dining Room and was found in the parking lot approximately 50 minutes later. Immediate Jeopardy (IJ) is a situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), (Named Company) Consultant, and Regional Project Manager were notified of the Immediate Jeopardy (IJ) on 8/4/2022 at 5:07 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed from 4/24/2022 through 4/28/2022. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyor on 8/3/2022 and 8/4/2022. The IJ was cited as past noncompliance and the facility is not required to submit a Plan of Correction. The findings include: Review of the facility's Elopement Policy, revised 7/7/2022, revealed .The intent of the policy is to ensure residents' safety and protect their rights and dignity. Residents will be evaluated for risk of elopement and preventative interventions implemented for those identified as an elopement risk .Elopement: occurs when a resident leaves the premises or safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so .Each resident may be evaluated for elopement risk upon admission, quarterly and with change of condition. Residents displaying exit-seeking behavior will be evaluated for elopement risk. A care plan will be developed and implemented for each resident identified as an elopement risk. An elopement risk binder will be kept at a secure location known to stakeholders. A routine check will be completed of alarmed doors to ensure the proper functioning. Facility may provide increased activity involvement, diversion and redirection related to exit seeking. If a resident is identified as missing, refer to the missing resident guidelines . Review of the facility's policy titled, Elopement/Missing Resident, reviewed 10/1/2018, revealed .Elopement precautions and response procedures are carried out for Resident safety. Elopement drills are conducted a minimum of twice per year and documented accordingly .staff shall remain alert and follow re-direction techniques if a wandering Resident gains access to any exit areas .staff shall request help if wandering Resident cannot be redirected easily .staff will be routinely alerted by the Executive Director/Nursing of Residents identified to be at risk . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Dementia without Behaviors, Cerebral Infarction, [CONDITION(S)], Transient Ischemic Attacks, History of Falling, and Depression. Review of the Elopement Risk Evaluation dated 2/14/2022, revealed .Is resident cognitively impaired? yes .Is resident independently mobile [ambulatory or wheelchair]? yes .Does resident have poor decision-making skills? yes .Has resident demonstrated exit-seeking behavior? yes .Does resident wander oblivious to safety needs? yes .Does resident have the ability to exit the facility? yes .Resident is determined to be AT RISK for elopement . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 6, which indicated Resident #1 had severe cognitive impairment for daily decision making. Resident #1 required Supervision with one-person physical assist with Activities of Daily Living (ADL), of transfer from bed to wheelchair, and moving between locations in her room and off the unit. Review of the Safety Event Note dated 4/24/2022 at 1:11 PM, revealed .Description Elopement .where was the resident found? in parking lot .outside temperature 79 [degrees Fahrenheit (F)] .Progress note 4/24/2022 at 12:01 PM elder observed, by CNA [Certified Nursing Assistant (CNA #1)] staff through window [while doing routine care] outside sitting in wheelchair. CNA went outside and escorted elder back into building without incident. Elder returned into building with no signs of distress .When asked by nurse 'How did you get out of the building?' Elder stated 'Well I went out through the box [Foyer] and out the front door. I am trying to go to my sister's house, can you give me a ride?' Elder escorted to gated community [Secure Unit] and currently attempting to open doors on unit. [Named Responsible Party] notified of incident at 1:30 PM and is okay with move. MD [Medical Doctor] [Named Doctor] notified of situation .Evaluation notes: resident admitted to gated community . Review of Local Weather.com, revealed the high temperature on 4/24/2022 was 82 degrees F. Observation in the resident's room on 8/3/2022 at 6:00 PM, revealed Resident #1 seated in a wheelchair, alert and oriented to self, and able to self-propel in a wheelchair throughout the room. During an interview in the Conference Room on 8/4/2022 at 10:49 AM, CNA #1 stated, .On Sunday 4/24 [2022] I took [Named Resident #1] to the Dining Room for lunch .I returned to the hall, passed trays, fed the residents that needed to be fed, picked up trays, and took them [carts] back to the service hall. I was standing in the hallway looking in toward room [number] talking to a resident and through the window I saw a woman [Resident #1] in a wheelchair in the parking lot. She was using her feet to propel, headed back toward the front of the nursing home. I yelled for the other CNA and nurse. I ran out the side door [300 Hall] and the other aide went out the front door. We both got to her and said what are you doing. I can't recall what she said. She easily came back in .the nurse checked her out and she was moved to another unit [Secure Unit] .Earlier when I was picking up lunch trays [Named Licensed Practical Nurse (LPN) #1] had gone to get lunch for the staff and she said 'come to the end door and get it' [the food]. So, I went to the 300-hall door, pushed the code to open the door, the alarm sounded she [LPN #1] gave me the food. The door shut, the alarm went off, and I took the food to 100 Hall. I didn't see Ms. [Named Resident #1] in the hall . Observation on 8/4/2022 at 11:18 AM of the area outside the facility, revealed on two sides of the the parking lot where Resident #1 was found were the main streets of the downtown area. Observation of the exit door revealed the door exited from the side of the building. Measurements from the exit door to the location where the resident was found was approximately 143 feet, down a wheelchair ramp to a sidewalk, parallel with the parking lot. The parking lot was asphalt with an incline and had a concrete bordered island as part of the covered drive to the front door of the facility. During a telephone interview on 8/4/2022 at 11:37 PM, a witness that was in a passing vehicle the day of the elopement stated, .I was driving down [Named Street] in my car and noticed a woman [Resident #1] in a wheelchair coming out the end door [300 Hall door]. I saw the door closing behind her as she came out. I had my windows up so I didn't hear anything, but I previously worked at that place as Maintenance Director, and I knew she shouldn't be coming out that door. I stopped and watched to make sure she didn't get hurt. The woman came down the ramp in her wheelchair and I was afraid because once she was in the parking lot, she could go right, and go into the main road. She didn't, she turned left and rolled toward the front of the parking lot and not toward the street. I saw two aides come out the front door. I watched her about 5-8 minutes before the aides came out to get her. I wasn't going to leave till [until] I knew she was safe .it was sometime after lunch but before supper I don't know what time .it was a fairly nice day no rain . During a telephone interview on 8/4/2022 at 12:47 PM, LPN #1 stated, .I had went [gone] to get lunch for the staff and when I returned I asked [Named CNA #1] to come to the 300 Hall door to get the food .She did .the door alarmed and then closed .I went back to my car and got my stethoscope out of the trunk and went back into the facility through the front door .I did not see anyone come out the 300 Hall door . Observation in the 100-Hall Common Area on 8/4/2022 at 3:40 PM, revealed Resident #1 was seated in a wheelchair, alert and oriented to self, confused, and interacting with other residents and staff. During an interview on 8/4/2022 at 4:00 PM, (Named Company) Consultant confirmed the staff last saw Resident #1 at approximately 11:35 AM and did not know Resident #1 was missing until CNA #1 observed her in the parking lot at approximately 12:25 PM, and it was unsafe for Resident #1 to be out of the facility unsupervised. The facility's corrective action plan included the following: 1. Resident #1 exited through the door located at the end of the 300 Hall at approximately 12:15 PM on 4/24/2022. Resident #1 was noted by CNA #1 to be in the parking lot when she (CNA #1) looked out the window while in a resident's room. The resident was in control of the wheelchair and self-propelling her wheelchair toward the front of the building. CNA #1 immediately called for help and went out the 300-hall door to go to the resident. CNA #2 responded by going out the front doors. The resident stated she was going to her sister's house. The CNAs assisted Resident #1 into the building. A full body assessment was completed, and no injuries were noted. She did not complain of pain. Vital signs were obtained and were within normal limits. The outside temperature was 79 degrees F. Resident #1 was moved to the Gated Community for closer supervision. The investigation revealed that CNA #1 had opened the 300 Hall door so that LPN #1 could give her the lunch she had gone to get for the staff. CNA #1 walked up the 300 Hall and LPN #1 went around to enter through the front door. Both LPN #1 and CNA #1 were given coaching and counseling on inhibiting an investigation and were suspended pending the outcome of the investigation. Both were re-instated after the investigation was completed and no malicious intent was substantiated. The surveyor verified this through record review, investigation, and interviews with staff. 2. A head count was conducted on 4/24/2022 and all residents were accounted for. The surveyor verified this through record review and interview. 3. On 4/24/2022, all egresses were physically checked for proper operation by the Maintenance Director. All were working properly. The keypad codes were changed at that time. The surveyor verified this through record review and staff interviews. 4. All residents were re-assessed for elopement risk by the DON, Social Services Director, and Restorative Nurse Manager beginning on 4/25/2022 and completed by 4/26/2022. Beginning 4/25/2022 and completed on 4/29/2022 all Care Plans were reviewed/updated with any changes made to the exit seeking status of the residents. The surveyor verified this through record review and staff interviews. 5. The Facility Administrator, DON and Weekend Supervisor were educated by the (Named Company) Consultant on 4/24/2022 on the Elopement Policy and Procedure, Accidents/Incidents Policy, Missing Residents Policy and Procedure, Abuse Policy and Procedure, and Code Green. This education was performed face to face to facilitate discussion and questions. The Administrator, DON, and Weekend Supervisor were administered a post-test, and all scored 100 percent (%). The surveyor verified per record review, review of the education, post-tests, and staff interviews. 6. The Administrator, DON, and Staff Development Coordinator (SDC) educated all full-time stakeholders on the Elopement Policy and Procedure, Accidents/Incidents Policy, Missing Residents Policy and Procedure, Abuse Policy and Procedure, and Code Green. The education was performed face to face to facilitate discussion and questions. This education was completed by 4/29/2022. A post-test was administered and a score of 100% was achieved. If the stakeholder did not achieve a 100% on the post test, the stakeholder was re-educated and given a post test. This process continued until all achieved 100%. As needed/agency staff will be educated and given a post-test prior to working a shift. They will not be allowed to work until they score 100% on the post test. Education on the Elopement Policy and Procedure, Accidents Incidents Policy, Missing Residents Policy and Procedure, Abuse Policy and Procedure, and Code Green will be included in the orientation for all new stakeholders. No newly hired stakeholders will be allowed to work until elopement education is provided and a 100% score is achieved on the post test. The surveyor verified this through record review, review of the education, post-tests, orientation packets, and staff interviews on all shifts. 7. (Named System, electronic documentation for maintenance record keeping) was reviewed on 4/26/2022 by the Administrator to ensure the doors had been checked daily for 30 days prior to the occurrence on 4/24/2022. There were no concerns identified. The surveyor verified this through record review and staff interviews. 8. The DON reviewed the last 30 days of Events for exit seeking behaviors or elopement. This was completed on 4/25/2022. There were no concerns identified. The surveyor verified this through record review and staff interviews. 9. The (Named Company) Consultant reviewed the last 30 days of progress notes/documentation for all elders for exit seeking behaviors and/or elopement. This was completed on 4/29/2022. There were no concerns identified. The surveyor verified this through record review and staff interviews. 10. The last elopement drills were conducted 1/29/2022 and 1/13/2022; no concerns were identified. Elopement drills were conducted on 4/24/2022, 4/25/2022, and 4/26/2022 to cover all shifts. An elopement drill will be conducted weekly for 4 weeks, then monthly for 2 months, then quarterly. The surveyor verified this through record review and staff interviews. 11. The following will be monitored daily for 2 weeks, then decrease to Monday thru Friday for 3 months to determine if there are any new behaviors related to wandering: a. Events in the electronic medical record, b. 24-hour report, and the c. Progress notes in the electronic medical record The surveyor verified this through record review and staff interviews. 12. Beginning 5/2/2022, elopement tests will be administered as follows: a. 2 stakeholders/shift (6/day) for 1 week, b. 1 stakeholders/shift (3/day) for 1 week, c. 2 stakeholders/week for 2 weeks, and d. 1 stakeholder/every other week for 4 weeks The surveyor verified this through record review and staff interviews. 13. A nurse from the regional team has been available on site or by telephone since 4/24/2022 and will remain in daily contact with the facility for 2 weeks. The regional nurses are assisting with investigations, observing staff treatment of residents, performing chart audits, observing environmental safety, care delivery as documented in the Care Plans, and providing oversight and consultation. The surveyor verified this through record review and staff interviews. 14. Facility Department Directors, the Business Office Manager, Administrator, Dietary Director, DON, Assistant Director of Nursing (ADON), Plant Operations Director, Social Services Director, Restorative Director, and Unit Managers assigned by the Administrator will have a presence in the facility daily to ensure the audits are complete, without any concerns, and to ensure the safety of the residents. The surveyor verified this through record review and staff interviews. 15. A Quality Assurance (QA) meeting was held 4/26/2022, with the Medical Director and will be held for 4 weeks beginning 5/4/2022, then monthly for recommendations and further follow up regarding the above stated plan. At that time the QA Committee will determine at what frequency any ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident well-being as well as an effective plan to identify facility concerns and implement a Plan of Correction to involve all staff of the facility. The surveyor verified this through record review and staff interviews.

Based on medical record review, observation, and interview, the facility failed to ensure timely documentation of controlled medications when Licensed Practical Nurse (LPN) #1 failed to document controlled medications on the Controlled Drug Record for 13 of 13 (Resident #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) sampled residents reviewed for controlled medication administration. The findings include: Review of medical record, revealed Resident #3 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)]-acetaminophen .5-325 mg [milligrams] .Twice A Day - PRN [as needed] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .was administered. Review of the Controlled Drug Record dated 9/29/2021, revealed the [MEDICATION(S)]-acetaminophen 5-325 mg was not documented as administered at 12:40 PM. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] .300 mg .Three Times a Day . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Record dated 9/29/2021, revealed the [MEDICATION(S)] 300 mg was not documented as administered between 7:00 AM -11:00 AM. Review of a medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)]-acetaminophen .5-325 mg .q (every) 6 hours for pain . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)]-acetaminophen .5-325 mg .Every 4 hours . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Record dated 9/29/2021, revealed the [MEDICATION(S)]-acetaminophen 5-325 mg was not documented as administered at 12:00 PM. Review of the medical record, revealed Resident #6 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .oxycodone .5 mg .Twice A Day . Review of a MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Record dated 9/29/2021, revealed the oxycodone 5 mg was not documented as administered between 7:00 AM and 11:00 AM. Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] ([MEDICATION(S)]) .0.25 mg .Three Times A Day . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Record dated 9/29/2021, revealed the [MEDICATION(S)] 0.25 mg was not documented as administered between 7:00 AM and 11:00 AM and between 11:15 AM and 3:00 PM. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] .50 mg .Twice A Day . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Record dated 9/29/2021, revealed the [MEDICATION(S)] 50 mg was not documented as administered between 7:00 AM and 11:00 AM. Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] .2 mg .Three Times A Day . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Record dated 9/29/2021, revealed the [MEDICATION(S)] 2 mg was not documented as administered between 7:00 AM and 11:00 AM and between 11:15 AM and 3:00 PM. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] 300 mg .1 CAPSULE .THREE TIMES DAILY . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Record dated 9/29/2021, revealed the [MEDICATION(S)] 300 mg was not documented as administered between 7:00 AM and 11:00 AM and between 11:15 AM and 3:00 PM. Review of the medical record, revealed Resident #10 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] ([MEDICATION(S)]) 2 mg .One A Day . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Record dated 9/29/2021, revealed the [MEDICATION(S)] 2 mg was not documented as administered between 7:15 AM and 11:00 AM. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] ([MEDICATION(S)]) .2 mg .Twice A Day . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Record dated 9/29/2021 between 7:00 AM and 11:00 AM, revealed the [MEDICATION(S)] 2 mg was not documented as administered. Review of the medical record, revealed Resident #12 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .oxycodone-acetaminophen .5-325mg .Three Times A Day . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Record dated 9/29/2021, revealed the oxycodone-acetaminophen 5-325 mg was not documented as administered between 7:00 AM and 11:00 AM. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] .1 mg .Three Times A Day . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Record dated 9/29/2021, revealed the [MEDICATION(S)] 1mg was not documented as administered between 7:00 AM and 11:00 AM. Review of the medical record, revealed Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .lorazepam .1mg .Three Times A Day . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Record dated 9/29/2021, revealed the lorazepam 1 mg was not documented as administered between 7:00 AM and 11:00 AM. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)]-acetaminophen .7.5-325 mg .Three Times A Day . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Record dated 9/29/2021, revealed the [MEDICATION(S)]-acetaminophen 7.5-325 mg was not documented as administered between 11:15 AM and 3:00 PM. Review of the medical record, revealed Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] (oxycodone-acetaminophen) .10-325mg .Every 6 hours . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Record dated 9/29/2021, revealed the oxycodone-acetaminophen 10-325 mg was not documented as administered at 7:00 AM. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] .150 mg .Three Times A Day . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Controlled Drug Record dated 9/29/2021, revealed the [MEDICATION(S)] 150 mg was not documented as administered between 7:00 AM and 11:00 AM. During an interview on 9/29/2021 at 2:15 PM, LPN #1 confirmed she hadn't signed out any of the controlled medications she had administered today on the Controlled Drug Record. During an interview conducted on 9/29/2021 at 2:30 PM, the Administrator confirmed controlled medications should be documented on the Controlled Drug Record immediately after administration.

Based on medical record review, observation, and interview, the facility failed to ensure 2 of 5 (Licensed Practical Nurse (LPN) #1 and #2) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 3 errors were observed out of 29 opportunities, resulting in an error rate of 10XXX 759 %. The findings include: 1. Medical record review revealed Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Order Date .4/19/2019 .[MEDICATION NAME] ACID (Vitamin C) 500 MG (milligrams) TABLET .GIVE 1 TABLET BY MOUTH 2 TIME(S) DAILY .[MEDICATION NAME] 300 MG CAPSULE .2 CAPSULES ORALLY DAILY X (times) 6 WEEK . Observations in Resident #79's room on 5/8/19 at 8:56 AM, revealed LPN #1 administered Vitamin C 250 mg 1 tablet and [MEDICATION NAME] 300 mg 1 capsule to Resident #79. Interview with LPN #1 on 5/8/19 at 12:51 PM, at the 200 Hall Nurses' Desk, LPN #1 confirmed she administered Vitamin C 250 mg 1 tablet and [MEDICATION NAME] 300 mg 1 capsule to Resident #79. The failure of the nurse to provide 2 tablets of Vitamin C for a total of 500 mg resulted in medication error #1. The failure of the nurse to administer 2 capsules of [MEDICATION NAME] 300 mg for a total of 600 mg resulted in medication error #2. 2. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] DR (delayed release) 5000 UNIT CAPSULE .1 CAPSULE PER TUBE THREE TIMES DAILY .DISSOLVE IN CRANBERRY JUICE . Observations in Resident #57's room on 5/8/19 at 11:35 PM, revealed LPN #2 opened 1 capsule of [MEDICATION NAME] DR 5000 units, mixed the contents with water, and administered it to Resident #57 through his gastrostomy tube. Interview with LPN #2 on 5/8/19 at 12:47 PM, at the 300 Hall Nurses' Desk, LPN #2 was asked if she mixed the [MEDICATION NAME] with water. LPN #2 stated, Yes ma'am, I usually do. LPN #2 confirmed the physician's orders [REDACTED]. The failure of the nurse to dissolve the [MEDICATION NAME] in cranberry juice resulted in medication error #3.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure the environment was free from accident hazards for 1 of 12 (Resident #38) sampled residents observed for smoking. The findings include: The facility's Smoking Policy dated 10/1/18 documented, .It is not the intent of the facility to prohibit or restrict smoking privileges, but to provide safety for Residents .These smoking regulations shall be explained to the Residents and family upon admission . Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations on in the Back Courtyard on 5/8/19 at 10:15 AM, revealed Resident #38 seated in his wheelchair. He removed a cigarette and a lighter from his pocket and lit the cigarette. The facility was unable to provide documentation that Resident #38 was assessed to be safe to possess smoking materials or to smoke without supervision. Interview with Registered Nurse (RN) #1 on 5/8/19 at 10:33 AM, in the Conference Room, RN #1 was asked about the smoking policy. RN #1 stated, .the residents are not to have cigarettes or lighters . Interview with the Admissions/Marketing Coordinator on 5/8/19 at 10:43 AM, in the Conference Room, the Admissions/Marketing Coordinator stated, .Upon admission if I see they are a smoker, cigarettes and lighters have to be locked up. Those products are not allowed to be kept in the room .

Based on review of the National Pressure Ulcer Advisory Panel (NAUAP) Pressure Ulcer Prevention quick reference guide, medical record review, and interview, the facility failed to accurately document treatment and services related to pressure ulcers for 1 of 2 (Resident #64) sampled residents reviewed for pressure ulcers. The findings include: 1. The NAUAP Pressure Ulcer Prevention quick reference guide documented, Accurate documentation is essential for monitoring progress of the individual and to aiding communication between professionals . 2. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 3. The Nursing Admission Skin Evaluation form dated 2/27/19 documented, .stage 2 pressure ulcer .open area to upper left back . There was no documentation of a wound to the ischium. Review of the (MONTH) 2019 Treatment Administration Record (TAR) revealed treatments were performed on the ischium on 2/27/19 and 2/28/19. Review of the wound assessments revealed no ischium wound. Interview with the Assistant Director of Nursing (ADON) / Treatment Nurse on 5/9/19 at 10:52 AM, in the Conference Room, the ADON was asked to provide the wound care notes for the ischium wound. The ADON stated, .I saw no issues with the ischium when I assessed the resident (Resident #64) . The ADON confirmed the (MONTH) TAR was inaccurate because no treatments were provided to the ischium but were documented as being performed. 4. The physician's telephone order dated 3/1/19 documented, .Clean pressure to coccyx with wound cleanser and pat dry. Apply calcium alginate to WB (wound bed) and cover with foam drsg (dressing) daily & (and) prn (as needed) . A physician's telephone order dated 3/11/19 documented, .Apply santyl to WB on Stage 3 for coccyx daily until slough is gone . The (MONTH) 2019 TAR documented, .coccyx wound apply [MEDICATION NAME] every 48 hours apply .skin prep to periwound skin and edges of foam to seal . This treatment was documented as performed on 3/1/19, 3/3/19, 3/5/19, 3/7/19, and 3/11/19. Interview with the ADON 5/8/19 at 9:44 AM, in the Conference Room, the ADON was shown the (MONTH) 2019 TAR and was asked if the physician's orders [REDACTED]. The ADON stated, .Looks like they were not put into the system .No, the orders to apply calcium alginate to the wound were not followed . The ADON was asked what treatment she used for the coccyx wound. The ADON stated, .I didn't treat him with [MEDICATION NAME] as it is charted .it is inaccurate .I treated him with calcium alginate .the order did not get put back in for calcium alginate . 5. The Pressure Ulcer Record dated 3/4/19, 3/11/19, and 3/18/19 documented, .Length (cm) (centimeter) .3 .width (cm) .3 Depth (cm) .0 .Area CDI (clean, dry, intact) . The Pressure Ulcer Record dated 4/1/19 and 4/8/19 revealed the depth of the coccyx wound was 0.3 cm. Interview with the ADON on 5/7/19 at 3:23 PM, in the Conference Room, the ADON was asked about the depth of Resident #64's wound. The ADON stated, . it was never a 0, was charted incorrect has always been 0.3 . 6. The Nursing Admission Skin Evaluation form dated 3/4/19 documented, .Elder presents with a wound to coccyx area which is treated with [MEDICATION NAME] every 48 hours with skin prep to the periwound skin and edges of foam to seal. lift foam daily. Clean left ischium with wound cleanser apply venelex, [MEDICATION NAME], or ABD (abdominal) pad and paper tape everyday and as needed . The (MONTH) 2019 TAR documented, .clean left ischium clean with wound cleanser. Apply Venelex, [MEDICATION NAME] or ABD pad and paper tape every day and as needed . The TAR documented this treatment was performed on 3/1/19, 3/2/19, 3/3/19, 3/4/19, 3/5/19, 3/6/19, 3/7/19, 3/8/19, and 3/9/19. Interview with the ADON on 5/08/19 at 10:27 AM, in the Conference Room, the ADON was asked if treatments were provided to the resident's ischium. The ADON stated .there were no treatments provided for the ischium .the documentation is inaccurate .someone did not dc (discontinue) the order and were just signing off that it had been done .I did not see any issues with the ischium when I evaluated the resident . 7. The Nursing Admission Skin Evaluation form dated 3/15/19 documented, .Elder has pressure ulcer to coccyx stage III (3) to IV (4) . A physician's telephone order dated 3/15/19 documented, .Santyl to WB daily for debridement apply CA (calcium alginate) after cleansing w/ (with) wound cleanser then apply foam drsg daily & prn . Interview with the ADON on 5/08/19 at 10:27 AM, in the Conference Room, the ADON was asked where it was documented on 3/11/19 to 4/17/19 that the treatment of [REDACTED]. The ADON stated, .the calcium alginate order wasn't put in .and it looked like I was giving [MEDICATION NAME] the entire time .but I wasn't .I treated the wound with calcium alginate and santyl . The ADON was asked if Santyl and Calcium Alginate treatments were documented as performed between 3/11/19 through 4/17/19. The ADON stated, No. The ADON confirmed Resident #64's medical record was inaccurate due to inaccurate location of wounds, inaccurate measurements, and inaccurate documentation on the TARs.

Based on policy review, medical record review, observation, and interview, the facility failed to maintain respiratory equipment for suction equipment, nebulizer, and oxygen for 2 of 2 (Resident #57 and #79) sampled residents reviewed for respiratory care. Findings include: 1. The facility's Departmental (Respiratory Therapy) - Prevention of Infection policy revised (MONTH) 2011 documented, .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment .Change the oxygen cannulae and tubing every seven (7) days, or as needed . 2. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed Resident #57 was cognitively intact and required extensive to total dependence for activities of daily living and received respiratory services. Review of the Care Plan revised 5/28/18 revealed Resident #57 was at risk for aspiration related to Dysphagia, increased secretions,vomiting and required suctioning as needed. The physicians order dated 5/28/18 documented, .TREATMENT/PR[NAME]EDURE .place suction machine at bedside for elder's use to assist with oral secretion clearance .PRATT ([MEDICATION NAME])-ALBUT ([MEDICATION NAME]) 0.5-3(2.5) MG (milligrams)/3 ML (milliliters) .ADMINISTER 1 AMP ([MEDICATION NAME]) VIA (by way of) NEBULIZER THREE TIMES DAILY . Observations in Resident #57's room on 5/6/19 at 9:21 AM, and 5/7/19 at 7:33 AM and 8:35 AM, revealed a suction catheter with a canister dated 2/8/19, suction tubing dated 2/8/19, an open and undated suction catheter with a dried unknown substance in the suction catheter and tubing, and an uncovered and undated nebulizer mask. Interview with Unit Manager #1 on 5/7/19 at 10:42 AM, in Resident # 57's room, Unit Manager #1 was asked if the nebulizer was dated. Unit Manager #1 stated, It's not in a bag or dated. Unit Manager #1 was asked if the suction set up was dated and clean. Unit Manager #1 stated, The Yaunker (suction catheter) is dirty and not dated, it looks like it might have a date of 2/8/19 on the end of the suction tubing .the canister is dated 2/8/19 . Unit Manager #1 was asked if this was acceptable. Unit Manager #1 stated, No, ma'am .the nebulizer mask is supposed to be in a bag and dated .when suction is used and dirty it's to be changed. Interview with the Director of Nursing (DON) on 5/7/19 at 1:09 PM, in the Conference Room, the DON was asked if a suction canister, suction tubing, and suction catheter should be labeled 2/8/19 and if there should have been a dried substance in the suction catheter and tubing. The DON stated, No, it is not acceptable. 3. Medical record review revealed Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #79 was cognitively intact, required extensive assistance with his activities of daily living and received oxygen therapy. The physician's orders [REDACTED].O2 (oxygen) @ (symbol for at) 2 L (liters) / (symbol for per) MIN (minute) BNC (by nasal cannula) AS NEEDED FOR SOB (shortness of breath) . Observations in Resident #79's room on 5/6/19 at 9:20 AM, 12:27 PM, and 2:29 PM, revealed Resident #79 in his bed with the humidified oxygen at 2 L/MIN BNC with the humidified water bottle dated 4/28/19. Observations in Resident #79's room on 5/7/19 at 7:23 AM and 7:30 AM, revealed a humidified water bottle dated 4/28/19. Interview with the DON on 5/7/19 at 11:35 AM, in the Conference Room, the DON was asked how often should the oxygen tubing and humidified water bottles for oxygen administration be changed. The DON stated, .supposed to be weekly .

Based on policy review, observation, and interview, the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by dust above the stove and on the oven fan, carbon build up on the deep fat fryer, 1 large roasting pan, 20 cookie sheets and 2 frying pans, the inside black coating flaking off of 2 frying pans, and grease build up in the oven's drip pan and the filter under the deep fat fryer. The facility had a census of 75, with 73 of those residents receiving a meal tray from the kitchen. The findings included: 1. Review of the facility's DEEP-FAT FRYER policy revised 1/26/16 documented, .scrape off oxidized fat from sides of the fryer . 2. Review of the facility's POTS AND PANS-SANITIZING SOLUTION policy revised 7/12/16 documented, .Pots and pans need to be free of black buildup, deep scratches and dents . 3. Observations in the kitchen with the Dietary Manager on 6/25/18 beginning at 9:18 AM and on 6/26/18 at 10:00 AM, revealed the following: a. Dust observed on the following: Vent hood. Oven fan. b. Carbon build up on the following: 1 deep fat fryer. 1 large roasting pan. 20 cookie sheets. 2 frying pans. c. The inside black coating flaking off of 2 frying pans. 4. Observations in the kitchen on 6/26/18 beginning at 10:00 AM, revealed grease build up in the oven's drip pan and the filter under the drip under the deep fat fryer. Interview with the Dietary Manager (DM) on 6/26/18 at 10:25 AM, in the kitchen, the DM was asked if it was acceptable to use frying pans with the inside black coating flaking off and carbon buildup on baking pans. The Dietary Manager stated, No. The Dietary Manager was asked if it was acceptable to have dust on the vent hood and the oven fan, and grease build up in up in the oven's drip pan and the filter under the deep fat fryer. The Dietary Manager stated, No .Needs cleaned. Interview with the Administrator on 6/26/18 at 10:25 AM, in the Kitchen, the Administrator was asked if it was acceptable to use frying pans with the inside black coating flaking off and dust on the vent hood and the oven fan. The Administrator stated It is not.

Based on policy review, manufacturer's recommendations, medical record review, observation, and interview the facility failed to appropriately disinfect a glucometer (a machine that checks blood sugar) before and after use for 1 of 2 (Resident #2) sampled residents observed during medication administration. The findings included: The facility's Blood Glucose Monitoring policy documented, . Testing shall be performed in accordance with the Standard Precautions for the handling of blood and body fluids .Actual performance of the blood glucose monitoring device shall be performed as outlined in the manufacturer's manual. The manufacturer's User Instruction Manual documented, .Cleaning and disinfecting can be completed by using a commercially available EPA (Environmental Protective Agency)-registered disinfectant detergent or germicide wipe . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Accuchecks AC (before meals) & (and) HS (bedtime) . Observations on the 200 hall beside the medication cart on 6/26/18 at 12:26 PM, Licensed Practical Nurse (LPN) #1 wiped the glucometer with an alcohol pad prior to use. Upon completion of checking Resident #2's blood sugar, LPN #1 returned to the cart and wiped the glucometer with an alcohol pad. Interview with LPN #1 on 6/26/18 at 12:30 PM, on the 200 hall, LPN #1 was asked, if she had cleaned the glucometer with alcohol before and after she used the glucometer on Resident #2. LPN #1 stated, Yes, but sometimes I clean it with bleach wipes if available. Interview with the Director of Nursing (DON) on 6/27/18 at 10:15 AM, in the Conference Room, the DON was asked if it was appropriate to clean the glucometer with alcohol pads. The DON stated, No.

Based on policy review, medical record review and interview the facility failed to follow physician orders [REDACTED].#82) sampled residents reviewed for unneccessary medications of the 34 residents included in the stage 2 review. The finding included: 1. The facility's Medication Administration policy documented, .Medications are administered as prescribed .Medications are administered in accordance with written orders of the prescriber .The individual who administers the medication dose, records the administration on the resident's MAR (Medication Administration Record) . 2. Medical record review revealed Resident #82 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]., Dysphagia, Hypertension, Diabetes Mellitus, Dementia with Behavioral Disturbance, Restlessness and Agitation, Personal History of Urinary Tract Infections, [MEDICAL CONDITION], and Generalized [MEDICAL CONDITION]. A. The physician order [REDACTED]. The Medication Administration Record [REDACTED].HUMALOG .INJECT 5 UNITS .WITH SUPPER . The administration area of the MAR for March 2017 did not document the Humalog insulin was administered with supper (5 PM) on 3/4/17, 3/5/17, 3/14/17 and 3/31/17. The physician order [REDACTED].ACCUCHECK AC (before meals) AND HS (hour of sleep) . The administration area of the MAR for March 2017 did not document that an accucheck was performed on 3/4/17, 3/5/17 and 3/31/17 at 5 PM. B. The physician order [REDACTED].HUMALOG .INSULIN .INJECT 5 UNITS .WITH SUPPER . The MAR for April 2017 scheduled, HUMALOG .INJECT 5 UNITS .WITH SUPPER . The administration area of the MAR for April 2017 did not document the Humalog insulin was administered with supper on 4/1/17, 4/5/17, 4/6/17, 4/14/17, 4/15/17, 4/16/17, 4/18/17, 4/19/17, 4/26/17 and 4/29/17. The physician order [REDACTED].Humalog 3u (units) at brk (breakfast) (sign for and) lunch . The MAR for April 2017 scheduled HUMALOG .INJECT 3 UNITS .WITH BREAKFAST & (and) WITH LUNCH . The administration area of the MAR indicated [REDACTED]. The physician order [REDACTED].HUMALOG .INSULIN .GIVE ACCORDING TO SLIDING SCALE .0700, 1100, 1700, 2100 . The administration area of the MAR for April 2017 did not document an accucheck was performed on 4/1/17, 4/5/17, 4/6/17, 4/15/17, 4/16/17, 4/18/17, 4/19/17, 4/25/17, 4/26/17 and 4/29/17 at 5 PM. C. The physician order [REDACTED].[MEDICATION NAME] .INSULIN .INJECT 22 UNITS .AT BEDTIME . The MAR for May 2017 scheduled, .[MEDICATION NAME] .INJECT 22 UNITS .AT BEDTIME . The administration area of the MAR for May 2017 did not document [MEDICATION NAME] was administered on 5/5/17 at bedtime. The physician order [REDACTED].Humalog 3u (units) at brk (breakfast) (sign for and) lunch . The MAR for May 2017 scheduled, .HUMALOG .INJECT 3 UNITS .WITH BREAKFAST & WITH LUNCH . The administration area of the MAR indicated [REDACTED]. The physician order [REDACTED].HUMALOG .INSULIN .GIVE ACCORDING TO SLIDING SCALE .0700, 1100, 1700, 2100 . The administration area of the MAR for May 2017 did not document an accucheck was performed on 5/2/17, 5/3/17, 5/6/17, 5/9/17, 5/13/17, 5/17/17, 5/18/17, 5/19/17, 5/20/17 and 5/23/17 at 5 PM. D. Interview with the Director of Nursing (DON) on 5/24/17 at 2:50 PM, in the DON office, the DON was asked about the MARs for the month of March, April and May 2017 for the days no accuchecks were documented as performed. The DON confirmed the lack of documentation. The DON was asked if accucheck should be done according to physician orders. The DON stated, Yes ma'am. The MARs were reviewed for the months of March, April and May 2017 related to insulin administration and the DON confirmed the lack of documentation that the insulin was administered as ordered.

Based on policy review, medical record review, observation, and interview, the facility failed to follow the care plan related to blood glucose testing, insulin administration and therapeutic diets for 2 of 11 (Resident #82 and 109) sampled residents of the 34 residents included in the stage 2 review. The findings included: 1. The facility's Care Plans-Comprehensive policy documented, .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .Reflect treatment goals, timetables and objectives in measurable outcomes .Care plan interventions are implemented after consideration of each resident's problem areas and their causes. 2. Medical record review revealed Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Dysphagia, Hypertension, Diabetes Mellitus, Dementia with Behavioral Disturbance, Restlessness and Agitation, Personal History of Urinary Tract Infections, [MEDICAL CONDITION] in [MEDICAL CONDITION] and Generalized [MEDICAL CONDITION]. The care plan dated 12/4/14 with a goal date of 6/4/17 documented, I am at risk for complications associated with hyper ([MEDICAL CONDITION])/[DIAGNOSES REDACTED] R/T (related to) DX (diagnosis) of Type 2 diabetes and side effects of medication .Approach .Administer oral and/or insulin as ordered .Perform Accuchecks (blood glucose test) as ordered . A. The Medication Administration Record [REDACTED].HUMALOG .INSULIN .ACCUCHECKS AC (before meals) AND HS (hour of sleep) GIVE HUMALOG ACCORDING TO SSI (sliding scale insulin) SCALE .0-149=0.0 Units, 150-250 =3.0 Units, 251-350=5.0 Units, 351-400=7.0 Units, 401-999=7.0 Units . Accuchecks were scheduled on the MAR indicated [REDACTED]. Continued review of the MAR for March 2017 revealed the following: a. 3/3/17 at 5 PM accucheck result was 233 with no documentation that sliding scale insulin was administered. b. 3/4/17 and 3/5/17 and 3/31/17 at 5 PM no accucheck was documented. c. The administration area of the MAR indicated [REDACTED]. 3/10/17 at 5 PM accucheck result was 132 3/10/17 at 9 PM accucheck result was 149 3/11/17 at 7 AM accucheck result was 138 3/11/17 at 11 AM accucheck result was 126 3/17/17 at 7 AM accucheck result was 94 3/23/17 at 9 PM accucheck result was 107 3/24/17 at 7 AM accucheck result was 133 3/24/17 at 11 AM accucheck result was 143 3/25/17 at 5 PM accucheck result was 145 3/30/17 at 9 PM accucheck result was 128 The MAR for March 2017 documented, HUMALOG .INJECT 5 UNITS .WITH SUPPER . Review of the administration area of the MAR indicated [REDACTED]. B. The MAR for April 2017 documented, .HUMALOG .GIVE HUMALOG ACCORDING TO SLIDING SCALE .0-149=0.0 Units, 150-250 =3.0 Units, 251-350=5.0 Units, 351-400=7.0 Units, 401-999=7.0 Units .GIVE ACCORDING TO SLIDING SCALE . The administration area of the MAR for April 2017 documented insulin was administered on the following dates and times even though according to the SSI no insulin was to be administered with an accucheck value of 0-149: 4/5/17 at 7 AM accucheck result was 128 4/8/17 at 7 AM accucheck result was 114 4/20/17 at 7 AM accucheck result was 143 4/23/17 at 5 PM accucheck result was 127 The MAR for April 2017 documented, HUMALOG .INJECT 5 UNITS .WITH SUPPER . The administration area of the MAR for April 2017 did not document the Humalog insulin was administered with supper on 4/1/17, 4/5/17, 4/6/17, 4/14/17, 4/15/17, 4/16/17, 4/18/17, 4/19/17, 4/26/17 and 4/29/17. The MAR for April 2017 documented, HUMALOG .INJECT 3 UNITS .WITH BREAKFAST & (and) WITH LUNCH . The administration area of the April MAR indicated [REDACTED]. The MAR for April 2017 did not document a 5 PM accucheck was performed on 4/1/17, 4/5/17, 4/6/17, 4/15/17, 4/16/17, 4/18/17, 4/19/17, 4/25/17, 4/26/17 and 4/29/17. C. The MAR for May 2017 documented, .[MEDICATION NAME] .INJECT 22 UNITS .AT BEDTIME . The administration area of the MAR for May 2017 did not document [MEDICATION NAME] was administered on 5/5/17 at bedtime. The MAR for May 2017 documented, .HUMALOG .INJECT 3 UNITS .WITH BREAKFAST & WITH LUNCH . The administration area of the MAR for May 2017 did not document Humalog insulin was administered on 5/5/17, 5/7/17, 5/9/17, 5/12/17, 5/16/17, 5/21/17 at 7 AM, and 5/12/17 at 11 AM. The MAR for May 2017 documented, .HUMALOG .INSULIN .GIVE ACCORDING TO SLIDING SCALE .0-149=0.0 Units, 150-250 =3.0 Units, 251-350=5.0 Units, 351-400=7.0 Units, 401-999=7.0 Units . The May 2017 MAR indicated [REDACTED] 5/5/17 at 7 AM accucheck result was 68 5/5/17 at 5 PM accucheck result was 117 5/6/17 at 7AM accucheck result was 81 5/7/17 at 7 AM accucheck result was 68 5/7/17 at 5 PM accucheck result was 127 5/9/17 at 7 AM accucheck result was 102 5/10/17 at 7AM accucheck result was 74 5/11/17 at 5 PM accucheck result was 142 5/16/17 at 7AM accucheck result was 54 5/16/17 at 5 PM a accucheck result was 114 5/20/17 at 7AM accucheck result was 145 5/21/17 at 7AM accucheck result was 58 The MAR for May 2017 did not document an accucheck was performed on 5/2/17, 5/3/17, 5/6/17, 5/9/17, 5/13/17, 5/17/17, 5/18/17, 5/19/17, 5/20/17 and 5/23/17 at 5 PM. D. Interview with the Director of Nursing (DON) on 5/25/17 at 8:17 AM, in the DON office, the DON was asked if a resident has a care plan that documented administer insulin as ordered and the insulin was not documented as ordered was the care plan being followed. The DON stated, No, ma'am. The DON was asked if accuchecks are not documented as ordered was the care plan being followed. The DON stated, No, ma'am. 3. Medical record review revealed Resident #109 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] and the admission MDS dated [DATE] documented Resident #109 received a therapeutic diet. A telephone physician's orders [REDACTED].Mechanical Soft Diet R/T (related to) having trouble chewing food up . The care plan dated 8/25/16 documented, .at nutrition risk R/T I am on a mechanically altered diet .Approach .Provide diet as ordered: mechanical soft . Observations in Resident #109's room on 5/24/17 at 8:05 AM, revealed Certified Nursing Assistant (CNA) #2 assisted Resident #109 to eat breakfast consisting of a banana, scrambled eggs, 2 whole pieces of bacon, 1 piece of toast cut into 2 diagonal slices, and oatmeal. Interview with CNA #2 on 5/25/17 at 11:35 AM, at the old nurses' station, CNA #2 was asked what she normally does with the meal cards after the meal. CNA #2 stated, .shredder . CNA #2 was asked whether she assisted Resident #109 on 5/24/17 with bacon, eggs, and toast at breakfast. CNA #2 confirmed she did. CNA #2 was asked whether this resident typically received bacon on his breakfast tray. CNA #2 stated, It just depends. Interview with the Director of Nursing (DON) on 5/25/17 at 11:38 AM, the DON was asked whether it was acceptable for a resident on a mechanical soft diet to receive bacon. The DON stated, It would depend on the consistency of it. Interview with the Therapy Director on 5/25/17 at 11:00 AM, in the Therapy Gym, the Therapy Director was asked whether bacon is acceptable for a resident on a mechanical soft diet. The Therapy Director stated, It would have to be ground or chopped. Not whole bacon

Based on observation and interview the facility failed to provide effective housekeeping services to maintain resident care rooms in a sanitary condition as evidenced by 1 of 50 (Resident #5's room) resident rooms had a strong urine odor. The findings included: Observations in Resident #5's room on 5/22/17 at 11:51 AM and 3:56 PM, 5/23/17 at 8:16 AM, 9:01 AM, and 6:20 PM, 5/24/17 at 8:20 AM, and 5/25/17 at 8:32 AM, revealed a strong urine odor. Interview with Certified Nursing Assistant (CNA) #1 on 5/24/17 at 8:21 AM, on the 200 Hall, CNA #1 was asked whether there was a urine odor from Resident #5's room. CNA #1 confirmed the urine odor. Interview with Licensed Practical Nurse (LPN) #1 on 5/24/17 at 5:18 PM, on the 200 Hall, LPN #1 was asked whether there was a urine odor in Resident #5's room. LPN #1 confirmed the urine odor. Interview with the Housekeeping Supervisor on 5/25/17 at 9:00 AM, in the conference room, the Housekeeping Supervisor was asked whether there was an odor in Resident #5's room. The Housekeeping Supervisor stated, Yes . Interview with the Administrator on 5/25/17 at 9:34 AM, in the conference room, the Administrator was asked about the odor in Resident #5's room. The Administrator confirmed she was aware of the odor.

Intake: TN 226 Based on review of the "National Pressure Ulcer Advisory Panel (NAUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE," policy review, medical record review, observation and interview, it was determined the facility failed to accurately identify and assess and follow interventions for pressure ulcers for 2 of 5 (Resident #8 and 9) sampled residents with pressure ulcers. The failure to identify and prevent skin breakdown prior to the development of an unstageable pressure ulcer resulted in actual harm to Resident #9. The findings included: 1. Review of the "National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE" documented, "...3. Inspect skin regularly for signs of redness...Ongoing assessment of the skin is necessary to detect early signs of pressure damage. 4. Skin inspection should include assessment for localized heat [MEDICAL CONDITION], or induration (hardness), especially in individuals with darkly pigmented skin..." 2. Review of the facility's "Skin Care and Wound Management Program" policy documented, "...The Licensed Nurse is responsible in completing the weekly skin assessment to identify any new skin impairments and to document skin condition..." Review of the facility's "BATH POLICIES" policy documented, "...Report to the Charge Nurse any unusual conditions you notice while bathing the resident..." 3. Medical record review for Resident #9 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "Weekly Skin Rounds" documented the following: a. "...Date: 9/6/11 Skin Condition: pressure ulcer to buttocks (coccyx area circled on diagram)..." b. "...Date: 9/13/11 Skin Condition: (no skin assessment documented)..." c. "...Date: 9/20 Skin Condition: skin W/D/I (warm/dry/intact) stg (stage) I to buttocks DM (diabetes mellitus) ulcer to R (right) ankle & L (left) heel..." Review of the "INDIVIDUAL SKIN REPORT" dated 9/26/11 documented, "DATE OF ONSET: 9/26/11...Facility Acquired: X...Check one...X Pressure...X Unstageable Pressure Ulcers due to slough and/or eschar...Date 9/26/11 Week # 1 Type Wound pressure Stage unstageable Measurements (cm) (centimeter) L (length) 1.1 W (width) 1.1 D (depth) N/A (not applicable)...Wound Bed...(symbol for check mark) Slough Tissue...Periwound Wound margins reddened Secondary tissue reddened Surrounding tissue color/description pink... Observations in Resident #9's room on 9/26/11 at 4:35 PM with Nurse #2 revealed Resident #9 lying in bed on her left side with her buttocks exposed. Observations revealed a large red area with a round dark area with white edges in the center of the red area on her right buttock. Observations in Resident #9"s room on 9/26/11 at 4:55 PM with Nurse #2 revealed Resident #9 lying on her right side with her buttocks exposed. Nurse #2 measured the dark area with white edges on the right buttock as L 1.1 cm W 1.1 cm. During an interview in Resident #9's room on 9/26/11 at 4:35 PM, when asked when the ulcer on the right buttock started, Nurse #2 stated,"...This is the first time I've seen this (ulcer to right buttock)..." During an interview at the nurses station on 9/27/11 at 7:45 AM, when asked about the stage of the pressure ulcer found on 9/26/11, Nurse #2 stated, '...it is unstageable and there is slough around the edge..." During an interview in the conference room on 9/27/11 at 2:35 PM, when asked about daily skin assessment documentation by the Certified Nursing Assistant, the DON stated, "...any issue, take to nurse. If find something it's charted..." The DON confirmed there is no daily documentation. The failure to identify and prevent skin breakdown prior to the development of an unstageable pressure ulcer resulted in actual harm to Resident #9. 4. Medical record review for Resident #8 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #8's room on 9/26/11 at 12:45 PM, 2:15 PM, 3:45 PM and on 9/27/11 at 7:45 AM, revealed Resident #8 lying in bed and her heels were not floating/offloaded. During an interview in Resident #8's room on 9/26/11 at 3:45 PM, Nurse #1 stated, "No they (referring to Resident heels) are not floating..."