Every finding on record at Signature Healthcare of South Louisville

Based on observation, interview and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Observations revealed dented canned food items in the storage area, available for use. Additionally, observation revealed staff failed to practice hand hygiene during plating of meals. The findings include:1. Review of a policy from the dietary services company contractor titled, Receiving, revised 02/2023, revealed, Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. The policy revealed the Procedures included, 1. The Dining Services Director or designee receives all items and checks each against the order; 2. The Dining Services Director or designee signs and dates the delivery slip from the vendor. Omissions or damaged goods will be noted on the delivery receipt; 3. The Dining Services Director or designee will inspect all refrigerated and frozen supplies for safe transport including, proper temperature maintenance, acceptable quality, and store immediately. If quality is unacceptable, the item(s) will be immediately returned for credit; and 4. All canned goods will be appropriately inspected for dents, rust or bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal, as appropriate.During an observation of the kitchen dry storage area and a concurrent interview on 02/23/2026 beginning at 9:28 AM, one 4-pound, dented can of chunk light chicken in water was observed with a dent on the top and bottom of the can. Observations of the can storage rack in the food preparation area revealed one 7-pound can of classic apple with a dent on the top seal and one 6.6-pound can of mandarin oranges with a dent on the top and bottom seal. The Dietary Manager (DM) stated they had a new person stocking that started the previous week, and he had never worked in the kitchen and was learning the process. She stated regular staff should check the cans before they went out, and new staff may not be checking the cans for dents as they should be.During an observation of the can storage rack and a concurrent interview on 02/25/2026 at 10:30 AM, there were three 50-ounce cans of tomato soup that were dented at the seal with a received date of 02/20/2026, one 50-ounce can of cream of chicken soup was dented at the seal with a received date of 02/10/2026, and one 46-ounce can of vegetable juice was dented on the side with a received date of 12/16/2025. [NAME] #3 stated that when the food delivery truck came in, the staff member who put away the cans screened the canned food items for dents and put them in the dented can room. [NAME] #3 stated that the 46-ounce can of vegetable juice with handwritten date of 12/16/2025 was the date the can came in. [NAME] #3 stated they could not use the dented can and could not give it to a resident because they may get sick.During an interview on 02/26/2026 at 2:41 PM, the Director of Nursing (DON) stated she expected dented cans to be thrown out immediately.During an interview on 02/26/2026 at 2:55 PM, the Administrator stated screening for dented cans should be completed and dented cans should be separated and checked for safety. He stated that he expected dented cans to not be used for any meal preparation.2. Review of an undated facility policy titled, Handwashing for Food Safety, revealed, Here are crucial moments when you should remember to wash your hands, which included, Before, during and after you prepare a meal, Especially after handling raw meat, poultry, seafood or eggs or their juices.During an observation of the lunch meal tray line on 02/25/2026 at 11:23 AM, [NAME] #3 touched her eyeglasses then pulled her phone out of her right pants pocket, then placed the phone back in the right pants pocket. Without performing hand hygiene after touching her eyeglasses, cellphone, and clothing, she then pulled tongs down by the tips that contacted food and served bread using those tongs.During an interview on 02/25/2026 at 12:34 PM, the Dietary Manager (DM) stated that anytime staff changed to a new task, they should wash their hands. She stated personal phones were not allowed in the kitchen. She stated she expected dietary staff to wash their hands if they touched a phone or their face.During an interview on 02/26/2026 at 2:41 PM, the Director of Nursing (DON) stated that she expected hand hygiene to be completed before touching any produce, food, or tray line, after the removal of gloves, after they touched their phone, and prior to touching utensils.During an interview on 02/26/2026 at 2:55 PM, the Administrator stated he expected staff to follow the facility process regarding hand hygiene, after touching their face or phone, and prior to using tongs.

Based on interview, record and facility policy review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective, person-centered care for 1 of 2 residents sampled for respiratory services (Resident (R) 76). Record review revealed the baseline care plan for R76 did not address the resident's CPAP (continuous positive air pressure) equipment use. The findings include:Review of facility policy, Baseline Care Plan Policy, reviewed 01/30/2026, indicated, A Baseline Care Plan is developed and implemented to promote continuity of care and communication among facility stakeholders to increase resident safety and safeguard against adverse events that are most likely to occur right after admission. The policy also indicated, 1. The Baseline Care Plan will be developed and implemented within 48 hours of a resident's admission, with the following: i. Initial goals based on admission orders ii. Physician orders iii. Dietary orders iv. Therapy services v. Social Services vi. Preadmission Screening & Resident Review (PASRR) recommendations, if applicable.Review of facility document Resident Face Sheet, indicated the facility admitted Resident #76 on 02/15/2026 with diagnoses including obstructive sleep apnea.Review of Resident #76's Orders, revealed the following orders dated 02/15/2026: CPAP/BiPAP (bilevel positive air pressure), with home settings to be used daily from 6:00 PM to 6:00 AM. CPAP/BiPAP: Remove in the morning and clean mask/equipment after use (once each morning). CPAP/BiPAP: Head of bed elevated to alleviate shortness of breath while lying flat (every shift). CPAP/BiPAP: Change tubing monthly.Review of Resident #76's admission Observation dated 02/15/2026 indicated CPAP was included under respiratory devices.Review of Resident #76's 48-Hour Baseline Care Plan revealed it did not indicate the resident's use of a CPAP device.During an interview on 02/26/2026 at 10:54 AM, Registered Nurse (RN) #24 stated the facility completed a 48-hour baseline care plan at admission that should include pertinent information such as special equipment. He stated the use of a CPAP device should have been included if it was on the admission orders.During an interview on 02/26/2026 at 12:16 PM, RN #15 stated she entered the CPAP order for Resident #76 and confirmed the use of a CPAP device should have been included in the baseline care plan since it was part of the admission orders.During an interview on 02/26/2026 at 11:16 AM, Licensed Practical Nurse (LPN) #5, who was also the Unit Manager, stated the admitting nurse completed the baseline care plan and Minimum Data Set (MDS) staff reviewed it the next day. She confirmed the baseline care plan should include activities of daily living (ADL) care, special equipment, oxygen, and respiratory equipment. She reviewed Resident #76's baseline care plan and confirmed it did not include CPAP use.During an interview on 02/26/2026 at 11:35 AM, the MDS Coordinator stated the baseline care plan should include respiratory equipment if present on admission. She reviewed Resident #76's baseline care plan and confirmed the resident's use of a CPAP device was not included but should have been.During an interview on 02/26/2026 at 1:41 PM, the Director of Nursing (DON) stated the admitting nurse completed the baseline care plan, and the MDS nurse reviewed it the following morning to ensure it was appropriate. She stated the baseline care plan would not necessarily say CPAP but should include respiratory equipment. She reviewed Resident #76's baseline care plan and confirmed that the resident's use of a CPAP device was not included. She stated that she recalled discussing CPAP device settings with the resident and thought it was addressed in the clinical meeting but confirmed it was not included on the baseline care plan and should have been listed under respiratory equipment.During an interview on 02/26/2026 at 2:37 PM, the Administrator stated baseline care plans must be completed within 48 hours and should include any respiratory equipment ordered at admission.

Based on observation, interview, record and policy review the facility failed to ensure a resident with pressure ulcers received care consistent with professional standards of practice to promote healing for 1 of 2 residents (Resident (R) 84). Observations revealed an ordered pressure relieving device not in place as ordered.The findings include: Review of facility policy titled, Skin Integrity, reviewed 01/31/2026, revealed, The facility will ensure that based on the comprehensive assessment of a resident, and 2. A resident with impaired skin integrity receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infections and prevent avoidable skin integrity issues from developing.Review of facility document, Resident Face Sheet revealed the facility admitted Resident #84 on 12/17/2025. According to the Resident Face Sheet the resident had a medical history that included diagnoses of displaced intertrochanteric fracture of left femur (upper thigh bone), need for assistance with personal care, and protein-calorie malnutrition.Review of the 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/06/2026, revealed the facility assessed Resident #84 with a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated Resident #84 required partial to moderate assistance with transferring from the bed to the chair or the chair to the bed. The MDS further indicated Resident #84 was always incontinent of bowel and bladder. Continued review revealed the MDS indicated Resident #84 was at risk for developing pressure ulcers, had one or more unhealed pressure ulcers, and one unstageable pressure ulcer due to coverage of the wound bed with slough and/or eschar. The MDS indicated Resident #84 had a pressure-reducing device for their chair.Review of a Physical Therapy Treatment Encounter Note, dated 12/30/2025 at 12:36 PM, revealed Physical Therapist (PT) #17 changed the resident's wheelchair cushion to a [Brand name, an air-cell based cushion to reduce pressure points] cushion to help with improve sitting tolerance.Review of Resident #84's Care Plan included a problem area, created 01/07/2026, for skin integrity that indicated the resident had a pressure ulcer to the sacrum. Interventions directed staff to implement pressure reducing devices such as a mattress and a cushion to the wheelchair as needed, 01/07/2026; and [Brand name, air-cell based cushion] cushion to wheelchair, 01/16/2026.Resident #84's undated C.N.A. Care Report [Certified Nursing Assistant Care Report, a report used by CNAs to direct resident care] revealed the resident used a wheelchair for mobility, required the assistance of one staff member for ambulation and transfers, and was incontinent. The C.N.A. Care Report included a handwritten note, [Brand name, air-cell based cushion] or gel equivalent, and LAL [low air loss] mattress.Resident #84's Physician Order Report, with orders for the timeframe from 12/17/2025 through 02/25/2026, revealed an order, dated 01/16/2026, for a [Brand name, air-cell based cushion] cushion to the resident's wheelchair, every shift day and night.A Medication Administration Record [MAR], dated 02/2026, did not include the transcription of the physician's order for the Brand name, air-cell based cushion.A nurse practitioner's Progress Notes, dated 01/14/2026 at 12:51 PM, 01/21/2026 at 1:28 PM, 01/28/2026 at 1:13 PM, 02/04/2026 at 2:15 PM, 02/11/2026 at 1:38 PM, and 02/18/2026 at 1:29 PM revealed Resident #84 was on a chair cushion due to a high risk of pressure ulcer formation.An observation and interview, on 02/23/2026 at 11:06 AM, revealed Resident #84 sitting up in a wheelchair, and the wheelchair did not have a cushion in the seat.An observation and interview, on 02/24/2026 at 1:25 PM, revealed that Resident #84 sat in a wheelchair with no cushion in the seat. Family Member (FM) #18 stated they brought in a cushion from home for the resident to sit on and did not know why the resident did not have a cushion in the wheelchair.An observation, on 02/25/2026 at 8:37 AM, revealed a cushion in Resident #84's chair; however, it was not the ordered (Brand name) air-cell based cushion.During an interview on 02/25/2026 at 11:53 AM, FM #18 stated the cushion Resident #84 had in the wheelchair was the one they (family) supplied for the resident. During an interview on 02/25/2026 at 1:50 PM, CNA #18 stated that Resident #84 had a wound on their buttocks and used an air mattress and a cushion in their wheelchair. CNA #18 stated Resident #84 had always had a cushion in their wheelchair, and CNAs did not document if cushions were in place.During an interview on 02/25/2026 at 2:00 PM, Licensed Practical Nurse (LPN) #20 stated if a resident had an order for a (Brand name, air-cell based cushion) cushion, it should appear on the MAR, and she would check for those things during her rounds. LPN #20 stated when they received an order for a cushion, management would bring the cushion to the floor staff and nurses should look every day to ensure the resident had the ordered cushion. LPN #20 stated whoever implemented the orders would put the order in the electronic medical record (EMR), and then make sure the device was there. LPN #20 stated once the device was implemented, nurses were responsible to document that it was in place.During a telephone interview on 02/25/2026 at 2:13 PM, Registered Nurse (RN) #15, who was the facility's Wound Care Nurse, stated she tried to implement orders as she entered them in the EMR, and she also had help from other staff to implement orders. RN #15 stated usually if she entered an order into the EMR the order would be put on the MAR. RN #15 stated if she put the order in the EMR, she would get the equipment and put that equipment in the resident's room. RN #15 stated staff removed the cushion when they cleaned the wheelchair, and sometimes the cushion would not make it back to the resident's room. RN #15 stated that it could very well have been a data entry error on her part that the order did not appear on the MAR for the nurses to document on. When asked who made sure care plan approaches were implemented, RN #15 stated she was usually the one who ensured care plan approaches to pressure ulcers were implemented. RN #15 stated she was usually the one who placed the cushions in the resident's room. During an interview on 02/25/2026 at 3:58 PM, the Director of Nursing (DON) stated they ordered a (Brand name, air-cell based cushion) cushion for Resident #84 in 02/2026. The DON stated that she took the resident's cushion and cleaned the cushion on Monday, 02/23/2026, and on 02/24/2026 the was still wet. The DON stated Resident #84 had a gel cushion they put in the resident's chair as well. The DON stated she expected nurses to check that the cushion was placed appropriately. The DON stated she expected that orders be entered so that the orders appeared on the MAR. The DON stated she was sure they ordered the cushion in 02/2026, but understood that the cushion was not in Resident #84's room.During an interview on 02/26/2026 at 9:13 AM, CNA #21 stated Resident #84 had an area on their buttocks that was healing, and the resident had been using a cushion for a while. CNA #21 stated they cared for Resident #84 on Tuesday, 02/24/2026, and the resident had a black foam cushion then. CNA #21 stated Resident #84 usually had a square black cushion, and she was not sure why Resident #84 did not have the square black cushion in their wheelchair.During an interview on 02/26/2026 at 11:41 AM, the DON stated she was not sure what had happened to Resident #84's cushion that had been in the wheelchair and why it had not been in place on Monday, 02/23/2026, or Tuesday, 02/24/2026. The DON stated she believed that there was an issue with the way the order was entered and if the order had been entered correctly the nurses would have known to look for Resident #84's cushion and would have realized when the resident did not have it. During an interview on 02/26/2026 at 11:56 AM, the Administrator stated that the care plan was to be a general guide of how staff cared for the residents. Administrator stated the nurse managers should ensure orders were on the MAR for the nurses to verify. The Administrator stated he expected that when staff got a resident up to a chair, staff made sure the resident had some type of pressure-reducing cushion.

Based on observation, interview, and review of facility policy review and records, the facility failed to ensure medication was securely stored for 1 (Resident #22) of 3 residents reviewed for accident hazards. The facility also failed to ensure medication carts were free from loose pills and debris, which affected 1 (West Wing Cart #1) of 3 medication carts observed.The findings included:Review of facility policy, Medication Storage, Storage of Medication, dated 01/2025, revealed Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy revealed the Procedures included, 4. Medications should be stored so that various routes of administration are separated. Internally administered medications are stored separately from medications used externally such as lotions, creams, ointments, and suppositories, 9. Potentially harmful substances (such as urine test reagent tablets, household poisons, cleaning supplies, disinfectants) are clearly identified and stored in an area separate from medications, and 16. Medication storage areas should be kept clean, well lit, organized and free of clutter. Review of facility policy, Medication Administration, dated 06/24/2024, revealed, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. The policy revealed the Guidelines included, 6. Medications should be administered at the time they are prepared. 1. Review of the facility document, admission Record indicated the facility admitted Resident #22 on 07/03/2023. Further review revealed the resident had a medical history that included diagnoses of atherosclerosis (build of fatty deposits inside artery walls causing them to harden and narrow) of native arteries (original arteries [vessels] within the body) of other extremities with ulceration (painful, open sores) and type 2 diabetes mellitus. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2025, revealed the facility assessed Resident #22 with a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #22 was at risk for developing pressure ulcers/injuries and had a total of three venous or arterial ulcers present. The MDS also revealed Resident #22's treatment included applications of dressings to their feet. Review of the facility's comprehensive care plan for Resident #22 revealed a focus area initiated 02/11/2026, that indicated the resident had an arterial ulcer to the left third toe. Interventions directed staff to change dressings per physician orders (initiated 02/11/2026). Review of Resident #22's Physician Order Report, dated 02/24/2026, contained an active order, dated 02/09/2026, for povidone iodine (an antiseptic and germicide) 10% solution to be painted on the third toe arterial ulcer once daily. The Physician Order Report also included an active order, dated 02/09/2026, for povidone iodine 10% solution to be painted on the left great toe arterial ulcer once daily. The Physician Order Report further included an active order, dated 02/24/2026, for Wound Care, with instructions to cleanse the arterial ulcer to left third toe with wound cleanser and paint the wound with povidone iodine as needed. During a concurrent observation and interview on 02/23/2026 at 2:24 PM in Resident #22's room, six opened bottles of povidone iodine topical solution 10% covered with residual stains outside the bottle were observed atop Resident #22's bedside table. At the time of observation, Resident #22 stated they had wounds on their backside, and staff changed the dressings three to four times a week. During an observation on 02/24/2026 at 9:30 AM inside Resident #22's room, a 16 fluid (fl) ounce (oz) bottle of povidone iodine 10% solution was observed atop Resident #22's bedside table. During a concurrent observation and interview on 02/24/2026 at 2:18 PM inside Resident #22's room, there was a bottle of povidone iodine atop the resident's bedside table. Registered Nurse (RN) #13 stated that the bottle of povidone iodine was used for wound dressings and was a medication. RN #13 stated the bottle should have been stored in the treatment cart. During an interview on 02/24/2026 at 2:24 PM, Licensed Practical Nurse (LPN) #14 stated wound care supplies should have been locked up inside the treatment cart. LPN #14 stated there should not be any medications inside Resident #22's room. LPN #14 stated wound dressing supplies, which included povidone iodine, were prepared outside the room at the treatment cart, and the bottle should not have been brought or kept in the room. LPN #14 stated there was a potential for harm towards other residents, and they could have developed allergic reactions if exposed. During a telephone interview on 02/25/2026 at 2:00 PM, RN #15, the Certified Wound Care Nurse, stated wound care supplies were supposed to be kept inside the treatment cart. RN #15 stated the povidone iodine should not have been inside Resident #22's room. RN #15 stated that the povidone iodine was a medication and could potentially have caused stomach issues and led to toxicity for confused residents if they drank it. During an interview on 02/26/2026 at 10:45 AM, the Director of Nursing (DON) stated the povidone iodine should not have been inside Resident #22's room. The DON stated for medications to be stored in a resident's room, a doctor's order was required, and the medication should be hidden from view. The DON stated the only reason the bottles of povidone iodine would be in the room was if either the nurse had started wound care or had forgotten to remove it after wound care was completed. The DON stated there was potential for confused, wandering residents to drink the medication and have potential allergic reactions. During an interview on 02/26/2026 at approximately 1:30 PM, the Administrator stated treatment supplies and medications should be locked in treatment carts or the supply room. 2. An observation on 02/25/2026 at 2:43 PM of [NAME] Wing Cart #1 with the Assistant Director of Nursing (ADON) revealed two loose pills with debris from pills and trash in the second drawer of the cart, behind the medication cards and one loose pill in the third drawer with debris from pills and trash. The medication cards were tightly packed in both drawers. During an interview on 02/25/2026 at 2:35 PM, Certified Medication Aide (CMA) #23 stated that each nurse was responsible for keeping the medication carts clean and organized. During an interview on 02/25/2026 at 2:43 PM, the ADON stated there should not be loose pills or trash in the medication carts, and it was each nurse's responsibility to keep the carts clean. The ADON stated the medication cards were in the drawer too tight, which could cause pills to come out of the cards accidentally. She stated overflow medications should be kept in a separate area to allow more room for the cards that were in use, and that would prevent pills from accidentally being popped out of the cards. During an interview on 02/25/2026 at 2:50 PM, Registered Nurse (RN) #22 stated that each nurse was responsible for the medication cart to be clean and organized. She stated there were so many cards in the drawer that it was very hard to get them in and out, and that caused the loose pills in the drawer. She stated loose pills should be removed and disposed of, but she had not noticed them. She stated the cart should be clean and not have trash and dust from pulls in the drawers. During an interview on 02/26/2026 at 1:41 PM, the Director of Nursing (DON) stated medication carts needed to be clean and organized by the nurse. She stated the cart drawers should not be so full that they caused medications to come out of the package. She stated that loose pills, dust from pills, or trash should not be left in the carts. During an interview on 02/26/2026 at 2:37 PM, the Administrator stated medication carts needed to be clean and organized by the nurse and stated they should not be so full that they caused medications to come out of the package. He stated that loose pills, dust from pills, or trash should not be left in the carts.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure physician orders were followed related to the administration of supplemental oxygen for 1 of 5 residents residents sampled for respiratory care (Resident (R)18) of a total resident sample of 24 residents. The findings include: Review of the facility policy titled, Oxygen Administration Policy, revised 05/30/2024, revealed, Purpose: Oxygen therapy is administered as ordered by a physician. Per policy review, Check the resident's medical record to confirm the presence of a complete and appropriate physician's order. Review of the Face Sheet for R18 revealed the facility admitted the resident on 04/10/2024, with diagnoses that included: acute on chronic diastolic (congestive) heart failure (CHF), acute and chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD). Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/17/2024, revealed the facility assessed R18 as having a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. Continued review of the MDS revealed the facility assessed R18 to have shortness of breath with exertion when sitting, and when lying flat and to require oxygen therapy. Review of R18's Comprehensive Care Plan revealed the facility identified a problem dated 04/12/2024, that indicated the resident had impaired oxygen gas exchange related to COPD/respiratory failure/CHF and required oxygen therapy. Continued review of the care plan revealed interventions which included staff to administer R18's supplemental oxygen as ordered (initiated 04/12/2024). Review of R18's physician's Orders revealed an active order for supplemental oxygen to be administered via nasal cannula at 3 liters per minute (L/min) continuously every shift, with a start date of 08/13/2024. Observation on 01/19/2025 at 1:16 PM, revealed R18 in his/her room, seated in a wheelchair, receiving supplemental oxygen via a nasal cannula. Further observation revealed the oxygen concentrator was set at 4 L/min and not the ordered 3 L/min. Review of R18's Medication Administration History, for the timeframe of 01/01/2025 through 01/20/2025, revealed on 01/19/2025, Registered Nurse (RN) 3 (dayshift nurse) and RN 4 (nightshift nurse) both documented administering supplemental oxygen to R18. During interview on 01/20/2025 at 9:19 AM, RN 2 stated R18's supplemental oxygen should have been flowing at 3 L/min. RN 2 stated the nurses needed to check R18's oxygen every morning to see if it flowing at the correct rate. She said she had not checked the resident's oxygen yet that morning. RN 2 reported the nursing staff had orders in the facility's electronic health record (EHR) and the nurses needed to check the orders every morning. She stated the nurses were to sign that they checked the supplemental oxygen rate. Observation at 9:21 AM, revealed RN 2 entered R18's room and confirmed the resident's oxygen concentrator was set at 4 L/min rate and not the ordered 3 L/min rate. In interview, at the time of observation, R18 stated staff turned it up the oxygen when he/she was out of breath. In additional interview, at the time of observation, RN 2 stated the night nurse must have increased R18's supplemental oxygen. Review of R18's Progress Notes, for the timeframe from 01/18/2025 through 01/21/2025, revealed no documented evidence of notification to the physician or Nurse Practitioner (NP), by facility nurses, for the increase in the resident's supplemental oxygen. During telephone interview on 01/21/2025 at 5:01 PM, RN 4 stated R18 should have been on 3 L/min of supplemental oxygen as ordered. RN 4 stated typically, during medication administration, she checked the resident's supplemental oxygen amount to ensure it was flowing correctly. She reported she worked the night shift (6:00 PM to 6:00 AM) on 01/18/2025 and said at the end of her shift, R18 had been in bed and the supplemental oxygen was set at 3 L/min. RN 4 further stated RN 3 had been the RN who worked on 01/19/2025, during the day shift (6:00 AM to 6:30 PM). During telephone interview on 01/21/2025 at 6:00 PM, RN 3 stated she thought R18's supplemental oxygen was to be on 3 L/min. RN 3 said every morning, during medication administration, she checked R18's supplemental oxygen rate and oxygen saturation (O2) rate because the resident had pneumonia. She stated she worked the day shift on 01/19/2025 (when R18's oxygen was at 4 L/min). RN 3 stated R18 asked her about the supplemental oxygen that morning, and RN 3 said she checked the oxygen concentrator, and it was at the prescribed rate of 3 L/min in the morning time. She reported she was not aware of how or why the amount of R18's supplemental oxygen was adjusted differently and stated no other nurse changed the amount. RN 3 further stated she had not contacted the physician to increase the amount of supplemental oxygen. During interview on 01/22/2025 at 10:06 AM, R18 stated he/she did not change the settings on the oxygen concentrator. R18 further stated, I don't mess with the medical stuff. During telephone interview on 01/23/2025 at 3:23 PM, the NP stated the expectation was if resident's supplemental oxygen needed to be increased, the provider or herself needed to be notified. The NP further stated the medical staff did not want a resident to have more supplemental oxygen than needed, to avoid them becoming dependent on the supplemental oxygen. During interview on 01/23/2025 at 2:55 PM, the Director of Nursing (DON) stated nurses were to be checking residents' supplemental oxygen rates when administering medication and when checking on the residents. The DON further stated the nurses should be following the physician's orders. During interview on 01/23/2025 at 4:28 PM, the Chief Executive Officer (CEO)/Administrator stated the nurses should follow the physician's orders to the best of their ability.

Based on observation, interview, facility document and policy review, the facility failed to ensure it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents sampled for enhanced barrier precautions (Resident (R)298) out of a total resident sample of 24. Observation revealed staff failed to wear the proper personal protective equipment (PPE) when providing care to R298, who was on enhanced barrier precautions (EBP). The findings include: Review of the facility policy titled, Enhanced Barrier Precautions Policy, revised 03/25/2024, revealed the facility's infection control policies and practices was intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections. Further review of the policy revealed, 5. EBP are indicated for residents who have chronic wounds and/or indwelling medical devices regardless of MDRO [multi-drug resistant organism] status. Review of an undated facility document titled, Enhanced Barrier Precautions, revealed R298 was on EBP. Review of the Resident Face Sheet for R298 revealed the facility admitted the resident on 01/10/2025, with diagnoses that included fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with healing. Review of R298's Care Plan revealed the facility identified a problem, initiated on 01/13/2025, that noted the resident required EBP related to a surgical incision and an indwelling catheter. Continued review revealed an intervention for staff to wear PPE as indicated (initiated 01/13/2025). Per review additional review of R298's Care Plan, the facility identified a problem for R298 for potential for complications related to an indwelling catheter, initiated 01/20/2025, with interventions that included staff to provide catheter care as needed. Review of R298's Physician Order Report, dated 01/23/2025, revealed an active order, with a start date of 01/13/2025, for the resident to be on EBP due to a surgical incision. Continued review of the Physician Order Report revealed an active order with a start date of 01/20/2025, to change R298's catheter bag as needed and to contact the physician if the indwelling catheter or balloon size needed to be changed. Observation on 01/19/2025 at 1:36 PM, revealed R298's room door had a sign indicating the resident was on EBP and staff were to wear a gown and gloves when completing high-contact resident care activities, that included device care such as urinary catheters. Continued observation revealed however, Certified Nursing Assistant (CNA) 12 emptied R298's urinary catheter bag wearing only gloves. During interview on 01/19/2025 at 1:38 PM, CNA 12 stated she only wore gloves; however, should have worn a gown and gloves as per the resident's EBP. During interview on 01/23/2025 at 3:06 PM, the Director of Nursing (DON) stated she expected staff to wear a gown and gloves when coming in contact with residents on EBP. During interview on 01/23/2025 at 1:46 PM, the Chief Executive Director (CEO)/Administrator stated he expected staff to follow the facility's guidance regarding residents on EBP.

Based on interview, record review, facility document and policy review, the facility failed to maintain a complete and accurate medical record for 1 of 5 residents sampled for unnecessary medications (Resident (R) 18) out of a total resident sample of 24. Observation revealed staff did not accurately document the correct dosage of insulin administered to R18. The findings include: Review of the facility policy titled, Physicians Orders, revised 11/16/2023, revealed it was the facility's standard for physician orders to be followed and reviewed to ensure delivery of applicable care. Continued review revealed staff were to be alert for changes in (a resident's) condition related to new orders, and the need to notify the physician for adverse effects from new orders or potential order changes as needed. Review of the facility document titled, Job Description for Charge Nurse a licensed practical nurse (LPN) or registered nurse (RN), updated December 2011, revealed the Essential Duties & Responsibilities included to Report all discrepancies noted concerning physician's orders, diet change, charting error, etc. [et cetera], to the Nurse Supervisor, Unit Manager or ADON [Assistant Director of Nursing]/DON [Director of Nursing]. Continued review of the Job Description revealed, Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures. Further review revealed, Prepare and administer medication as ordered by the physician. In addition, review revealed the document had been electronically signed by LPN 5 on 10/25/2018. Review of the Face Sheet for F18 revealed the facility admitted the resident on 04/10/2024, with diagnoses that included type 2 diabetes mellitus without complications. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/17/2024, revealed the facility assessed R18 as having intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Further review revealed the facility additionally assessed R18 as receiving insulin injections each day during the seven-day look back period of the Assessment. Review of R18's Care Plan revealed the facility identified a problem, initiated 04/12/2024, for the resident's diagnosis of diabetes and risk for an adverse event. Continued review revealed the interventions (initiated 04/12/2024) which included: staff being alert for signs and symptoms of hypoglycemia/hyperglycemia; completing blood glucose monitoring as ordered; and obtaining laboratory tests as ordered. Review of R18's physician's Orders revealed an active order with a start date of 11/15/2024, for insulin glargine insulin pen, 100 unit/milliliters (u/mL), 3 mL. Further review revealed the instructions noted to administer 35 units under R18's skin at bedtime related to diabetes. Review of R18's Medications Administration History, for the timeframe from 11/01/2024 through 11/30/2024, revealed LPN 5 documented the following glargine insulin pen dosages as administered to the resident: 11/16/2024 - 13 units. 11/17/2024 - 33 units. 11/19/2024 - 33 units. 11/20/2024 - 33 units. 11/22/2024 - 33 units. 11/27/2024 - 33 units. 11/30/2024 - 33 units (not the 35 units as ordered). Review of R18's Medications Administration History, for the timeframe from 12/01/2024 through 12/31/2024, revealed LPN 5 documented the following glargine insulin pen dosages as administered to the resident: 12/01/2024 - 33 units. 12/03/2024 - 33 units. 12/04/2024 - 33 units. 12/10/2024 - 33 units. 12/11/2024 - 33 units. 12/14/2024 - 33 units. 12/15/2024 - 33 units. 12/25/2024 - 36 units (not the 35 units as ordered). During telephone interview on 01/23/2025 at 9:15 AM, LPN 5 stated she had given R18 the correct dosage; however, had entered the wrong dosage amount in the electronic health record. She stated a lot of times she got interrupted, and might have documented an incorrect amount as a result of that. LPN 5 reported R18 did have an order for 33 units at one time; however, knew the correct dose currently was 35 units. During interview on 01/23/2025 at 2:59 PM, the DON stated she expected the documentation in residents' medical records to be accurate.

Based on observation, interview, record review, the insulin manufacturers' instructions for use, and facility policy review, the facility failed to ensure the medication error rate was less than 5%. This was evidenced by 2 medication errors out of 34 opportunities, resulting in a medication error rate of 5.88%, which affected 1 of 5 residents observed during medication pass (Resident (R) 63) out of a total resident sample of 24. The findings include: Review of the facility policy titled, Medication Administration, revised 06/24/2024, revealed, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Further review revealed, Guideline: 1. Medication are administered in accordance with written orders of the prescriber. Review of the facility policy titled, Physicians Orders, revised, 11/16/2023, revealed, the Policy Statement noted, It is the standard of this facility that physician orders are followed, and reviewed to ensure delivery of applicable care. Per review, the facility's standard also included staff being alert for changes in (a resident's) condition related to new orders, and need to notify the physician for adverse effects from new orders or potential order changes as needed. Continued review revealed, Guideline: 1. Each resident will have physician's orders to guide the facility in caring for and treating each resident. 2. Licensed Nurses and Medication Aides are expected to follow physician's orders. Review of the Lantus SoloStar (insulin glargine injection) Instruction Leaflet, revised 11/2018, revealed to follow the instructions completely each time the SoloStar insulin was used to ensure an accurate dose. Per review, if the instructions were not followed a person might get too much or too little insulin, which might affect their blood glucose. Continued review revealed, Important information for use of SoloStar: included, Always perform the safety test before each injection. Review of the Instruction Leaflet revealed, Step 3. Perform a Safety test included Performing the safety test ensures that you get an accurate dose by: - ensuring that pen and needle work properly and remove air bubbles. Further review revealed to select a dose of 2 units by turning the dosage selector; take off the outer needle cap and keep it to remove the used needle after injection; and take off the inner needle cap and discard it. In addition, review revealed to hold the pen with the needle pointing upwards; tap the insulin reservoir so that any air bubbles rise up towards the needle; press the injection button all the way in, and check if insulin comes out of the needle tip; and You might have to perform the safety test several times before insulin is seen. Review of the [NAME] Lilly and Company's website, reference for the Instructions For Use for the Humalog KwikPen, revised 07/2023, revealed, Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you no not prime before each injection, you may get too much or too little insulin. Continued review revealed, Step 6: To prime your Pen, turn the Done Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the tip. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until is stops, and '0' is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the pen. Review of the Resident Face Sheet for R63 revealed the facility admitted the resident on 03/21/2022, with a medical history that included diagnoses of type 2 diabetes mellitus with unspecified complications. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/12/2024, revealed the facility assessed R63 to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. Further MDS review revealed the facility assessed R63 to receive hypoglycemic medication during the assessment timeframe. Review of R63's physician's Orders revealed an active order dated 12/16/2024, for Lantus Solostar U-100 insulin pen, 16 units to be injected under the skin for diabetes mellitus twice a day. Continued review of the Orders also revealed an active order dated 01/22/2025, for Humalog KwikPen Insulin, with instructions to administer per the following sliding scale: - If blood sugar is less than 70, call the physician. - If blood sugar is 200 to 249, give one unit. - If blood sugar is 250 to 299, give two units. - If blood sugar is 300 to 349, give three units. - If blood sugar is 350 to 399, give four units. - If blood sugar is 400 to 450, give five units. - If blood sugar is greater than 450, give five units. - If blood sugar is greater than 450, call the physician. Further review revealed the order included special instructions to give the insulin before meals, at 7:00 AM, 11:15 AM, and 5:00 PM. During observation of medication administration on 01/22/2025 at 7:32 AM, Registered Nurse (RN) 7 checked R63's blood glucose level at 333. Observation at 7:53 AM, revealed RN 7 obtained a Lantus insulin pen that was dated 01/19/2025 and then stated, I immediately turned the dial to 16 units (without performing the safety test as per the manufacturer's instructions). Observation at 8:10 AM, revealed RN 7 administered 16 units of insulin from the Lantus pen to R63 right lower abdomen. During observation of medication administration on 01/22/2025 at 8:26 AM, RN 7 removed the cover from a new Humalog pen and attached a needle. Per observation, RN 7 entered R63's room, dialed the Humalog pen to 3 units and administered the insulin to the resident's left lower abdomen. During interview, at the time of observation, RN 7 confirmed the Humalog pen was new and stated, I shot out six units prior to administering the units. However, observation revealed RN 7 had not primed the insulin pen (as per the manufacturer's instruction) after the needle was attached. During interview on 01/22/2025 at 4:15 PM, RN 7 stated when a new insulin pen was received, that was the only time it was primed with six units. RN 7 stated when a new insulin pen was delivered, there was no specific instructions included, just the pen in a plastic bag, with a label with instructions on dosing. RN 7 reported the insulin pen did not need to be primed any more than what the pharmacy staff stated. The RN further stated if the insulin pen was primed before each use, then you are wasting it. During phone interview on 01/23/2025 at 11:25 AM, the Facility Pharmacist (FP) stated there were specific instructions for each insulin pen and said staff should refer to the manufacturer's instructions. The FP said the insulin pen's contained extra insulin in each vial in order to verify/test it was working properly. Per the FP in interview, the Lantus pen makers always indicated to perform a safety dose check before administering the insulin, by turning the dose selector to two units and holding the pen end up, so any air bubbles would rise up each time. The FP further stated the customary practice for the Humalog insulin was to make sure the needle was on correctly and primed. During phone interview on 01/23/2025 at 3:23 PM, the Nurse Practitioner (NP) stated manufacturers' instructions should be followed regarding preparing insulin pens for resident use. The NP further stated it was expected medications were given as prescribed. During interview on 01/23/2025 at 1:28 PM, the Director of Nursing (DON) stated the expectation was for nurses to follow the physician's orders and guidelines. In interview on 01/23/2025 at 2:46 PM, the Chief Executive Officer (CEO)/Administrator stated it was the expectation that nursing staff followed physician's orders and the manufacturers' guidelines.

Based on interview, record review, review of the facility's policy, and it's Administrator job description, it was determined the facility failed to ensure it was administered in a manner that enabled it to use its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident for two (2) of eighteen (18) sampled residents (Resident #2 and Resident #10). The facility failed to utilize its resources to provide quality care and services to meet the needs of its residents. The facility was cited Immediate Jeopardy in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F656); 42 CFR 483.25 Quality of Care (F684 and F692); and 42 CFR 483.70 Administration (F835). (Refer to F656, F684, and F692) The facility's Administration failed to ensure Resident #2's Comprehensive Care Plan (CCP) reflected the required interventions, to ensure the resident was assessed and treated for hypertension and heart failure. The facility failed to assess Resident #2 after the resident's hypertension medication was held related to the resident's low blood pressure. Certified Medication Technician (CMT) #1, did not notify licensed staff, on [DATE], when she withheld the medication, and did not recheck the resident's blood pressure within thirty (30) minutes. The resident was found unresponsive in his/her room at 5:03 PM and was transferred to the hospital. Resident #2 was pronounced deceased at 6:08 PM at the hospital. The facility admitted Resident #10 to the Long Term Care (LTC) side from the Rehabilitation area of the facility on [DATE]. The Registered Dietician assessed the resident to require 1775 milliliters (ml) of fluids daily to meet his/her daily hydration needs. However, the facility's Administration failed to ensure staff followed the facility's hydration policy. Record review revealed documentation for the month of [DATE], noted the resident's average daily fluid intake was 772 ml and for [DATE], it was 705 ml. However, the facility failed to implement the resident's care plan to prevent dehydration in July and August when the resident did not meet his/her daily fluid intake needs. Record review and interviews also revealed Resident #10, had sixteen (16) days in [DATE], and eighteen (18) days in [DATE], without documentation of bowel movements and no interventions in place. The facility failed to develop Resident #10's CCP; failed to follow its policy and procedures; and failed to put interventions in place to prevent constipation. Subsequently on [DATE], the facility transferred Resident #10 to the Emergency Department for a change in his/her mental status. The hospital admitted Resident #10 and treated him/her for Dehydration, UTI, fecal impaction and Sepsis. The facility readmitted the resident on [DATE]. Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F656) at Scope and Severity (S/S) of J; and at 42 CFR 483.25 Quality of Care (F684) at S/S of J; 42 CFR 483.25 Quality of Care (F692) Nutrition/Hydration Status Maintenance at S/S of J; and 42 CFR 483.70 (F835) Administration at S/S of J. Substandard Quality of Care was identified at 483.25 F684 and F692. The facility was notified of Immediate Jeopardy on [DATE]. An Partial Extended Survey was initiated on [DATE] and concluded on [DATE]. The facility provided a credible Immediate Jeopardy Removal Plan, on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy on [DATE], as alleged, prior to exit on [DATE] with remaining non-compliance at 42 CFR 483.12 Comprehensive Resident Centered Care Plans (F656) at Scope and Severity (S/S) of D; and 42 CFR 483.25 Quality of Care (F684) Quality of Care at S/S of D; 42 CFR 483.25 Quality of Care (F692) Nutrition/Hydration Status Maintenance at S/S of D; and 42 CFR 483.70 (F835) Administration at S/S of D while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systematic changes. The findings include: Review of the facility's Administrator's Job Description, dated [DATE], revealed the Administrator would lead and direct the overall operations of the facility in accordance with customer (residents) needs, government regulations and company policies, with focus on excellent care for residents while achieving the facility's business objectives. Per review, the essential duties and responsibilities of the Administrator included: monitoring and addressing issues that affect performance of the facility; overseeing regular rounds to monitor delivery of nursing care; overseeing the operation of support departments; ensuring cleanliness and appearance of the facility; and morale of staff and ensure residents' needs were addressed. Further review revealed the Administrator was also to meet with department heads and address areas of improvement and have responsibility for the facility's Quality Assurance Program. 1. Review of Resident #2's closed clinical record revealed the facility admitted the resident on [DATE] for rehabilitation services. The failed to develop and implement a Comprehensive Care Plan (CCP) to ensure Resident #2 was monitored for cardiovascular disease and for the administration of the resident's blood pressure medication to include set parameters to withhold the medication in relation to the blood pressure being too low. Review of Resident #2's closed clinical record revealed the facility failed to assess the resident when his/her blood pressure medication was withheld on [DATE]. Record review revealed Certified Medication Technician (CMT) #1 noted she held Resident #2's dose of Hydralazine (medication used to treat high blood pressure) 25 milligrams (mg) because the resident's blood pressure was too low for the second dose, between 11:15 AM to 3:00 PM. However, record review revealed the CMT failed to document Resident #2's low blood pressure, and failed to inform the licensed nurse, so the nurse could recheck the resident's blood pressure within thirty (30) minutes, and conduct any necessary follow up. Further review revealed, on [DATE] at 5:03 PM, Resident #2 was found unresponsive in his/her room and Cardiopulmonary Resuscitation (CPR) was initiated. Record review revealed facility staff called for Emergency Medical Services (EMS). The facility transferred the resident to the hospital. Resident #2 was pronounced deceased at 6:08 PM in the Emergency Department (ED). 2. Interview and record review revealed, on [DATE], Resident #10's son voiced his concerns to the Unit Manager (UM) and Nurse Practitioner (NP) about the resident's appearance and change in behavior. The facility reported labs (laboratory tests) had been ordered urgent around 11:00 AM. However, by 5:00 PM, no labs had been drawn and the NP canceled the order. At 5:15 PM, the Director of Nursing (DON) called the resident's son to inform him Resident #10 was being sent to the ED related to an Altered Mental Status (AMS). The hospital admitted Resident #10 and diagnosed and treated the resident for Dehydration, Urinary Tract Infection (UTI), fecal impaction, and Sepsis. Additionally, within six (6) minutes of arrival to the ED, Resident #10 required Cardioversion/Defibrillation related to Tachycardia (rapid heart rate). Interview, with the Director of Nursing (DON), on [DATE] at 3:45 PM, revealed the facility transferred Resident #10 to the hospital due to altered mental status. Per the DON, otherwise, she would not have sent Resident #10 out to the hospital as the facility was able to administer intravenous fluids (IVFs) and care for Peripherally Inserted Central Catheter (PICC) at the facility. However, record review revealed the resident was admitted to the hospital with diagnoses of Dehydration, Urinary Tract Infection (UTI), fecal impaction, Sepsis and required Cardioversion/Defibrillation related to Tachycardia (rapid heart rate). Interview with the Administrator, on [DATE] at 4:35 PM, revealed he counted on the nursing staff to ensure they assessed residents as they had been trained. He stated assessments were important because they were what determined the care needs of residents. Continued interview revealed assessments had not been identified as an area of concern in the facility's QAPI meetings. The Administrator stated since his background was not in nursing he depended on the DON and the Medical Director to stay on top of the medical concerns within the facility. He stated when a resident had a change of condition one of the medical staff should be contacted, the DON, Nurse Practitioner (NP) or the Medical Director. According to the Administrator, there had been no concerns brought to his attention regarding Resident #2 at any time. He stated he did not know how it was overlooked. However, he believed it had only been a documentation issue and not a concern of the facility's protocol being followed. Continued interview with the Administrator, on [DATE] at 4:35 PM, revealed he was not very familiar with the facility's Bowel and Bladder program. The Administrator stated he expected staff to follow the facility's policies and procedures. He stated it was the responsibility of the aides to document when a resident had a bowel movement or not. Per interview, he was aware the system alerted when a resident went too many days without a bowel movement, and the DON discussed those residents in the clinical meetings. The Administrator stated there were no explanations as to why, Resident #10's condition of fecal impaction had not been identified and addressed before the resident ended up in the hospital. He stated the facility was unable to explain its failure. An additional interview with the Administrator on [DATE] at 1:30 PM, revealed the facility ensured each resident maintained their highest practicable physical, mental and psychosocial well-being through following the care plan and ensuring the resident and family were involved in the development of that care plan. Per the Administrator, it was important for the facility, the resident, and the family to frequently revisit the care plan and evaluate where the resident wanted to go with their care. He stated the expectation of staff was for them to ensure all residents were provided a good and healthy atmosphere, homelike environment and a great experience. Further interview revealed he expected all staff to follow the facility's policies and procedures and he also expected the DON to ensure the nursing staff did so. The Administrator stated when a staff member signed their job descriptions that validated they had read and understood what their job duties entailed and that they were able to meet those duties. In addition, he stated the facility needed to do a better job on documentation; however, no other concerns had been identified. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #10's Comprehensive Care Plan was reviewed and revised by the Regional Clinical Reimbursement Specialist (RCRS), with the DON, ADON, Unit Manager (UM) and resident and family giving input. Resident #10 was re-assessed, and his/her Comprehensive Care Plan was thoroughly reviewed and revised to ensure the resident maintained the highest practicable physical, mental, and psychosocial well-being. A care plan conference was held with Resident #10, his/her family and the IDT all in attendance. 2. The RCRS completed an audit of all residents' Comprehensive Care Plans beginning on [DATE], validating that the Comprehensive Care Plan was current and accurate and included: risk for dehydration, current diagnoses, medication, contractures, constipation and/or Change of Condition (COC). This audit was completed on [DATE]. Any areas identified were revised immediately and communicated to the floor staff through daily huddles (licensed staff, aides and Certified Medication Technicians (CMT)). 3. On [DATE], the RCRS completed education with both MDS Coordinators and the IDT on accurate and complete Comprehensive Care Plans. On [DATE], Regional Nurse Consultant (RNC) #1 and Regional Staff Development Coordinator (RSDC) initiated education for licensed nurses on accurate and complete Comprehensive Care Plans. This education was completed on [DATE]. 4. The CMT received performance improvement regarding medication administration and notification of a change in condition to the licensed nurse. 5. The Medical Director (MD) and Registered Dietitian (RD) #1 assessed Resident #10's hydration and bowel status. Recommendations were communicated to the resident's family and the care plan was reviewed and/or revised as needed. The Medical Director ordered a Complete Blood Count (CBC), Basic Metabolic Panel (BMP) and Thyroid Stimulating Hormone (TSH) blood draws for Resident #10 on [DATE]. 6. Occupational Therapy (OT) attempted an evaluation of Resident #10's bilateral upper extremity contractures. The resident refused the OT evaluation and services on [DATE]. 7. On [DATE], all residents had a hydration risk assessment completed by the DON, Unit Manager (UM), ADON, Staff Development Coordinator (SDC), or the Medical Records Nurse to identify any residents at risk of dehydration. Any residents identified at risk were communicated to the Registered Dietitian (RD) and the Nurse Practitioner (NP). 8. On [DATE], the RD completed a review of all the residents' hydration needs to ensure accurate and current interventions were care planned and updated if necessary. At risk residents were assessed by the NP, orders put in place and the family notified. Residents were to be transferred to the hospital if required. This was completed on [DATE]. Starting [DATE], one (1) of the four (4) RDs was to be at the facility twice a week and one (1) was to be available seven (7) days per week to review residents at risk related to hydration adequacy. Starting [DATE], an RD was to be accessible to the facility seven (7) days a week to review any residents at risk for dehydration needing to be evaluated. 9. On [DATE], audits were completed by the DON, UM, ADON, SDC and Medical Records Nurse on all residents to validate a bowel movement had occurred within the last three (3) days and the provider notified as necessary for intervention. 10. On [DATE], an audit was completed by the Restorative Nurse of all residents to identify any residents with contractures present. Any resident with contractures was referred to therapy and a care plan implemented for contractures. 11. On [DATE], the Independent Risk Manager completed audits of all residents with orders for a blood pressure medication, The audit validated the orders for parameters and when to hold blood pressure medication had been implemented. Any areas identified were corrected immediately and communicated to the NP and/or Physician. 12. On [DATE], audits were completed, by [NAME] President of Clinical Operations (VPCO) #2, of all residents' vital signs to validate if any resident with blood pressure medication had their medication withheld due to their blood pressure being above or below the parameters. Any areas identified were corrected immediately and communicated to the NP and/or Physician. 13. Education was provided to all staff members initiated on [DATE] and completed on [DATE]. Reeducation was completed by RNC #1 with all licensed staff and other nursing staff to include the aides and certified medication technicians. The education covered hydration, how to monitor residents' intakes, Bowel Movement (BM) Policy, Bowel Movement monitoring, Change of Condition (COC), and communicating the COC. 14. Starting [DATE], licensed nurses were to review the BM management report and initiate any bowel interventions if needed and notification to the Physician seven (7) days per week until the immediacy was removed. Starting [DATE], the DON, ADON, UM, RD and NP reviewed all residents' intake seven (7) days per week until immediacy was removed. If further assessment was necessary, the NP or Physician was to be notified. 15. Starting [DATE], the NP was to be available at the facility five (5) days a week for evaluation of any resident with decreased oral intake, at risk for dehydration, assessment for a COC related, but not limited to, hydration, blood pressure changes and bowel status. The DON, ADON and UM were to communicate with the NP seven (7) days per week until immediacy was lifted. 16. The VPCO educated the facility's Administrator, Medical Director, Regional Nurse Consultant and DON on CMS regulations F656, F684, F692 and F835 on [DATE]. Starting [DATE], the facility's consultant, regional team member or the VPCO provided daily administrative oversight seven (7) days per week to the facility and was to continue in person or by telephone until immediacy was removed. On [DATE], the facility had a Regional Clinical Nurse, consultant and/or VPCO provide oversight daily and provide support, resources, and guidance until immediacy was lifted. In addition, the regional team members or VPCO assisted in ensuring an effective jeopardy removal plan was in place, and ensured an effective plan of correction was developed and implemented. 17. Findings of the audits was to be presented to the facility's Quality Assessment and Performance Committee (QAPI) consisting of the Executive Director (ED), DON, and Medical Director, daily until the immediacy was removed, then monthly. The QAPI Committee was to determine when compliance was achieved and/or if ongoing monitoring was required. An AD HOC Quality Assurance meeting was held on [DATE] and [DATE], in regards to the Immediate Jeopardy identified. The State Survey Agency validated the facility took the following actions: 1. Review of Resident #10's medical record on [DATE], revealed the resident's care plan had been reviewed and revised for each section of concerns. Changes were made to add new interventions for hydration, contractures and bowel management, which was completed on [DATE]. Interview with the Unit Manager on [DATE] at 11:00 AM, revealed there had been multiple people who looked at Resident #10's chart and made changes. Per interview, Resident #10 was re-assessed, and staff were informed of changes to his/her care plan at the morning huddle, and/or staff looked in the huddle binder to review any changes. She stated she was reeducated on the care required for Resident #10, in reference to hydration, bowel status and contractures. Per interview, the ADON was out on vacation and therefore, was not interviewed. Interview with the DON, on [DATE] at 2:14 PM, revealed Resident #10's care plan was reviewed and/or revised at the care plan meeting held on [DATE]. She stated Resident #10's family member was present at the care plan meeting held on [DATE], and he was informed of all concerns regarding the resident and of the new interventions implemented. She stated the Physician did a full regular exam of Resident #10 on [DATE], and Registered Dietitian (RD) #1 reassessed the resident's hydration status on that same date. Per the DON, the Psychiatrist recommended changes to Resident #1's medication after being informed the resident was being too sleepy. She expressed each department reviewed their section of the resident's care plan and made the determinations of whether any changes were needed. Interview with the RCRS on [DATE] at 3:37 PM, revealed Resident #10 was reassessed due to a change of condition regarding his/her hospitalization on [DATE]. Per interview, she reviewed Resident #10's assessment and made changes to his/her care plan. She further revealed Resident #10's MDS Assessment was reviewed to ensure the care plan matched the resident's needs. 2. Review of the facility's documentation revealed a list of all residents in the facility, with their names and room numbers noted. Interview with the RCRS, on [DATE] at 3:37 PM, revealed she met with the MDS Coordinators and they completed the audit of each resident's care plan. She stated residents' MDS Assessments were also reviewed and compared to their care plans to ensure the two (2) matched and were current for the residents. Further interview revealed she did a lot of revisions to care plans and the findings of the audits were discussed in the morning clinical meetings. The RCRS further stated by [DATE], all residents' care plans had been reviewed and/or revised. 3. Review of the facility's documentation revealed a signature sheet, dated [DATE], noting the RCRS trained both MDS Coordinators on ensuring residents' care plans were complete and accurate. Continued review revealed the RCRS trained the MDS Coordinators on ensuring any complications a resident experienced related to a diagnosis was care planned. Record review revealed the RCRS trained the MDS Coordinators to ensure residents who were at risk for dehydration, constipation, or who had contractures had their care plans updated during the facility's morning clinical meetings if problems were identified. Further review revealed the RCRS's training included the MDS Coordinators ensuring they reviewed residents' admission/readmission hospital records for any new changes that needed to be added to the residents' care plans. Record review revealed the RCRS's training additionally included educating the MDS Coordinators on care plan development and revision of residents' care plans as needed. Interview with MDS Coordinator #1 on [DATE] at 11:30 AM, revealed she was reeducated by the RCRS and several other regional staff members on many different subjects. MDS Coordinator #1 stated the education she received included ensuring residents' care plans were accurate and complete, and for the nurses to review the care plans and note each residents' required specialized care needs. She revealed she had been educated to ensure residents' care plans and MDS Assessments matched for accuracy in provision of resident care. Continued interview revealed she had been educated that the facility had new bowel and hydration protocols in place, and the Registered Dietitian was responsible for updating residents' care plans related to hydration. She further stated she was reeducated on her responsibility for updating residents' care plans related to elimination. In addition, she stated she was reeducated on determining if a resident was incontinent or continent of bowel and bladder, and then to update the resident's care plan accordingly. MDS Coordinator #2 was not available for interview due to being on vacation. Interview with the RCRS, on [DATE] at 3:37 PM, revealed she provided the reeducation for both MDS Coordinators and completed the audit of all the residents' care plans. She stated residents' care plans were based on what the residents' assessments determined as all residents were different. Per interview, the RCRS and MDS Coordinators reviewed residents' assessments and made any necessary changes to the care plans at that time. The RCRS stated the audit findings were discussed in the facility's daily morning clinical meetings. Further interview revealed she reeducated staff face-to-face and performed some follow-up reeducation by phone with staff. In addition, she stated all care plan audits were completed by [DATE] and reflected all residents' current status. Interview with Licensed Practical Nurse (LPN) #10 on [DATE] at 9:45 AM, revealed she had been reeducated on changes in care plans by ensuring she read residents' care plans and looked at the nursing report. She stated she received education on ensuring residents' care plans were accurate and their care plans were complete. Interview with LPN #6, on [DATE] at 10:16 AM, revealed nursing staff were reeducated one (1) to two (2) weeks ago on ensuring residents' care plans were accurate and complete by the Regional Nurse Consultant and Regional Clinical Reimbursement Specialist (RCRS). Interview with Regional Nurse Consultant (RNC) #1, on [DATE] at 3:51 PM, revealed she provided training to the Certified Medical Technicians (CMTs), Medical Records Nurse, UM, ADON, DON, Nurse Practitioner (NP), Nurses, State Registered Nursing Assistants (SRNA) and Registered Dietitians (RDs). Per interview, most of the training had been face-to-face; however, any employee not available in person received the training by telephone. She stated the training covered hydration, care planning, monitoring fluid intake, review of the facility's bowel movement policy and protocol, blood pressure monitoring, withholding blood pressure medication, change of condition, and communication of change in condition. Further interview revealed she re-checked staff's knowledge after the training with a posttest. 4. Review of the facility's General Medication Administration Competency training, dated [DATE], revealed CMT #1 had completed the competency training on checking the medication administration sheet, following the directions of the medication (such as shaking), and confirming the resident's identity by using two (2) identifiers. Per review, the competency training CMT #1 received also included ensuring the nurse was notified of a change of condition in a resident. Continued review revealed the training additionally included charting the medications after given, and monitoring for side effects of the medication given. Review further revealed CMT #1 completed a competency supervised by the Staff Development Coordinator and both had signed the competency training sheet on [DATE]. Interview with CMT #1, on [DATE] at 2:21 PM, revealed she received training on making sure if she held residents' blood pressure medications to report that information to the nurse on duty and recheck the resident's blood pressure again. Per interview, the training had been for performance improvement. She further stated she had also completed all the required training with the rest of the staff as well. 5. Review of Resident #10's clinical record revealed the Medical Director completed a physical examination of the resident on [DATE] at 10:58 AM. Per review, the chief complaint noted for Resident #10 was documented as weakness and poor oral intake. Continued review of the Medical Director's examination documentation revealed he noted Resident #10 was not in any acute distress, and his/her oral mucosa was moist. Further review revealed the Medical Director assessed Resident #10's to have a soft abdomen, which was non-tender and his/her bowel sounds were present. Continued review of Resident #10's clinical record revealed a copy of the resident's laboratory (lab) report, dated [DATE], which included results for CBC, BMP and TSH lab testing. Review of a Progress Note, by the Medical Director, revealed the lab results were received on [DATE] and the results of the lab testing were documented. Additional review of Resident #10's clinical record revealed a Progress Note completed by Registered Dietitian (RD) #4, on [DATE] at 4:50 PM. Per review, the RD's assessment tool utilized noted Resident #10 to be a medium risk for dehydration, and therefore was referred for additional review by the RD. Record review revealed the RD lowered Resident #10's daily recommended fluid intake to ,d+[DATE] milliliters (ml) per day. Interview with the Medical Director, on [DATE] at 11:20 AM, revealed he completed a full medical evaluation of Resident #10 on [DATE], and ordered lab testing which included a BMP, CBC, and TSH. He stated he had not identified any concerns at the time of Resident #10's physical evaluation. He further stated he had agreed with the RD's dehydration risk assessment for Resident #10. In addition, he stated he had been pleased with the resident's lab results and felt no new recommendations were needed. 6. Review of Resident #10's clinical record revealed an Occupation Therapy (OT) Evaluation, dated [DATE], which documented the resident's refusal of a OT evaluation. Continued review of the OT Evaluation documentation, dated [DATE], revealed Resident #10 had received OT services from [DATE] to [DATE]. 7. Review of the facility's hydration evaluation tool documentation, dated [DATE], revealed all residents had been assessed by the DON, UM, ADON, SDC, or Medical Records Nurse to assess each of the residents to determine if they were low, medium or high risk for dehydration. Per review, residents who scored as medium or high risk were forwarded to the RDs for an assessment, who notified the NP of any concerns. Interview with the Medical Records Nurse Manager, on [DATE] at 1:54 PM, revealed she assisted with assessing the facility's residents for their hydration risks. Per interview, she completed the audit forms after assessing residents. Interview with the UM, on [DATE] at 11:00 AM, revealed she assisted, as a part of the team, in getting all residents assessed for their hydration risks. According to the UM, she helped tally up the residents who were forwarded to the RD after the assessment. She further stated she had forwarded two (2) new residents who had been assessed to be at risk for dehydration. Interview, with the SDC on [DATE], at 11:48 AM, revealed she helped assess residents to determine who was at risk for dehydration. She stated she completed assessments of residents on the weekends when she was the weekend supervisor. The SDC stated many residents were assessed as not drinking enough fluids daily, so staff were educated on encouraging the residents to drink fluids throughout the day. She further stated any residents assessed as at risk were forwarded to the RD for further evaluation. An attempt to interview the ADON was unsuccessful as she was on leave per management staff. Interview with the DON, on [DATE] at 2:14 PM, revealed she assisted other management staff to assess all residents and ensure their hydration risks were documented. She stated any resident found to be at a medium or high risk were referred for further assessment by the RD and NP. The DON stated she guessed about twenty (20) residents required additional assessment by the RD and/or NP, with no major concerns identified. 8. Review of residents' clinical records revealed Progress Notes documenting residents identified as at risk for dehydration had been assessed by an RD on [DATE] and [DATE]. Further clinical record review revealed the NP assessed residents who required additional assessment with recommendations made based on the NP's assessments. Interview with RD #1 on [DATE] at 3:06 PM, revealed she had looked at residents, who were identified as at risk for dehydration and required an additional assessment based on being assessed as a medium or high risk for dehydration. She stated she determined residents' total daily fluid intake requirements, and further explained that was decided based on several different factors for each resident. RD #1 further stated she was at the facility twice a week and could always be reached by phone if the facility needed additional assistance. The RD stated nursing staff reviewed the residents' intakes and if they noted decreased intakes they notified the RDs to investigate. Continued interview revealed an RD was at the facility seven (7) days per week. Further interview revealed if a resident did not meet his/her daily assessed fluid needs, the RDs evaluated the resident and put additional interventions in place as necessary. Interview with RD #2, on [DATE] at 2:28 PM, revealed she had been onsite helping review all the residents' hydration needs. Per interview, after the RD team assessed residents identified as at risk for dehydration had been referred to the RDs. Continued intervi [TRUNCATED]

Based on observation, interview, record review and facility policy review, it was determined the facility failed to provide the necessary hydration care and services to ensure residents' assessed hydration needs were met for one (1) of eighteen (18) sampled residents (Resident #10). Interview with the Nurse Practitioner (NP) on 08/30/2022 at 9:24 AM, revealed Resident #10's son had been concerned about the resident's behavior and how he/she looked on 08/29/2022. She stated she assessed Resident #10; however, she had not reviewed the resident's oral intake. The NP stated she would only have reviewed the resident's input and output if nursing staff had brought it to her attention. Per the NP, Resident #10 was sent out to the ED on 08/29/2022, because of his/her altered mental state. Interview with Resident #10's son revealed, on 08/29/2022, he voiced concerns to the Unit Manager (UM) and Nurse Practitioner (NP) about the resident's appearance and change in behavior. At 5:15 PM, the Director of Nursing (DON) called the resident's son to inform him Resident #10 would be sent to the ED related to an Altered Mental Status (AMS). However, the hospital admitted the resident and treated him/her for dehydration, Urinary Tract Infection (UTI), fecal impaction,and Hypernatremia (excess sodium in the blood) and sepsis. Additionally, within six (6) minutes of arrival to the ED, the resident required Cardioversion/Defibrillation related to Tachycardia (rapid heart rate). Immediate Jeopardy (IJ) was identified on 09/20/2022 and determined to exist on 12/09/2021 at 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F656) at Scope and Severity (S/S) of J; and at 42 CFR 483.25 Quality of Care (F684) at S/S of J; 42 CFR 483.25 Quality of Care (F692) Nutrition/Hydration Status Maintenance at S/S of J; and 42 CFR 483.70 (F835) Administration at S/S of J. Substandard Quality of Care was identified at 483.25 F684 and F692. The facility was notified of Immediate Jeopardy on 09/20/2022. An Partial Extended Survey was initiated on 10/03/2022 and concluded on 10/07/2022. A Partial Extended Survey was concluded on 10/07/2022. The facility provided an Acceptable Immediate Jeopardy Removal Plan, on 09/23/2022. The State Survey Agency validated the Immediate Jeopardy had been removed on 10/07/2022 as alleged, before exit on 10/07/2022. The facility's non-compliance remained at 42 CFR 483.12 Comprehensive Resident Centered Care Plans (F656); 42 CFR 483.25 Quality of Care (F684) and Assisted Nutrition and Hydration (F692); and 42 CFR 483.70 (F835) Administration, all at a Scope and Severity (S/S) of D; while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systematic changes. The findings include: Review of the facility's policy, Hydration, dated 06/27/2018, revealed residents were to receive sufficient amounts of fluid to maintain proper hydration. Per review, staff was to offer fluids to residents between meals, at mealtime, during activities and before bedtime and at bedtime. Further review of the policy revealed changes in a resident's hydration was to be assessed by nurses; and, the Dietitian was to assess residents quarterly for hydration adequacy or more often as per the resident's need. Review of the facility's policy, titled Assistance with Meals, revised 06/27/2018, revealed residents shall receive assistance with meals in a manner that met the individual needs of each resident. Facility staff would serve meals and assist residents who required assistance with eating. Residents who could not feed themselves would be fed with attention to safety, comfort and dignity. Review of the facility's policy titled, Bowel and Bladder Management, revised 07/19/2018, revealed the facility was to evaluate, monitor and track residents' bowel and bladder patterns and identify the need for early intervention. Policy review revealed the facility was to evaluate residents upon admission, readmission, quarterly, annually and with significant changes. Further review revealed for incontinent residents, a baseline was to be established and the Interdisciplinary Team (IDT) was to determine if a pattern might be determined. In addition, policy review revealed the care plan was to be updated to reflect the results and interventions put in place. Review of Resident #10's clinical record revealed the facility admitted the resident on 05/13/2022. Review of Resident #10's Admission MDS Assessment, dated 05/20/2022, revealed the facility admitted the resident with diagnoses that included metabolic encephalopathy, constipation, muscle weakness, retention of urine and cognitive communication deficit. The facility assessed the resident with a BIMS' score of twelve (12) out of fifteen (15) and determined the resident was interviewable. The facility assessed the resident to require two (2) staff for transfers and the assistance of one (1) staff for bed mobility, dressing, eating, toileting, and personal hygiene. Upon admission, the resident had an indwelling urinary catheter and was noted to always be incontinent of bowel and bladder. Further review of the MDS revealed the resident was free of upper/lower impairments to any extremities and had the ability to use a wheel chair for mobility. Review of Resident #10's Comprehensive Care Plan, dated 05/16/2022, revealed the facility assessed and care planned the resident as at nutrition and/or hydration risk related to being a new admission. Review of the care plan revealed the Nurse Practitioner (NP) and the Registered Dietitian (RD) were to monitor Resident #10 for signs and symptoms of dehydration. Additionally, record review revealed the goal was for Resident #10 to remain adequately hydrated as evidenced by good skin turgor, pink and moist mucous membranes and sufficient fluid intake. Review of the Medical Nutrition Therapy Evaluation for Resident #10, dated 05/23/2022, completed by the Registered Dietitian (RD) revealed Resident #10 was to remain free from decreased food intake, and not to have weight loss. Continued review revealed based on the RD's assessment, the expectation was for Resident #10 to eat 75-100% of meals and have a daily fluid intake of 1773 milliliters (ml). Review of Resident #10's Medical Nutrition Therapy Evaluation, dated 05/25/2022, revealed Registered Dietitian #1 assessed the resident to require 1773 millimeters (ml) of fluids daily. However, review of Resident #10's documented fluid intake for July 2022 revealed a daily average intake of 772 ml. Review of the Vitals/Fluid section of Resident #10's clinical record revealed the resident's documented daily fluid intake for July 2022 was an average of 772 ml which was 1,001 ml less than the RD's assessed need. Continued review of Resident #10's Vitals/Fluid clinical record revealed Resident #10's documented daily fluid intake average for August 2022 was 705 ml which was 1,068 ml less than the resident's assessed daily requirement need. In addition, clinical record review revealed no documented evidence licensed staff monitored and assessed Resident #10's daily fluid intake. Review of Resident #10's Vitals Report for July 2022, revealed the resident was absent a bowel movement on 07/01, 07/02, 07/03, 07/06, 07/07, 07/08, 07/09, 07/10, 07/11, 07/14, 07/16, 07/26, 07/27, 07/29, 07/30 and 07/31 without interventions put in place, per the facility's Bowel and Bladder protocol. Review of the Hospital Discharge Summary, dated 07/25/2022, revealed the resident was hospitalized on [DATE] to 07/25/2022 for dehydration, UTI and Clostridium difficile (C diff). Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/01/2022, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) which indicated moderate cognitive impairment. However, the resident was interviewable. Further review revealed the facility assessed Resident #10 to have one (1) side upper extremity impairment and to require one (1) staff person's assistance for eating. Review of Resident #10's Vitals Report Fluid Intake section, revealed the resident's documented daily average fluid intake for August 2022, was 705 ml per day. However, their was no documentation that licensed staff monitored and assessed the resident for signs and symptoms of dehydration based on the resident not meeting the assessed daily fluid intake. Review of the Vitals Report for Resident #10 for August 2022, revealed the resident was absent bowel movements on 08/01, 08/02, 08/03, 08/04, 08/06, 08/07, 08/08, 08/11, 08/12, 08/15, 08/17, 08/18, 08/19, 08/21, 08/22, 08/23, 08/25, 08/26, 08/28 and 08/29. Further review revealed the facility failed to put interventions in place to address this problem, as they should per the facility's Bowel and Bladder protocol. Review of Resident #10's medical history documented by the Medical Director upon admission, revealed the resident had a history of constipation. Review of Resident #10 vitals for bowel movements in July 2022, revealed the resident had sixteen (16) days without a bowel movement and without additional interventions put in place. Review of the resident's vitals report for bowel movements for August 2022, revealed the resident had eighteen (18) days without bowel movements in which additional intervention were not put in place. Observation of Resident #10 on 08/23/2022 at 1:17 PM, and at 3:52 PM, revealed the resident lying on his/her bed with his/her arms across his/her chest. Continued observation revealed Resident #10's overbed table was positioned next to the resident's bed with a cup of water on it; however, the cup was out of the resident's reach Interview with Resident #10's son on 08/29/2022 at 9:25 AM, revealed he had taken Resident #10 to a doctor's appointment on 07/22/2022 and while checking the resident in for the appointment, the resident began to vomit and became somewhat unresponsive for about thirty (30) seconds. Continued interview revealed Resident #10's son pushed the resident over to the hospital ED to have him/her assessed. Resident #10's son stated Resident #10 was admitted to the hospital and treated for Dehydration, a UTI, and C. diff (bacterium that causes diarrhea). Interview revealed Resident #10 was discharged from the hospital and returned to the facility on [DATE]. Observation of Resident #10, on 08/29/2022 at 3:40 PM and at 5:00 PM, revealed the resident lying on his/her bed with eyes closed. Continued observation revealed Resident #10's skin color appeared [NAME] than in the previous observations on 08/23/2022. Per observation, Resident #10's overbed table was positioned near the bed with a cup of water on it; however, it was out of the resident's reach. Interview with Licensed Practical Nurse (LPN) #10 on 08/29/2022 at 5:00 PM, revealed this was the first day she had cared for Resident #10 and did not know him/her. LPN #10 further stated two (2) other nurses had checked on Resident #10 earlier around 11:00 AM because the resident's son had been worried about how the resident was acting. Continued observation of Resident #10 on 08/29/2022 at 5:00 PM, revealed the Director of Nursing (DON) entered the resident's room and informed the State Survey Agency (SSA) Surveyor that urgent labs had been ordered that morning for the resident. The SSA Surveyor asked LPN #10 about Resident #10's vital signs (vitals) and the LPN stated she still needed to get them. Interview with LPN #10 further revealed Resident #10's vitals that morning had been: blood pressure was 139/82; heart rate was 118; temperature was 98.2; and his/her oxygen saturation (O2 sats) was 93 percent. Review of the Nurse Practitioner's (NP) Progress Note, dated 08/29/2022, revealed Resident #10's son reported the resident was not acting like himself/herself, not wanting to eat or drink for him that morning, and appeared sleepy. Per review, during the NP's exam Resident #10 opened his/her eyes to voice, and screamed out when touched. Continued review revealed Resident #10 agreed to allow the NP to examine him/her; however, when the NP tried to auscultate his/her lungs, the resident started screaming and stated I hurt. Review of the Progress Note revealed when the NP asked Resident #10 where he/she hurt, the resident stated all over. Further review revealed the NP assessed Resident #10's skin as warm and dry to touch, no cyanosis noted, overall appearance pale in color which was the resident's baseline. Further review revealed the NP had discussed, with the resident's son, ordering laboratory (lab) tests to include a Complete Blood Count (CBC), Basic Metabolic Panel (BMP), and a Urinary Analysis (UA) to rule out any acute illnesses. Additional review revealed Resident #10's son was agreeable to the NP's plan of care, and reported he did not want the resident sent out at this time. Interview with Resident #10's son, on 08/30/2022 at 7:50 PM, revealed the Director of Nursing (DON) informed him that the resident was admitted to the hospital again on 08/29/2022 for a UTI, and C. diff. The resident's son stated, Resident #10 was really bad this time. He stated about one (1) week ago he discussed his concerns about Resident #10 and the resident's inability to feed himself/herself with facility staff. He stated he asked the facility to provide Resident #10 help to eat and drink. Continued interview revealed Resident #10 had told him that staff would not help him/her eat or drink. Resident #10's son stated he visited the resident in the mornings to help him/her drink water. He stated he tried to get to the facility daily because if he missed a day, Resident #10 looked dehydrated when he returned to visit. Further interview revealed the resident's son stated he was present the morning of 08/29/2022 and had been concerned about how Resident #10 looked and behaved. Per the son, he told the Nurse Practitioner (NP) and DON on 08/29/2022, he was worried that Resident #10 might be dehydrated. Further interview revealed the NP told him she would have labs drawn on Resident #10 to check his/her blood. He further revealed he was an Emergency Medical Technician (EMT) and would never tell the facility not to send Resident #10 out to the hospital ED for evaluation. Interview, with FM (Family Member/Son) #3, on 08/30/2022 at 7:50 PM, revealed the facility had called him and informed him Resident #10 had been admitted to the hospital for a UTI and C diff. He stated he was aware when the resident had a UTI as the resident's behaviors changed, but he/she was really bad this time. FM #3 stated he talked with management about getting help feeding the resident because he/she could not eat or drink on his/her own about one (1) month ago. He stated, on 08/29/2022, he told the NP he was concerned about his family member being dehydrated and the NP had ordered labs. He said, he expected the facility to send his family member out to the hospital if it was needed. Review of Resident #10's hospital Admission Records, for 08/29/2022, revealed the resident arrived at the Emergency Department (ED) at 7:04 PM. Continued review revealed the hospital admitted Resident #10, on 08/29/2022, with diagnoses which included: Dehydration, Sepsis, UTI and Fecal Impaction. Further review revealed Resident #10 was discharged back to the facility on [DATE]. Observation, of Resident #10 on 09/07/2022 at 10:00 AM, revealed the resident was lying on his/her bed and asked the SSA Surveyor to give him/her a drink. Per observation, Resident #10's touch pad call light was near the resident's right elbow, and he/she was not able to locate the call light. Interview with Regional Nurse Consultant (RNC) #1, at the time of observation, revealed Resident #10 could not use his/her call light. Observation revealed RNC #1 told Resident #10 to call out for help if the resident was not able to push the call light when needing assistance. RNC #1 assisted the resident with a drink of water before she left the resident's room. Observation, of Resident #10 on 09/08/2022 at 9:05 AM, revealed the resident made a crying sound and stated, my butt hurts and asked if he/she could have a drink of water. Continued observation revealed Resident #10 asked the SSA Surveyor, Can you give me a drink of water? The SSA Surveyor asked Resident #10 if he/she could use his/her call light to call for assistance in getting a drink of water; however, the resident stated he/she could not see his/her call light. The SSA Surveyor found an aide who assisted Resident #10 with some water. Observation of Resident #10 on 09/13/2022 at 8:45 AM, revealed Resident #10's son was present in the resident's room. Interview with the son, at the time of observation, revealed Resident #10 was not able to drink without assistance. A follow up interview with Resident #10's son (Family Member #3) on 09/11/2022 at 12:50 PM, revealed when the resident moved from the facility's rehabilitation side to the Long-Term Care (LTC) side of the facility, he talked with the staff about the resident's ability to use only his/her right hand. He stated he currently was still very concerned about Resident #10's fluid intake because he/she could not drink fluids or eat without assistance. Continued interview revealed the facility talked about the possibility of a feeding tube being needed down the road and he told the staff he did not understand why. The son stated Resident #10 ate regular food with no problem, it was just that he/she did not have the ability to eat or drink on his/her own. Per interview, Resident #10's son stated he had to physically hold the cup up to the resident's mouth for him/her to take a drink. Further interview revealed Resident #10's son did not understand why it was considered a behavior to need help to eat and drink. He stated he did not understand how Resident #10 was different from any other resident in the facility that required such assistance. Interview, with Hospitality Aide (HA) #1, on 09/15/2022 at 11:48 AM, revealed Family Member #3 (Resident #10's son) visited daily. She revealed Resident #10 could not use his/her sippy cup to get a drink and could not eat without staff's assistance. Interview, with PCA (Personal Care Aide) #1 on 09/14/2022 at 7:21 PM, revealed Resident #10 was unable to drink fluids by himself/herself, and was currently totally dependent for staff. She stated Resident #10 always asked her to give him/her drinks of fluids. Interview, with SRNA #1 on 08/12/2022 at 2:41 PM, revealed it was her job to track the amount of fluids each resident drank throughout the day and to ensure it was documented in the system. She stated when she was aware that a resident did not take in their daily fluids, she reported that information to the nurse. She stated if a resident did not have a bowel movement, the nurse needed to know and it needed to be documented in the resident's medical record too. Interview, with State Registered Nurse Aide (SRNA) #8, on 09/09/2022 at 11:35 AM, revealed Resident #10 did not have the ability to hold a cup or fork. She stated about a month ago Resident #10 needed assistance with eating and drinking. SRNA #8 stated she would report it to the nurse, but she was not sure what was done about it. She stated she documented when the resident did not have a bowel movement and notified the nurse on duty. Interview with State Registered Nursing Aide (SRNA) #12, on 09/09/2022 at 11:35 AM, revealed she provided care for Resident #10 on 08/29/2022. She stated the DON called her the next day and asked if what was documented in the resident's medical record (vitals section) was accurate for the resident's intake and output. She informed the DON the resident had not had a bowel movement on 08/29/2022 and she had informed LPN #10. Interview with SRNA #12, on 09/15/2022 at 12:08 PM, revealed if a resident did not have a bowel movement during the shift, she would not document that in the file. She stated she would tell the nurse before she left for the night. She stated Resident #10 was pretty confused before he/she was sent to the hospital on 08/29/2022. SRNA #12 stated she informed the nurse that day, that the resident had not had any output (urine or bowel movement). The SRNA stated when she checked on residents she would encourage them to drink. She stated it was the responsibility of the aides to document the resident's fluid intake, outputs and meal intakes each day. Interview, with SRNA #10, on 09/09/2022 at 2:21 PM, revealed staff had to assist Resident #10 with eating and drinking. SRNA #10 said if there was no one in the room and the resident could not use the call light he/she would call out for help. She revealed the resident could not get his/her call light to work if it was not in the right position. Interview, with Registered Nurse (RN) #10, on 09/15/2022 at 3:15 PM, revealed each day the Unit Manager provided nurses with a printout for all residents which documented fluid intake and bowel movements for the resident the day prior. She stated nursing staff were to follow up with each resident, who had not met his/her daily fluid intake needs or had (2) or three (3) days without a bowel movement. RN #10 stated nursing staff was expected to document when a resident was given extra fluids. She stated the sheets that showed the previous day's fluid intake were not passed out until noon. Continued interview with RN #10, on 09/15/2022 at 3:15 PM, revealed the aides were expected to tell the nurse if a resident had a bowel movement or not, she stated the next day it would be followed up on. She stated an assessment of the resident's bowel sounds would be checked and if there were no bowel sounds or any other concerns the NP would be notified. The RN stated the NP would decide the plan of care at that point. RN #10 stated if a resident went three (3) days without a bowel movement and the as needed medication was attempted without success the NP/Physician must be notified. If this happened on shift, the nurse would pass the information along to the next nurse. The RN explained if a resident had a bowel obstruction it could lead to sepsis, the resident could become sick with chills, nausea and vomiting which could all be signs of an infection. RN #10 stated, sepsis could be life threatening if not treated. She stated another symptom to look for was decreased appetite which could be a result of constipation. Interview, with Licensed Practical Nurse (LPN) #10, on 09/15/2022 at 3:25 PM, revealed if a resident had not had a bowel movement, she would first look to see what the resident had ordered. The LPN stated if the resident had an order for medication for constipation, she would give the resident the medication and continue to monitor the resident to ensure he/she had a bowel movement. She stated nurses were provided with a printout of residents who had not had a bowel movement for two (2) days and they would give the resident something by mouth to help with the process. Further interview revealed if that did not work, they would give the resident a suppository. She stated the same process was followed on the weekend. LPN #10 explained if the resident was not listed on the bowel sheet, the resident's bowels would not be assessed that day. She stated for residents, who were cognitively impaired, they depended on staff to document what took place for the resident each day. Continued interview revealed the aides were expected to document the resident's fluid intake, meal intake and bowel movements. However, she stated, It did not always get documented when a bowel movement did not take place. Interview with the NP on 08/30/2022 at 9:24 AM, revealed she managed chronic and acute conditions of the residents residing at the facility. She stated she collaborated with the Medical Director regarding residents' care. The NP stated she was in the facility Monday through Friday from 8:30 AM to 4:30 PM, and could be reached by phone as needed. She stated she was informed by staff on 08/29/2022, that Resident #10's son was concerned the resident was acting differently, and since the resident had a history of UTI's the son wanted the resident checked out. Continued interview revealed staff had not informed her of any concerns regarding Resident #10 until that day. She stated she expected nursing staff to keep her informed if a resident did not take in their daily fluid requirements, or did not have regular bowel movements. The NP stated otherwise, if a resident was having problems it would not be on her radar. Further interview revealed the NP had not taken Resident #10's vitals the morning of 08/29/2022, and had not felt the resident showed any signs of distress when she assessed him/her. She stated based on the information she learned about Resident #1 after the resident was discharged from the hospital on 09/05/2022, nursing staff should have informed her of the resident's decreased intake and output prior to him/her being sent out. The NP stated had the nursing staff notified her she would have started Resident #10 on intravenous (IV) fluids and had the resident more closely monitored. Additional interview with the NP, on 09/09/2022 at 3:00 PM, revealed she ordered labs around 11:00 AM and felt the resident was not in distress. Later in the day she found out that the resident had bitten a staff member and his/her behaviors had increased. She stated the facility sent the resident out because the labs had not been done. During, the investigation, the NP learned the lab work had not ordered as Urgent and by 5:15 PM, the technician had not arrived to draw the resident's blood. The NP, stated she expected the nursing staff to have followed up well before 5:00 PM to determine the status of the resident's labs. Further interview revealed it was determined there was some confusion between the NP and nursing staff if the labs were ordered as STAT or not. The laboratory did not have the order as STAT. During the interview, after the NP reviewed Resident #10's Discharge Summary, which showed dis-impaction, UTI and Sepsis, the NP stated she knew it was in the resident's best interest that he/she was sent to the ED. The NP stated sepsis could lead to organ failure, and a resident could end up in Intensive Care and could die Interview with the UM, on 09/01/2022 at 4:43 PM, revealed all floor staff were trained to watch for signs and symptoms of dehydration and work towards prevention. She stated a step in prevention was to make sure the residents had fluids throughout the day. The UM stated it was important for residents to get their daily fluid intake, and staff needed to check the resident's skin and oral membranes, but it was more important to get to know the residents. She stated when staff knew the residents, they could tell when something was different. Further interview revealed any concerns were discussed daily in the clinical meetings and the facility would determine if new interventions were needed. She stated it was a team effort. The UM stated all staff were trained to notice when a resident had a Change of Condition (COC) and there were several ways the team passed on information. She stated the aides could use the Stop and Watch sheet; a message could be left for the NP; or it could be documented on the twenty-four (24) hour report. Interview, with the DON on 09/14/2022 at 1:53 PM, revealed the aides were responsible for tracking how much fluid each resident took in daily, and if there were any concerns they were to report it to the nurse on duty. Per interview, residents' decreased intakes were also discussed in clinical meetings. She stated the Unit Manager (UM) then discussed what needed to be done with the floor staff. The DON stated any resident whose fluid intake was under fifty (50) percent the day before was to be monitored and if decreased fluid intake occurred for more than two (2) days, the NP was informed. The DON stated later that day she went back to Resident #10's room to check on the resident, and he/she already had shown more behaviors. She stated Resident #10 bit her when she tried to wipe the resident's mouth, and that was when she decided she would not be able to get a good assessment of him/her without holding the resident down. Further interview revealed that was why the facility sent Resident #10 to the ED. The DON stated she would not have done anything differently that day. She further stated she was not aware Resident #10 had received cardioversion shortly after he/she arrived at the hospital. Interview with the DON, on 09/15/2022 at 3:00 PM, revealed all staff had been trained to watch for signs and symptoms of dehydration and aides were to report concerns to the nurse. The nurses were to assess the residents; based on which resident it was would determine if the physician was notified. The Director of Nursing stated if a resident went three (3) days without a bowel movement staff would know because a list was printed each morning in clinical meetings and reviewed as a team. She said any resident on the list would be assessed by their assigned nurse and given an as needed medication with additional fluids that day to get their bowels moving. The DON stated each resident listed would be checked that day. She stated aides needed to do better documenting input/output to ensure bowel movements were noted in the medical record. Resident #10 would not had been sent out for constipation as that could have been handled in house. Interview, with the Medical Director on 09/14/2022 at 11:49 AM, revealed, We try not to send too many residents out to the hospital. Insurance gets on us for sending residents out. Continued interview revealed staff would try to do labs and take care of stuff, and he told his staff to always follow their gut. Interview with the Administrator on 09/16/2022 at 4:35 PM, revealed he expected all his staff to follow the facility's policies and procedures. He stated he counted on the DON to hold nursing staff accountable to ensure they met the professional standards of practice for provision of care of each resident. Per the Administrator, he counted on the MDS Coordinators to ensure they did the proper assessments per the MDS Assessments and Social Services was to ensure the residents were assessed as the whole person. He stated any staff member who completed part of the assessment process was trained to do so and were expected to do so within their scope of training. The Administrator stated the facility had not identified any concerns with the quality of assessments being completed on the residents within the facility. He stated when it came to bowel movements, he expected the aides to document when a resident did not have one (1) and to inform the nurse. Continued interview revealed he expected the procedures for bowel monitoring to be followed. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The RCRS completed an audit of all residents' Comprehensive Care Plans beginning on 09/21/2022, validating that the Comprehensive Care Plan was an accurate and current plan of care for residents at risk for dehydration. This audit was completed on 09/21/2022. Any areas identified were revised immediately and communicated to the floor staff through daily huddles (licensed staff, aides and Certified Medication Technicians (CMT)). 2. The Medical Director (MD) and Registered Dietitian (RD) #1 assessed Resident #10's hydration status. The resident's care plan was to be reviewed and/or revised as needed after the assessment. 3. On 09/21/2022, all residents had a hydration risk assessment completed by the DON, Unit Manager (UM), ADON, Staff Development Coordinator (SDC), or the Medical Records Nurse to identify any residents at risk for dehydration. Any residents identified at risk were communicated to the Registered Dietitian (RD) and the Nurse Practitioner (NP). 4. On 09/21/2022, the RDs completed review of all the residents' hydration needs to ensure accurate and current interventions were care planned and updated if necessary. Starting 09/22/ [TRUNCATED]

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to promptly assess and provide the necessary care and services for one (1) of eighteen (18) sampled residents (Resident #2). Review of Resident #2's closed clinical record revealed the facility failed to assess the resident when his/her blood pressure medication was withheld on [DATE]. Certified Medication Technician (CMT) #1 held the resident's dose of Hydralazine, 25 milligrams (mg) on [DATE]. However, the CMT failed to document the low blood pressure and failed to inform the licensed nurse to ensure the resident was assessed within thirty (30) minutes; and, failed to conduct any necessary follow up. At 5:03 PM, staff found Resident #2 unresponsive in his/her room. Cardiopulmonary Resuscitation (CPR) was initiated. The staff called Emergency Medical Services (EMS) and the resident was transferred to the hospital. Resident #2 was pronounced deceased at 6:08 PM in the Emergency Department (ED). Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F656) at Scope and Severity (S/S) of J; and at 42 CFR 483.25 Quality of Care (F684) at S/S of J; 42 CFR 483.25 Quality of Care (F692) Nutrition/Hydration Status Maintenance at S/S of J; and 42 CFR 483.70 (F835) Administration at S/S of J. Substandard Quality of Care was identified at 483.25 F684 and F692. The facility was notified of Immediate Jeopardy on [DATE]. An Partial Extended Survey was initiated on [DATE] and concluded on [DATE]. A Partial Extended Survey was concluded on [DATE]. The facility provided an Acceptable Immediate Jeopardy Removal Plan, on [DATE]. The State Survey Agency validated the Immediate Jeopardy had been removed on [DATE] as alleged, before exit on [DATE]. The facility's non-compliance remained at 42 CFR 483.12 Comprehensive Resident Centered Care Plans (F656); 42 CFR 483.25 Quality of Care (F684) and Assisted Nutrition and Hydration (F692); and 42 CFR 483.70 (F835) Administration, all at a Scope and Severity (S/S) of D; while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systematic changes. The findings include: Review of the facility's policy, titled Notification of Change of Condition, effective [DATE], revealed staff was to ensure the appropriate individuals were notified of changes in condition. Staff must consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status and when there would be a need to alter treatment significantly. Documentation of notifications and attempted notifications should be recorded in the resident's medical record. Review of the facility's policy, titled Physician Services, revised [DATE], revealed the physician performed pertinent, timely medical assessments, prescribed the appropriate medical regimen, and provided adequate, timely information about the resident's condition and medical needs. The physician shall provide orders for the resident's immediate care and needs. Review of Resident #2's closed clinical record revealed the facility admitted the resident, on [DATE] for rehabilitative services, with a plan to discharge home. The resident's diagnoses included Hypertension, Heart Failure, Stroke, Type 2 Diabetes and Kidney Disease. Review of the five (5) Day Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) and determined the resident was cognitively intact. The facility assessed the resident to require two (2) staff for transfers, for personal hygiene, and for bathing; and the assistance of one (1) staff for all other Activities of Daily Living (ADLs). The facility assessed the resident to be mobile in his/her walker and wheelchair. Further review of the MDS, revealed Resident #2 did not have any conditions or chronic diseases that may result in a life expectancy of six (6) months or less. Review of Resident #2's Physician's Orders and Comprehensive Care Plan (CCP), dated [DATE], revealed Resident #2 received medication for management of his/her hypertension (high blood pressure). Further review of the Physician's Orders from [DATE] to [DATE], revealed no order for holding the resident's blood pressure medication (no parameters specified) if the resident's blood pressure was too low for medication administration. Review of Resident #2's closed clinical record revealed Certified Medication Technician (CMT) #1 held the resident's dose of Hydralazine, 25 milligrams (mg) because the resident's blood pressure was too low between 11:15 AM to 3:00 PM. However, the CMT failed to document the resident's low blood pressure. In addition, the CMT failed to inform the licensed nurse so they could recheck the resident's blood pressure within thirty (30) minutes, and conduct any necessary follow up. At 5:03 PM, staff found Resident #2 unresponsive in his/her room and Cardiopulmonary Resuscitation (CPR) was initiated. The staff called Emergency Medical Services (EMS) and the resident was transferred to the hospital. Resident #2 was pronounced deceased at 6:08 PM in the hospital's Emergency Department (ED). Review of the facility's Emergency Code Documentation, dated [DATE], revealed staff found Resident #2 unresponsive in his/her room at 5:02 PM. Further review revealed Cardiopulmonary Resuscitation (CPR) was initiated by CMT #1 until Emergency Medical Services (EMS) arrived on the scene and took over CPR. Resident #2 was transported to the Emergency Department (ED). Review of Resident #2's Medication Administration Record (MAR) for [DATE], revealed CMT #1 documented she withheld the resident's blood pressure medication for the 11:15 AM to 3:00 PM dose, because his/her blood pressure was too low. However, there was no evidence the CMT documented the resident's actual blood pressure or rechecked the resident's blood pressure within thirty (30) minutes, per the facility's protocol. Nor did she alert the licensed nurse and/or inform the physician to ensure the resident's blood pressure was monitored. Interview with CMT #1, on [DATE] at 10:38 AM, revealed she should have told the nurse about the resident's low blood pressure reading. She stated the resident's blood pressure should have been documented on the MAR, and his/her blood pressure should have rechecked within thirty (30) minutes. CMT #1 stated it would be up to the nurse to contact the physician, if needed. Interview with Registered Nurse (RN) #8, on [DATE] at 11:15 AM, revealed if a resident's blood pressure was too low to give medication and it was held, the nurse needed to contact the Nurse Practitioner (NP). RN #8 stated this was to be done when there was no order to hold the medication. Further interview revealed holding medications and contacting the NP needed to be documented in the Progress Notes. She stated the blood pressure would have to be rechecked within thirty (30) minutes. RN #8 stated the nurse needed to monitor the resident until he/she returned to his/her baseline. Interview with RN #9, on [DATE] at 11:25 AM, revealed she was required to contact the physician when she held blood pressure medication for a resident whose blood pressure was too low. She stated the MAR prompted the staff member passing medication to enter the actual blood pressure when medication was held. RN #9 stated it was standard practice to recheck the resident's blood pressure in thirty (30) minutes and continue to monitor him/her until the resident returned to normal. Interview, with the Director of Nursing (DON), on [DATE] at 3:00 PM, revealed the facility's process for high blood pressure or low blood pressure was to recheck the blood pressure and to notify the NP/MD or, the on call nurse. However, the DON stated the facility never identified any concerns related to this case. Interview with the Nurse Practitioner, on [DATE] at 9:25 AM, revealed if a resident's blood pressure was not within the normal range the nurse on duty would need to monitor and report it to her if the resident did not get back to normal within thirty (30) minutes. Interview with the Medical Director (MD), on [DATE] at 11:49 AM, revealed he expected licensed nurses to do vital signs for residents to include blood pressure and document in the medical record. Interview with the Administrator, on [DATE] at 4:35 PM, revealed prior to this survey, the facility had not identified assessments as an area of concern. He stated he counted on his medical staff to keep him abreast of all resident medical concerns as they came up. Continued interview revealed he attended Quality Assurance and Performance Improvement (QAPI) meetings and talked with the MD regularly. He stated he expected all Change of Conditions (COC) to be reported to the medical staff and the facility's policy to be followed. The Administrator stated, on [DATE], when Resident #2 expired, no concerns were brought to his attention. Review of Resident #2's closed clinical record revealed staff had not been documenting the resident's blood pressure readings. Interview with the Administrator, on [DATE] at 4:35 PM, revealed the DON reviewed Resident #2's record for documentation of the blood pressure and was unable to find it. The Administrator stated it concerned him that the documentation was not done, but he did not believe the care was not provided. Additionally, an email was provided on [DATE] at 11:03 AM by Care Consultant #3 which stated, I have looked and can not locate a B/P reading for (Resident #2) to also signify Resident #2's records had no blood pressure readings recorded. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #10's Comprehensive Care Plan was reviewed and revised by the Regional Clinical Reimbursement Specialist (RCRS), with the DON, ADON, Unit Manager (UM) and resident and family giving input. The facility reassessed Resident #10, and his/her Comprehensive Care Plan was thoroughly reviewed and revised to ensure the resident maintained the highest practicable physical, mental, and psychosocial well-being. A care plan conference was held with Resident #10, his/her family and the IDT all in attendance. 2. The RCRS completed an audit of all residents' Comprehensive Care Plans beginning on [DATE], validating that the Comprehensive Care Plan was accurate and addressed the current plan of care needs. The care plan included: risk for dehydration, current diagnoses, medication, contractures, constipation and/or Change of Condition (COC). This audit was completed on [DATE]. Any areas identified were revised immediately and communicated to the floor staff through daily huddles (licensed staff, aides and Certified Medication Technicians (CMT)). 3. On [DATE], the RCRS completed education with both MDS Coordinators and the IDT on accurate and complete Comprehensive Care Plans. 4. On [DATE], Regional Nurse Consultant (RNC) #1 and the Regional Staff Development Coordinator (RSDC) initiated education for licensed nurses on accurate and complete Comprehensive Care Plans. This education was completed on [DATE]. 5. The CMT received performance improvement regarding medication administration and notification of a change in condition to the licensed nurse. 6. The Medical Director (MD) and Registered Dietitian (RD) #1 assessed Resident #10's hydration and bowel status. Recommendations were communicated to the resident's family and the care plan was reviewed and/or revised as needed. The Medical Director ordered a Complete Blood Count (CBC), Basic Metabolic Panel (BMP) and Thyroid Stimulating Hormone (TSH) blood draws for Resident #10 on [DATE]. 7. Occupational Therapy (OT) attempted an evaluation of Resident #10 of his/her bilateral upper extremity contractures. The resident refused the OT evaluation and services on [DATE]. 8. On [DATE], all residents had a hydration risk assessment completed by the DON, Unit Manager (UM), ADON, Staff Development Coordinator (SDC), or the Medical Records Nurse to identify any residents at risk of dehydration. Any residents identified at risk were communicated to the Registered Dietitian (RD) and the Nurse Practitioner (NP). 9. On [DATE], the RD completed a review of all the residents' hydration needs to ensure accurate and current interventions were care planned and updated if necessary. At risk residents were assessed by the NP, orders put in place and the families notified. Residents were to be transferred to the hospital if required. This was completed on [DATE]. Starting [DATE], one (1) of the four (4) RDs was to be at the facility twice a week. Starting [DATE], an RD was to be accessible to the facility seven (7) days a week to review any residents at risk for dehydration needing to be evaluated. 10. On [DATE], audits were completed by the DON, UM, ADON, SDC and Medical Records Nurse on all residents to validate a bowel movement had occurred within the last three (3) days and the provider notified as necessary for intervention. 11. On [DATE], an audit was completed by the Restorative Nurse of all residents to identify any residents with contractures present. Any resident with contractures was referred to therapy and a care plan implemented for contractures. 12. On [DATE], the Independent Risk Manager completed audits of all residents with orders for a blood pressure medication to validate the orders for parameters and when to hold blood pressure medication had been implemented. Any areas identified were corrected immediately and communicated to the NP and/or Physician. 13. On [DATE], audits were completed by the [NAME] President of Clinical Operations (VPCO) #2 of all resident's vital signs to validate if any resident with blood pressure medication had their medication withheld due to blood pressure being above or below the parameters. Any areas identified were corrected immediately and communicated to the NP and/or Physician. 14. Education was provided to all staff members initiated on [DATE] and completed on [DATE]. Reeducation was completed by RNC #1 with all licensed staff and other nursing staff to include the aides and certified medication technicians. The education covered hydration, how to monitor residents' intakes, Bowel Movement (BM) Policy, bowel movement monitoring, Change of Condition (COC), and communicating the COC. 15. Starting [DATE], licensed nurses were to review the BM management report and initiate any bowel interventions if needed and notification to the Physician seven (7) days per week until the immediacy was removed. Starting [DATE], the DON, ADON, UM, RD and NP reviewed all residents' intake seven (7) days per week until immediacy was removed. If further assessment was necessary, the NP or Physician was to be notified. 16. Starting [DATE], the NP was to be available at the facility five (5) days a week for evaluation of any resident with decreased oral intake, at risk for dehydration, assessment for a COC related but not limited to, hydration, blood pressure changes and bowel status. The DON, ADON and UM were to communicate with the NP seven (7) days per week until immediacy was lifted. 17. The VPCO educated the facility's Administrator, Medical Director, Regional Nurse Consultant and DON on CMS regulations F656, F684, F692 and F835 on [DATE]. Starting [DATE] the facility's consultant, regional team member or the VPCO provided daily administrative oversight seven (7) days per week to the facility and was to continue in person or by telephone until immediacy was removed. On [DATE], the facility had a Regional Clinical Nurse, consultant and/or VPCO provide oversight daily and provide support, resources, and guidance until immediacy was lifted. In addition, the regional team members or VPCO assisted in ensuring an effective jeopardy removal plan was in place, and ensured an effective plan of correction was developed and implemented. 18. Findings of the audits was to be presented to the facility's Quality Assessment and Performance Committee (QAPI) consisting of the Executive Director (ED), DON, and Medical Director, daily until the immediacy was removed, then monthly. The QAPI Committee was to determine when compliance was achieved and/or if ongoing monitoring was required. An AD HOC Quality Assurance meeting was held on [DATE] and [DATE], in regards to the Immediate Jeopardy identified. 19. IDT consists of Chief Executive Officer (CEO), DON, UM, SDC, Medical Records Manager, MDS Coordinators, Social Service Director, Rehabilitation Service Manager and Discharge Planner. The State Survey Agency validated the facility took the following actions: 1. Review of Resident #10's medical record on [DATE], revealed the resident's care plan had been reviewed and revised for each section of concerns. Changes were made to add new interventions for hydration, contractures and bowel management, which was completed on [DATE]. Interview with the Unit Manager on [DATE] at 11:00 AM, revealed there had been multiple people who reviewed Resident #10's chart and made changes. Per interview, Resident #10 was re-assessed, and staff were informed of changes to his/her care plan at the morning huddle, and/or staff looked in the huddle binder to review any changes. She stated she was reeducated on the care required for Resident #10, in reference to hydration, bowel status and contractures. Per interview, the ADON was on vacation and was not interviewed. Interview with the DON, on [DATE] at 2:14 PM, revealed Resident #10's care plan was reviewed and/or revised at the care plan meeting held on [DATE]. She stated Resident #10's family member was present at the care plan meeting held on [DATE], and he was informed of all concerns regarding the resident and of the new interventions implemented. She stated the Physician did a full regular examination (exam) of Resident #10 on [DATE], and Registered Dietitian (RD) #1 reassessed the resident's hydration status on that same date. Per the DON, the Psychiatrist recommended changes to Resident #1's medication after being informed the resident was being too sleepy. She stated each department reviewed their section of the resident's care plan and made the determinations of whether any changes were needed. Interview, with the RCRS on [DATE] at 3:37 PM, revealed Resident #10 was reassessed due to a change of condition regarding his/her hospitalization on [DATE]. Per interview, she reviewed Resident #10's assessment and made changes to his/her care plan. She further stated Resident #10's MDS Assessment was reviewed additionally to ensure the care plan matched the resident's needs. 2. Review of the facility's documentation revealed a printed list of all residents in the facility, with their names and room numbers noted. Interview with the RCRS, on [DATE] at 3:37 PM, revealed she met with the MDS Coordinators and they completed the audit of each resident's care plan. She stated residents' MDS Assessments were also reviewed and compared to their care plans to ensure the two (2) matched and were current for the residents. Further interview revealed she did a lot of revisions to care plans and the findings of the audits were discussed in the morning clinical meetings. The RCRS further stated by [DATE], all residents' care plans had been reviewed and/or revised. 3. Review of the facility's documentation revealed a signature sheet, dated [DATE], noting the RCRS trained both MDS Coordinators on ensuring residents' care plans were complete and accurate. Continued review revealed the RCRS trained the MDS Coordinators on ensuring any complications a resident experienced related to a diagnosis was care planned. Per review, the RCRS trained the MDS Coordinators to ensure residents who were at risk for dehydration, constipation, or who had contractures had their care plans updated during the facility's morning clinical meetings if problems were identified. Further review revealed the RCRS's training included the MDS Coordinators ensuring they reviewed residents' admission/readmission hospital records for any new changes that needed to be added to the residents' care plans. Review further revealed the RCRS's training additionally included educating the MDS Coordinators on care plan development and revision of residents' care plans as needed. Interview with MDS Coordinator #1, on [DATE] at 11:30 AM, revealed she was reeducated by the RCRS and several other regional staff members on many different subjects. MDS Coordinator #1 stated the education she received included ensuring residents' care plans were accurate and complete, and for the nurses to review the care plans and note each resident's required specialized care needs. She stated she had been educated to ensure residents' care plans and MDS Assessments matched for accuracy in provision of resident care. Continued interview revealed she had been educated that the facility had new bowel and hydration protocols in place, and the Registered Dietitian was responsible for updating residents' care plans related to hydration. She further stated she was reeducated on her responsibility for updating residents' care plans related to elimination. In addition, she stated she was reeducated on determining if a resident was incontinent or continent of bowel and bladder, and then to update the resident's care plan accordingly. MDS Coordinator #2 was not available for interview due to being on vacation. Interview with the RCRS, on [DATE] at 3:37 PM, revealed she provided the reeducation for both MDS Coordinators and completed the audit of all the residents' care plans. She stated residents' care plans were based on what the residents' assessments determined as all residents were different. Per interview, the RCRS and MDS Coordinators reviewed residents' assessments and made any necessary changes to the care plans at that time. The RCRS stated the audit findings were discussed in the facility's daily morning clinical meetings. Further interview revealed she reeducated staff face-to-face and performed some follow-up reeducation by phone with staff. In addition, she stated all care plan audits were completed by [DATE] and reflected all residents' current status. 4. Interview with Licensed Practical Nurse (LPN) #10, on [DATE] at 9:45 AM, revealed she had been reeducated on changes in care plans by ensuring she read residents' care plans and looked at the nursing report. She stated she received education on ensuring residents' care plans were accurate and complete. Interview with LPN #6, on [DATE] at 10:16 AM, revealed nursing staff were reeducated one (1) to two (2) weeks ago on ensuring residents' care plans were accurate and completed by the Regional Nurse Consultant and Regional Clinical Reimbursement Specialist (RCRS). Interview with Regional Nurse Consultant (RNC) #1, on [DATE] at 3:51 PM, revealed she provided training to the Certified Medical Technicians (CMTs), Medical Records Nurse, UM, ADON, DON, Nurse Practitioner (NP), Nurses, State Registered Nursing Assistants (SRNA) and Registered Dietitians (RDs). Per interview, most of the training had been face-to-face; however, any employee not available in person received the training by telephone. She stated the training covered hydration, care planning, monitoring fluid intake, review of the facility's bowel movement policy and protocol, blood pressure monitoring, withholding blood pressure medication, change of condition, and communication of change in condition. Further interview revealed she re-checked staff's knowledge after the training with a posttest. 5. Review of the facility's General Medication Administration Competency training, dated [DATE], revealed CMT #1 had completed the competency training on checking the medication administration sheet, following the directions of the medication (such as shaking), and confirming the resident's identity by using two (2) identifiers. Per review, the competency training CMT #1 received also included ensuring the nurse was notified of a change of condition in a resident. Continued review revealed the training additionally included charting the medications after it was given, and monitoring for side effects of the medication given. Record review revealed CMT #1 completed a competency training supervised by the Staff Development Coordinator and both had signed the competency training sheet on [DATE]. Interview with CMT #1, on [DATE] at 2:21 PM, revealed she received training on making sure if she held residents' blood pressure medication to report that information to the nurse on duty and recheck the resident's blood pressure again. Per interview, the training had been for performance improvement. She further stated she had also completed all the required training with the rest of the staff as well. 6. Review of Resident #10's clinical record revealed the Medical Director completed a physical examination of the resident on [DATE] at 10:58 AM. Per review, the chief complaint noted for Resident #10 was documented as weakness and poor oral intake. Continued review of the Medical Director's examination documentation revealed he noted Resident #10 was not in any acute distress, and his/her oral mucosa was moist. Further review revealed the Medical Director assessed Resident #10's to have a soft abdomen, which was non-tender and his/her bowel sounds were present. Continued review of Resident #10's clinical record revealed a copy of the resident's laboratory (lab) report dated [DATE], which included results for CBC, BMP and TSH lab testing. Review of the Medical Director's Progress Note revealed the lab results were received on [DATE]. Additional review of Resident #10's clinical record revealed a Progress Note completed by Registered Dietitian (RD) #4 on [DATE] at 4:50 PM. Per review, the RD's assessment tool noted Resident #10 to be at medium risk for dehydration, and therefore was referred for additional review by the RD. Further review revealed the RD lowered Resident #10's daily recommended fluid intake to ,d+[DATE] milliliters (ml) per day. Interview with the Medical Director, on [DATE] at 11:20 AM, revealed he completed a full medical evaluation of Resident #10 on [DATE], and ordered lab testing which included a BMP, CBC, and TSH. He stated he had not identified any concerns at the time of Resident #10's physical evaluation. He further stated he had agreed with the RD's dehydration risk assessment for Resident #10. In addition, he stated he was pleased with the resident's lab results and felt no new recommendations were needed. 7. Review of Resident #10's clinical record revealed an Occupation Therapy (OT) Evaluation, dated [DATE], which documented the resident's refusal of a OT evaluation. Continued review of the OT Evaluation documentation dated [DATE], revealed Resident #10 had received OT services from [DATE] to [DATE]. 8. Review of the facility's hydration evaluation tool, dated [DATE], revealed all residents had been assessed by the DON, UM, ADON, SDC, or Medical Records Nurse to determine if they were low, medium or high risk for dehydration. Per review, residents who scored as medium or high risk were forwarded to the RDs for an assessment, who notified the NP of any concerns. Interview with the Medical Records Nurse Manager, on [DATE] at 1:54 PM, revealed she assisted with assessing the residents for their hydration risks. Per interview, she completed the audit forms after assessing residents. Interview with the UM on [DATE] at 11:00 AM, revealed she assisted, as part of the team, in getting all residents assessed for their hydration risks. According to the UM, she helped tally up the residents who were forwarded to the RD after the assessment. She further stated she had forwarded two (2) new residents who had been assessed to be at risk for dehydration. Interview with the SDC, on [DATE] at 11:48 AM, revealed she helped assess residents to determine who was at risk for dehydration. She stated she completed assessments of residents on the weekends when she was the weekend supervisor. The SDC stated many residents were assessed as not drinking enough fluids daily, so staff were educated on encouraging the residents to drink fluids throughout the day. She further stated any residents assessed as at risk were forwarded to the RD for further evaluation. An attempt to interview the ADON was unsuccessful as she was on leave, per management staff. Interview with the DON on [DATE] at 2:14 PM, revealed she assisted other management staff to assess all residents and ensure their hydration risks were documented. She stated any resident found to be at medium or high risk were referred for further assessment by the RD and NP. The DON further stated she guessed about twenty (20) residents required additional assessment by the RD and/or NP, with no major concerns identified. 9. Review of residents' clinical records revealed Progress Notes documenting residents that had been identified as at risk for dehydration had been assessed by an RD on [DATE] and [DATE]. Further record review revealed the NP assessed residents who required additional assessment with recommendations made based on the NP's assessments. Interview with RD #1, on [DATE] at 3:06 PM, revealed she had looked at residents who were identified as at risk for dehydration and required an additional assessment based on being assessed as a medium or high risk for dehydration. She stated she determined residents' total daily fluid intake requirements, and further explained that was decided based on several different factors for each resident. RD #1 stated she was at the facility twice a week and could always be reached by phone if the facility needed additional assistance. The RD stated nursing staff reviewed the residents' intakes and if they noted decreased intakes they notified the RDs to investigate. Per interview, an RD was at the facility seven (7) days per week. Further interview revealed if a resident did not meet his/her daily assessed fluid needs, the RDs evaluated the resident and put additional interventions in place as necessary. Interview with RD #2, on [DATE] at 2:28 PM, revealed she had been onsite helping review all the residents' hydration needs. Per interview, after the RD team assessed residents identified as at risk for dehydration had been referred to the RDs. Continued interview revealed the RDs measured residents' fluid intake for everything taken orally, to ensure their hydration needs were accurate. The RD stated if a resident was identified below his/her daily fluid intake needs, the RDs made recommendations and the residents' care plans were updated. Further interview revealed if a resident was not taking in enough fluids and their fluid intake was inconsistent, the DON, NP and Physicians were notified. In addition, RD #2 stated the RDs provided coverage at the facility seven (7) days a week. Interview with RD #4, on [DATE] at 2:52 PM, revealed she had assisted in assessing residents for their hydration status. She stated the RD team was provided a list of residents who had not met their daily intake requirements which was reviewed to determine what action needed to be taken. Further interview revealed the recommendations were documented in the residents' Progress Notes, and the NP was notified if a resident needed additional assessments to include new orders and/or blood work. RD #4 stated the RDs rotated at the facility to ensure an RD was available to [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to develop and/or implement a person-centered Comprehensive Care Plan (CCP) to ensure residents maintained the highest practicable physical, mental and psychosocial well-being as required for two (2) of eighteen (18) sampled residents (Resident #2 and Resident #10). 1. The facility admitted Resident #2 on [DATE], for rehabilitation services. The resident had medication ordered for management of his/her hypertension. However, there was no documentation the facility developed the Comprehensive Care Plan for management of Resident #2's diagnosed cardiovascular disease to include monitoring of his/her high or low blood pressure. Resident #2's hypertension medication was not administered as ordered, as his/her blood pressure was too low on [DATE]. There was no documentation the facility obtained the resident's vital signs on [DATE]. The resident was found unresponsive at 5:03 PM and was pronounced deceased , on [DATE] at 6:08 PM at the hospital. 2. The facility admitted Resident #10, on [DATE], for rehabilitation services with a contracture of the left hand, and diagnoses which included Constipation, and Urinary Tract Infection (UTI). However, the facility failed to develop and implement a CCP to prevent a decline in the resident's left hand contracture, and failed to develop the CCP to prevent a contracture to his/her right hand. The facility also failed to develop and implement a CCP related to Resident #10's bowel elimination and history of constipation. The resident had no documented bowel movements for sixteen (16) days in [DATE] and twenty (20) days in August of 2022. The facility developed Resident #10's CCP to include a risk for dehydration with a goal for Resident #10 to remain adequately hydrated. However, the facility failed to monitor the resident for signs and symptoms of dehydration. On [DATE], the facility transferred Resident #10 to the hospital for evaluation related to Altered Mental Status. The hospital admitted and treated Resident #10 for Dehydration, Sepsis, UTI (urinary track infection), fecal impaction, and Stercoral Ulcer of rectum (ulceration of the colon mucosa secondary to impacted feces). Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F656) at Scope and Severity (S/S) of J; and at 42 CFR 483.25 Quality of Care (F684) at S/S of J; 42 CFR 483.25 Quality of Care (F692) Nutrition/Hydration Status Maintenance at S/S of J; and 42 CFR 483.70 (F835) Administration at S/S of J. Substandard Quality of Care was identified at 483.25 F684 and F692. The facility was notified of Immediate Jeopardy on [DATE]. An Partial Extended Survey was initiated on [DATE] and concluded on [DATE]. An Partial Extended Survey was concluded on [DATE]. The facility provided an Acceptable Immediate Jeopardy Removal Plan, on [DATE]. The State Survey Agency validated the Immediate Jeopardy had been removed on [DATE] as alleged, before exit on [DATE]. The facility's non-compliance remained at 42 CFR 483.12 Comprehensive Resident Centered Care Plans (F656); 42 CFR 483.25 Quality of Care (F684) and Assisted Nutrition and Hydration (F692); and 42 CFR 483.70 (F835) Administration at S/S of D all at a Scope and Severity (S/S) of D; while the facility develops and implements Plans of Correction and monitors the effectiveness of the systematic changes. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised on [DATE], revealed the facility would create a CCP focused on each resident's needs, goals, preferences and would be resident centered. Per review, the Interdisciplinary Team (IDT) was to develop and maintain a CCP that identified the highest level of functioning for each resident based on a thorough assessment. Continued review revealed each CCP was designed to identify problem areas, incorporate risk factors, build strengths, aid in prevention or deduction of decline of the resident's functional status and/or functional levels and reflect currently recognized standards of practice for problem areas and conditions. The policy also revealed care plans were ongoing and were to be revised as information about the resident and resident's condition changed. Care plans should reflect the resident's current status and should be updated when there was a significant change, goals changed, desired outcome was not met, the resident was readmitted from the hospital and at least quarterly. The IDT, who prepared the CCP, included at least the Attending Physician/Nurse Practitioner, Registered Nurse (RN), Nurses Aide, a member of the food and nutrition services team and, the resident and/or representative. 1. Review of Resident #2's closed clinical record revealed the facility admitted the resident on [DATE], with diagnoses that included Stroke, Heart Failure, Hypertension, Kidney Disease, and Type 2 Diabetes. Record review revealed the facility admitted Resident #2 for rehabilitation (rehab) and expected him/her to return to his/her home upon completion of rehab services. Review of Resident #2's Admission Skilled Observation documentation, dated [DATE], revealed the resident had shortness of breath with exertion and his/her vital signs were within normal limits. Review of the Skilled Observation documentation, dated [DATE], for Resident #2 revealed no vital signs were documented. Review of the Skilled Observation documentation, dated [DATE], revealed the resident's lung sounds were diminished; however, there was no documented vital signs noted. Review of the Skilled Observation documentation, dated [DATE], revealed the resident had shortness of breath with exertion and his/her vital signs were within normal limits. Review of the five (5) day Minimum Data Set (MDS) Assessment report for Resident #2, dated [DATE], revealed the facility assessed the resident with a Brief Interview Mental Status (BIMS) score of thirteen (13) out of fifteen (15) which indicated the resident was cognitively intact and interviewable. Continued review revealed the facility assessed Resident #2 to require two (2) staff for transfers, personal hygiene and bathing and one (1) staff for all other Activities of Daily Living (ADLs). Per review, the facility assessed Resident #2 as short of breath; however, it was noted the resident did not have a condition or diagnoses with the life expectancy of less than six (6) months as identified by a Physician. Review of Resident #2's Comprehensive Care Plan created on [DATE], revealed no documented evidence the care plan had been developed regarding management of the resident's cardiovascular disease, to include blood pressure monitoring. Review of Resident #2's Medication Administration Record (MAR) revealed on [DATE], the Certified Medication Technician (CMT) held the resident's dose of blood pressure medicine (to have been given between 11:15 AM and 3:00 PM) due to his/her blood pressure being too low. Continued review revealed no documented evidence the CMT notified the licensed nurse on duty related to withholding Resident #2's blood pressure medication. Further review revealed no documented evidence the CMT or licensed nurses rechecked the resident's blood pressure in thirty (30) minutes or monitored the resident to determine if the Physician should have been notified. Review of the facility's Emergency Code Documentation, dated [DATE] at 5:03 PM, revealed staff found Resident #2 unresponsive, and initiated Cardiopulmonary Resuscitation (CPR). Per review, staff notified Emergency Medical Services (EMS). EMS arrived at the facility at 5:12 PM. Further review revealed Resident #2 was transported to the hospital and pronounced deceased at 6:08 PM on [DATE]. Interview with State Registered Nursing Assistant (SRNA) #1, on [DATE] at 2:41 PM, revealed residents' care plans were important because that was what showed staff how to care for the residents. She stated there was a book which was broken into sections by room number for staff to review that told you about each resident. Interview with SRNA #6, on [DATE] at 10:15 AM, revealed when she arrived for work on her shift, she got report from the person who was going off duty, or she looked at the residents' care plans. She stated there was a book kept behind the desk at the nurse's station, that contained all the care needs of each resident, which she could also use as a reference. Continued interview revealed the care plan was important because it showed the special instructions and ways to care for each resident and if the care plan was not followed, a resident could end up hurt. Interview with Licensed Practical Nurse (LPN) #3, on [DATE] at 10:12 AM, revealed care plans were important so staff had a comprehensive look at the resident to know what kind of care and treatment a resident required based. LPN #3 stated if there was no care plan to follow it could be considered neglect as staff would not be doing what was necessary for the resident. Further interview revealed care plans were personalized for each resident and were required to cover each area of the resident's care needs. Interview with LPN #8, on [DATE] at 3:38 PM, revealed she could not recall ever having been trained on residents' care plans since being at this facility. She stated when she worked at the facility she never looked at the care plan because she got her information off of the report sheet. Continued interview revealed the report sheet and/or the nurses' assignment sheet would have anything you needed to know for the resident's care for that day. Interview with the Staff Development Coordinator (SDC), on [DATE] at 10:40 AM, revealed she did most of the new employee orientation training, also sometimes she started the care plan for residents. However, further interview revealed completion of the care plan was done by other staff members and she was not sure as to who completed them. Interview with MDS Coordinator #1, on [DATE] at 4:21 PM, revealed she reviewed all new Progress Notes daily, Nurse Practitioner (NP) Notes, and Medical Director Notes. She stated she updated the residents' care plans in real time with that information. MDS Coordinator #1 stated nursing staff did not make changes to residents' care plans. She stated she was not sure what happened regarding residents' care plan updates on the weekends. Interview with MDS Coordinator #1, on [DATE] at 9:40 AM, revealed the facility did not go over residents' care plans daily, only when they needed to review them for a significant change or new orders. She stated if a resident had a condition that they received medication for or, if they were fragile that should be addressed on the care plan. She stated a diagnosis of Heart Failure would fall under that type of situation. Interview with the Unit Manager (UM), on [DATE] at 4:43 PM, revealed all facility staff were trained during the facility's new employee orientation on the importance of care plans and how it directed the resident's care. She stated although all nursing staff had been trained how and when care plan updates needed to be made, she did not believe all staff felt comfortable doing the updates. The UM stated, she along with the Staff Development Coordinator, the two (2) MDS Coordinators and the Director of Nursing updated residents' care plans as needed. Further interview revealed there were other ways for staff to find out the needs of residents which included pass down information at shift change and by doing rounds. She stated getting to know the resident was one of the best ways to recognize when the resident had a change. 2. Review of Resident #10's clinical record revealed the facility admitted the resident on [DATE], with diagnoses of Metabolic Encephalopathy, Muscle Weakness, Urine Retention and cognitive communication deficit. Per review, Resident #10 was also noted to have a history of Urinary Tract Infections (UTIs), and Constipation. Review of Resident #10's Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status' (BIMS') score of (9) out of fifteen (15) which indicated he/she was moderately cognitively impaired and interviewable. Continued review revealed the facility assessed Resident #10 to require two (2) staff assistance for transfers and bed mobility, and one (1) person physical assistance for all other Activities of Daily Living (ADLs). Further review of the MDS Assessment revealed Resident #10 was noted to have upper extremity impairment on the left side and he/she used a wheelchair for mobility. Review of Resident #10's Comprehensive Care Plan, created [DATE], revealed the facility care planned the resident to be at risk for dehydration related to being a new admission, and his/her diagnoses of B12 deficiency and Metabolic Encephalopathy. Continued review of the care plan revealed the facility noted the goal was for Resident #10 to remain adequately hydrated with good skin turgor, pink and moist mucous membranes and sufficient fluid intake. Further review revealed the interventions included staff to observe Resident #10 for signs and symptoms of dehydration and report any concerns to the nursing staff. Review of the Registered Dietitian's (RD) Medical Nutrition Therapy Evaluation, completed on [DATE], revealed the RD assessed the resident to require a daily fluid intake of 1772 milliliters (ml) per day. Review of Resident #10's clinical record, Vital Signs section, regarding fluid intake for [DATE], revealed the resident's average daily fluid intake was noted as 772 mls per day. The resident's average daily fluid intake for [DATE] was 705 mls per day. Further review of Resident #10's clinical record revealed no documentation the facility identified concerns regarding the resident's low fluid intakes or implemented additional interventions in attempts to increase his/her daily fluid intake. Review of Resident #10's clinical record revealed hospital Discharge Summaries dated [DATE] and [DATE], which noted the resident was treated for Urinary Tract Infections (UTI) in July and August of 2022. Interview with Resident #10's Family Member #3, on [DATE] at 7:50 PM, revealed he tried to visit the resident daily because he was concerned about Resident #10's hydration status. He stated the resident was not able to pick up a cup, hold it in his/her hand and could not move the cup to his/her mouth to drink. Review of Resident #10's diagnoses revealed constipation was listed as an active diagnosis. Review of the Medical Director's Progress Note, dated [DATE], revealed the resident had chronic constipation. Review of the CCP for Resident #10 revealed no documentation noting the facility had care planned the resident for his/her history of constipation, nor implemented interventions for staff to monitor the resident for signs and symptoms of constipation and report changes to the nurse. Review of Resident #10's Bowel Report revealed no documentation of a bowel movement noted for sixteen (16) days in [DATE], and eighteen (18) days in [DATE]. However, the facility failed to develop and implement interventions when the resident went three (3) days without a bowel movement. Further review revealed the facility transferred Resident #10 to the hospital Emergency Department on [DATE]. The hospital admitted Resident #10 on [DATE], where he/she was treated for Dehydration, UTI, fecal impaction (a mass of dry, hard stool that cannot pass out of the rectum) and Sepsis (the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death). Interview with MDS Coordinator #1, on [DATE] at 9:40 AM, revealed in reference to Resident #10 not having bowel movements and having the history of UTI's she might have missed that information, or it might not have been documented would be the reason that concern had not been care planned. She stated she did not recall reading Resident #10's hospital Discharge Summary from [DATE]. MDS Coordinator #1 stated Resident #10 was rather new to her and she had not been familiar with the resident when he/she moved over to the long term care (LTC) side of the facility on [DATE]. Review of the Hand Clinic Doctor Progress Note, dated [DATE] revealed Resident #10 was at risk for a decline in both his/her hands. Review of Resident #10's CCP, created [DATE], revealed no documented evidence the facility developed the CCP to address the resident's left hand contracture. Review of the CCP further revealed the facility also failed to develop a care plan to prevent contractures of Resident #10's right hand. Interview, with Resident #10's Family Member #3, on [DATE] at 7:50 PM, revealed when Resident #10 came to the facility, on [DATE], he/she was able to use his/her right hand. He stated he asked the facility to work with Resident #10 to prevent a decline in his/her right hand. Further interview revealed the facility had not done any therapy on the resident's right hand and now the resident had contractures. Interview with MDS Coordinator #1, on [DATE] at 9:40 AM, revealed when Resident #10 moved over to the LTC area a new assessment was not needed because they were only due every three (3) months, and that could be why the resident's hand contractures were overlooked and not care planned. Interview with LPN #8, on [DATE] at 3:38 PM, revealed she could not recall ever being trained on care plans at this facility. LPN #8 stated when she worked she never looked at the care plan because she got her information from the report sheet. She stated the report sheet and/or the nurses' assignment sheet would have anything you needed to know for the resident for that day. The LPN stated she got a blank one at the start of her shift and documented information from the off going nurse. She also stated she looked at the resident's orders for guidance. Observation of the LPN's sheet, at the time of the interview, revealed the document the LPN provided only listed the resident's room numbers and blood pressures. The LPN stated that was all she had documented that day. Interview with the Staff Development Coordinator (SDC), on [DATE] at 10:40 AM, revealed she did most of the new employee orientation training but other managers trained too. She stated she sometimes started the care plan but completion of the care plan was done by other staff members and she was not sure as to who completed the care plans. Interview with MDS Coordinator #1, Registered Nurse (RN), on [DATE] at 4:21 PM, revealed she daily reviewed all new Progress Notes, Nurse Practitioner (NP) Notes, and Medical Director (MD) Notes. She stated she worked to update Care Plans in real time with that information. She stated there were two (2) MDS Coordinators, but the other MDS Coordinator only worked in LTC when she was out. Further interview revealed nursing staff did not make changes to care plans and she was not sure what happened on the weekends. Interview with the Unit Manager (UM), on [DATE] at 4:43 PM, revealed all facility staff were trained during the facility's new employee orientation on the importance of care plans and how it directed the resident's care. She stated although all nursing staff had been trained how and when care plan updates needed to be made, she did not believe all staff felt comfortable doing that. The UM stated, she along with the Staff Development Coordinator, the two (2) MDS Coordinators and the Director of Nursing updated residents' care plans as needed. Further interview revealed there were other ways for staff to find out the needs of residents which included pass down information at shift change and by doing rounds. She further stated getting to know the resident was one of the best ways to recognize when the resident had a change. Interview with the DON, on [DATE] at 3:00 PM, revealed the facility did not review care plans daily. She stated, hopefully staff would review care plans on their shift to ensure they knew how to provide care of each resident. The DON stated staff also were to look at their twenty-four (24) hour sheets and their personal sheets. She stated personal sheets only had blood pressures and room numbers on them. The DON explained she used the word hopefully, because she was not there making sure staff looked at the care plans, but it was the expectation that staff did. Continued interview revealed during new employee orientation the Staff Development Coordinator met with and trained staff on care plans. The DON further explained staff were taught how to make updates to interventions, but they were not expected to do a CCP. She stated care plans were reviewed and updated quarterly by the MDS Coordinator. Interview with the Administrator on [DATE] at 4:35 PM, revealed the purpose of the care plan was to direct the care for each resident. He stated, when written right it provided a road map for the resident's care. The MDS Coordinator would initiate the initial care plan and then each department would give input. He stated the MDS Coordinator does the key stroke. The Administrator stated care plans were developed as a team to ensure each one was fully developed. He stated he counted on the DON to hold the nurses accountable to ensure they completed accurate assessments to develop complete care plans and provide necessary services for each resident. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #10's Comprehensive Care Plan was reviewed and revised by the Regional Clinical Reimbursement Specialist with the DON, ADON, Unit Manager and resident/family input and participation. Resident #2 expired on [DATE]. 2. The facility re-assessed Resident #10 and his/her Comprehensive Care Plan was thoroughly reviewed and revised to ensure the resident maintained the highest practicable physical, mental, and psychosocial well-being. 3. The Regional Clinical Reimbursement Specialists completed an audit of all residents' Comprehensive Care Plans beginning on [DATE], validating the Comprehensive Care Plan was an accurate and current plan of care. This audit was completed on [DATE]. 4. Audits included to ensure residents' Comprehensive Care Plans were thoroughly reviewed and revised to ensure the residents maintained the highest practicable physical, mental, and psychosocial well-being. Any areas identified were revised immediately and communicated to the floor staff (licensed nurses, SRNAs, and CMT's) through daily huddles. 5. On [DATE], the Regional Clinical Reimbursement Specialist (CRS) completed education with both MDS Coordinators and the Interdisciplinary Team (IDT) on accurate and complete Comprehensive Care Plans. 6. On [DATE], the Regional Nurse Consultant and Regional Staff Development Coordinator initiated education to licensed nurses on accurate and complete Comprehensive Care Plans. This education was completed on [DATE]. 7. The DON/ADON/SDC/UM/Restorative Nurse were to review and ensure care plans were reviewed and/or revised seven (7) days per week with any changes until immediacy was lifted, then daily in the Clinical Whiteboard Meeting. 8. The DON and/or the ADON was to report any findings to the QAPI Committee daily until the immediacy was lifted, then during monthly QAPI meetings. The QAPI Committee was to determine when compliance was achieved and/or if ongoing audits were required. The State Agency validated the facility took the following actions: 1. Interview with the Unit Manager (UM), on [DATE] at 11:03 AM, revealed Resident #10 was reassessed and his/her Comprehensive Care Plan was reviewed and updated. Interview with the Regional Clinical Reimbursement Specialist, on [DATE] at 3:37 PM, revealed the facility reassessed Resident #10 and his/her care plan was updated. The Regional Clinical Reimbursement Specialist stated she reviewed all documentation and the team looked at the resident to make sure everything was up to date. Review of Resident #10's Comprehensive Care Plan revealed it had been reviewed and updated on [DATE]. Resident #2 expired on [DATE]. 2. Interview with the UM on [DATE] at 11:03 AM, revealed the facility reassessed Resident #10 and his/her Comprehensive Care Plan was revised and updated. Review of the resident's Progress Notes, revealed the Medical Director assessed the resident on [DATE] through a full examination and noted no concerns. Review of the NP Progress Note, dated [DATE], revealed she reassessed the resident through a complete examination and no concerns were noted. 3. Interview with the Regional Clinical Reimbursement Specialist, on [DATE] at 3:37 PM, revealed an audit of all residents' comprehensive care plans was completed on [DATE]. Interview revealed the facility used its census with the list of residents' names to ensure all residents were included. According to the Regional Clinical Reimbursement Specialist, she reviewed all residents' assessment documentation, and made revisions. Further interview revealed after completing the audit, she discussed her findings with staff during the Clinical Morning meetings. She stated, by [DATE], the team had audited and updated the care plans to reflect every resident's current status. Review of an audit spreadsheet revealed they contained all residents' room numbers, medical record numbers, and status of their Comprehensive Care Plan review with a date of completion. 4. Interview with Licensed Practical Nurse (LPN) #10, on [DATE] at 9:45 AM, revealed she had been informed of changes in the residents' care plans, and also read them and looked at the nursing report. Per LPN #10, the UM notified staff of any changes in residents' care plans. Continued interview revealed revisions in care plans were made when there were changes in conditions of the residents. She stated she was trained by the Staff Development Coordinator (SDC) on residents' care plan updates and revisions. LPN #10 stated residents' care plans were important, as they let staff know how to take care of residents and if there were any changes in their conditions. Interview with LPN # 6 on [DATE] at 10:16 AM, revealed nursing staff was re-educated one (1) to two (2) weeks ago on residents' care plans by the Regional Nurse Consultant and CRS. LPN #6 stated residents' care plan revisions were made if a resident had a change of status. She stated she put interventions in place any time there was a change in a resident's condition. The State Survey Agency (SSA) reviewed residents' clinical records to verify the residents' Comprehensive Care Plans were reviewed and updated, as alleged on [DATE]. No concerns were identified. 5. Interview with Minimum Data Set (MDS) Coordinator #1, on [DATE] at 11:30 AM, revealed she had been educated on care plans, fluids intake, bowel movements, and blood pressure medication, by the Regional Nurse Consultant and the Regional Clinical Reimbursement Specialist (CRS). MDS Coordinator #1 stated it was important for residents' care plans to be accurate, current, and complete. Interview with the Regional CRS, on [DATE] at 3:37 PM, revealed she educated the MDS Coordinators and Interdisciplinary Team (IDT) on ensuring accurate and complete Comprehensive Care Plans. She stated the education included the importance of accuracy in care plans, interviewing techniques and how to update MDS documents and care plans. Further interview revealed the education was mostly performed face-to-face, with some education done by telephone. The Regional CRS further revealed she reviewed the MDS Coordinators' work, and her expectations were that each care plan reflected the residents' current status and was person-centered. The SSA reviewed the facility's Educational Log on [DATE], and verified the MDS Coordinators had been educated on accurate and complete Comprehensive Care Plans as alleged. Further review revealed the Education Log was signed and dated by the two (2) MDS Coordinators. 6. Interview with Licensed Practical Nurse (LPN) #10, on [DATE] at 9:45 AM, revealed she had been educated by the Regional Nurse Consultant and Regional SDC on ensuring residents' care plans were accurate and complete. Interview, with LPN #6, on [DATE] at 10:16 AM, revealed she and other nursing staff were re-educated by the Regional Nurse Consultant and CRS one (1) to two (2) weeks ago on residents' care plans. Interview, with the Regional Staff Development Coordinator, on [DATE] at 11:48 AM, revealed she assisted the Regional Nurse Consultant and CRS in providing the education for nursing staff on ensuring residents' care plans were complete and accurate. Interview, with the Regional Nurse Consultant, on [DATE] at 5:08 PM, revealed she and the Regional Nurse Consultant had provided education for nursing staff related to ensuring residents' care plans were accurate and complete. 7. Interview with the Unit Manager (UM), on [DATE] at 11:03 AM, revealed residents' care plans were being audited daily, and staff documented any changes. Per interview, any changes made were communicated to staff on the floor. The DON, ADON, SDC, NP and Dietitian were involved in the process of reviewing residents' care plans. Interview with the Restorative Nurse on [DATE] at 12:14 PM, revealed she participated in reviewing residents' care plans. As part of the review, she had looked at residents who had contractures, and ten (10) residents had contractures. She stated as a result of the care plan review three (3) out of the ten (10) residents with contractures were referred to therapy. Interview with the DON, on [DATE] at 2:14 PM, revealed the team sat down together and went through each resident's care plan. They reviewed and discussed each section to ensure it was current and complete, and made changes as they were needed. She stated each department was present to give input. The DON stated the facility now looked at care plans as a comprehensive plan instead of independent elements of a plan. The ADON was not available for interview. 8. Interview with the DON, on [DATE] at 2:14 PM, revealed she reported the results of the daily audits at each meeting and any concern were addressed immediately. The SSA reviewed the facility's daily Ad Hoc QAPI signature sheets for [DATE]-[DATE]. Further review revealed the documentation noted topics audited included: hydration; bowel movements; Comprehensive Resident Assessment; Comprehensive Care Plans; and Administration.

Based on observation, interview, record review and facility policy review it was determined the facility failed to store food in accordance with professional standards for food service safety as evidence by opened stored foods were undated and canned food labels were damaged/undated. The findings include: Review of the policy titled Food Storage, revised [DATE], revealed all products should be dated upon receipt and when they were prepared, and use-by-dates should be used on all foods stored in refrigerators, according to the timetable on Dry, Refrigerated, and Freezer Storage Chart found in policy. Foods stored in bins should be removed from their original packaging, labeled, and dated. Observation of kitchen, on [DATE] at 10:56 AM, revealed a plastic pitcher of prepared lemonade in a reach-in refrigerator with a use by date of [DATE]; an opened box of gravy mix, Crystal Light, and coffee without an open date; Cranberry juice in a juice dispenser without an open date; and dried beans in a plastic container with a torn label that read ,[DATE]/. Observation of the West Hall nourishment refrigerator, on [DATE] at 4:03 PM, revealed three (3) packs of tortillas in their original, zip-seal packaging without resident name or date and not sealed. Licensed Practical Nurse (LPN) #2 turned packages over to look for name and date and tortillas fell out onto floor. Interview with LPN #1, on [DATE] at 3:56 PM, revealed staff placing food in unit nourishment refrigerators were to label the food with the resident's name and date and place in the refrigerator. Prepared items and leftovers would be kept for three days. Interview LPN #2, on [DATE] at 4:03 PM, revealed she was not aware of who monitored the unit nourishment refrigerators for name, opened or use-by dates, or expiration dates. Interview with West Unit Manager, on [DATE] at 9:19 AM, revealed third shift nursing staff monitored nourishment refrigerators and checked for expiration dates nightly, but did not document monitoring. She stated tortillas were not expired and were labeled with a date reflecting when they were opened. She stated residents could get sick if foods were cross contaminated, as tortilla shells were not sealed. Interview with Dietary Manager (DM), on [DATE] at 10:56 AM, revealed nursing units have nourishment refrigerators and items were labeled with resident's name and date of when placed in refrigerator. She stated dietary monitored the nourishment refrigerators twice a month and nursing staff checks for expired foods every two (2) days. She stated that labels on foods would sometimes come off and that she would write dates on cans/boxes in black, permanent marker, if she ran out of labels. Further interview with Dietary Manager, on [DATE] at 2:47 PM, revealed items were dated as they were received and boxes had both date received and dated opened on them. She stated it was a misfortune that some boxes were not labeled properly and that labeling and dating was for safety; which let staff know when to dispose of food items. She stated she checked refrigerators in the kitchen and told staff to dispose of the lemonade that was past its use by date, but they did not follow her directions. She stated not following facility guidelines could pose a risk of illness to residents. Interview with Director of Nursing (DON), on [DATE] at 4:00 PM, revealed nursing staff checked unit nourishment refrigerators daily. The facility did not keep leftovers or prepared foods more than three days and used the best by or sell by date for other food items. Nursing staff labeld food with the residents name and date opened. She stated the tortillas should have been sealed according to how the packaging was made and was not aware that they were not sealed. She stated residents could get stomach illnesses or some type of food poisoning if food was not stored properly.

Based on observation, interview, record review, and facility policy it was determined the facility failed to ensure staff documented reconciliation of controlled medications at shift change. In addition, staff failed to immediately document removal of controlled medications; and, failed to keep medication carts locked and secured when unattended. Observations revealed staff failed to document removal of controlled medications, document verification of controlled substance medication counts at shift change, and insure medication carts were locked when unattended on three (3) of four (4) medication carts. The findings include: 1. Review of the policy Controlled Substances, dated 11/07, revealed controlled medications had special storage, disposal, and records on the nurse unit in accordance with federal and state regulation. When staff removed the controlled medication from the controlled storage area, the nurse immediately completed documentation of the removal on the accountability record. In addition, the facility had a physical inventory of all controlled medications conducted at the change of shift by two (2) licensed clinicians, which staff documented on an audit record. Observation, on 10/08/19 at 3:54 PM, of one (1) of two (2) medication carts on the East Hallway, revealed a card of [MEDICATION NAME] three hundred milligrams (300mg) tablets containing eighteen (18) tablets with nineteen (19) tablets documented on the reconciliation audit form. Further observation revealed a card of [MEDICATION NAME] tablets containing twenty-six (26) tablets but twenty-seven (27) tablets documented on the reconciliation audit form. Interview with RN #3, on 10/08/19 at 3:54 PM, revealed she forgot to document removal and administration of controlled medications on an audit forms while she performing medication administration. RN #3 stated staff were responsible to sign out controlled medications when they retrieved the medications from the secured area and removed medications from the blister pack. She stated an incorrect count could effect a resident potentially impacting availability of the medication. Observation, on 10/09/19 at 9:26 AM, revealed RN #2 removed from the controlled medication box one (1) tablet of [MEDICATION NAME], one (1) tablet of [MEDICATION NAME], and one (1) capsule of [MEDICATION NAME]. Continued observation revealed RN #2 placed the medications in a cup and proceeded to administer the controlled medications but did not verify the count or document removal of the controlled medications on the audit sheets. After administration of the medication, RN #2 documented the administration of the medication with no verification of the count of remaining tablets/capsules on the medication card in the box. Interview with RN #2, on 10/09/19 at 9:40 AM, revealed licensed staff visualized the count on the card and compared that count to the count in the audit book when dispensing the medication. RN #2 stated staff completed this verification to ensure the count was correct. RN #2 stated staff completed a count at the change of shift and every time a tablet was removed but stated she did not verify the count or update the count sheet immediately upon removal of the medication. RN #2 stated as the nurse assigned to the cart she was responsible to ensure the scheduled medication counts were accurate at all times. Continued interview with RN #2, on 10/09/19 at 10:12 AM, revealed upon beginning reconciliation of the controlled medications for her assigned medication cart, none of the administered controlled medications up to this point of her shift were documented on the count sheets because she was rushed. Further interview with RN #2, on 10/09/19 at 10:59 AM, revealed she was responsible to ensure the count on the medication sheet matched the count of tablets or liquids in the locked scheduled medication drawer and controlled medications were to be documented as soon as the medication was removed from the locked drawer. RN #2 stated she failed to follow the facility policy. Observation and interview, on 10/09/19 at 12:20 PM, of the East #1 medication cart with LPN #5 revealed the [MEDICATION NAME] count was four (4) and the count sheet was five (5). LPN #5 stated the medication was given at 11:15 AM to a resident who left the facility for an appointment and she forgot to sign off the medication. Interview with LPN #5, on 10/09/19 at 12:20 PM, revealed scheduled medications were to be documented when the medications were removed from the pack. She stated if a resident refused the medication, the nurse was to waste the medication with another nurse to witness the destruction. She stated it was a long time since the facility provided education on medication administration. 2. Review of the policy, Medication Storage, dated 09/18, revealed in order to limit access of medications the medication cart was to be locked at all times. Observation, on 10/09/19 at 11:59 AM, revealed the East #2 medication cart was unlocked and unattended with no staff in view of the medication cart. Continued observation revealed LPN #5 exited a resident room, approached the cart and locked the medication cart. Interview with LPN #5, on 10/09/19 at 12:02 PM, revealed she left the cart unlocked and unattended. She stated staff were to lock medication carts at all times to prevent staff or residents access into the cart. She stated medications consumed by the wrong person could cause an adverse effect, including nausea, vomiting and death. She stated the facility provided education to secure medication carts at all times and the facility audited for locked carts. Interview with Licensed Practical Nurse #2, on 10/09/19 at 12:00 PM, revealed staff were to complete documentation for scheduled medications when removed from the locked box in the medication cart. She stated inaccurate controlled medication documentation could cause diversion issues. She stated residents could be affected if the medication was unavailable due to inaccurate records. Interview with LPN #2, on 10/10/19 at 3:00 PM, revealed staff were to document removal of controlled medications immediately upon removal from the locked drawer of the cart. She stated then documented administration of the controlled medication after the resident accepted and consumed the medication. She further stated medication carts were to be locked at all times because it was a risk to residents who may get into the medication cart and take medications not prescribed to them. 3. Record review of the West Hall Cart #1 controlled substance accountability count form, dated 07/31/19 to 10/07/19, revealed staff failed to document verification of counts between shifts for a total of twenty-three (23) shifts. Record review of the West Hall Cart #2 controlled substance accountability count form, dated 08/24/19 to 10/0/19 revealed staff failed to document verification of counts between shifts for a total of twenty-four (24) shifts. Record review of the East Hall Cart #2 controlled substance accountability count form, dated 07/31/19 to 10/07/19, revealed staff failed to document verification of counts between shifts for a total twenty-four (24) shifts. Interview with the East Unit Manger (UM), on 10/10/19 at 4:17 PM, revealed licensed staff were to ensure the controlled medication in the locked box of the medication cart corresponded with the physician order. The UM stated staff were expected to document removal of controlled medication at the time of the removal from the locked area and document administration after it was completed. The UM stated it was poor practice to delay documentation of the removal of controlled medications and stated audits have not been completed recently. The UM stated staff were expected and required to sign the control accountability form with each shift. She stated she reviewed the forms when removed from the binder but did not review line by line. She stated staff who completed documentation of the scheduled medications from the cart at the time of removal could lead to a medication error. Interview with the Staff Development, Coordinator (SDC), on 10/10/19 at 4:45 PM, revealed the facility educated staff to complete documentation of removal of controlled medications on the resident medication record when the medications were removed from the locked area of the cart. Additionally, She stated staff were to document verification of counts at shift change. She further stated all medication carts were to be locked at all times. Interview with the Director of Nursing (DON), on 10/10/19 at 11:30 AM, revealed licensed staff were to sign out the controlled medications when removed. The DON stated she expected staff to complete the controlled medication verification form at shift change and the audit form was to be filled and completed every shift. The DON stated medication carts were to be locked at all times. Interview with the Administrator, on 10/10/19 at 6:15 PM, revealed the facility was not aware of issues with controlled medications regarding accuracy of counts or documentation of counts, or storage safety issues.

Based on observation, interview, and facility policy it was determined the facility failed to ensure staff performed hand hygiene during medication administration. Multiple observations revealed no hand hygiene performed by staff before or after medication administration and between residents. The findings include: Review of the facility skill checklist, Medication Administration, undated, revealed staff were to perform hand hygiene before and after administration of resident medications. Furthermore, anti-microbial sanitizer may be used in place of soap and water with the exception of a resident with the [DIAGNOSES REDACTED]. Observation, on 11/08/19 at 9:15 AM, revealed Registered Nurse (RN) #5 retrieved resident medications from the cart, handling various medication packets, manipulated computer equipment and cart surfaces, and then proceeded to administer the medications with no hand hygiene performed. Continued observations revealed RN #5 returned to the medication cart and proceeded to retrieve medications for other residents for a total of three (3) opportunities of medication administration with no hand hygiene performed. Observation, on 10/08/19 at 03:24 PM, revealed RN #3 was observed to prepare resident medications for administration in applesauce. RN #3 did not perform hand hygiene prior to administering the medications. Observation, on 10/09/19 at 09:26 AM, revealed RN #2 retrieved medications to prepare for residents. During this process, RN #2 contacted multiple medication cards, surfaces of the cart, and surfaces of the computer equipment. RN #2 administered medications to the resident, returned to the cart, and resumed medication administration duties without performing hand hygiene. Interview with RN #2, on 10/09/19 at 10:59 AM, revealed hand hygiene was to be completed before and after medications were administered. RN #2 stated proper hand hygiene prevented transmission of germs to other residents and helped prevent spreading illness to residents. Interview with LPN #2, on 10/10/19 at 03:00 PM, revealed staff were to ensure hand hygiene was completed before and after medications were administered and gloves worn if contact with the resident was required. LPN #2 stated it was important staff followed hand hygiene practices to prevent transmission of infections to residents. Interview with the East Unit Manger (UM), on 10/10/19 at 4:17 PM, revealed she expected staff to follow infection control practices including hand hygiene during medication administration. The UM stated she had not identified issues with staff not performing hand hygiene and hand hygiene was required in an effort to prevent transmissions of infections. Interview with the Staff Development, Coordinator (SDC) on 10/10/19 at 4:45 PM, revealed staff were expected to perform hand hygiene before and after medication pass and after contact with a resident. She stated staff's hands touched many surfaces including medication cart surfaces, and computer equipment. Interview with the Director of Nursing (DON), on 10/10/19 at 11:30 AM, revealed staff were expected to perform hand hygiene before and after contact with a resident. The DON stated the SDC completed spot audits of hand hygiene and infection control technique and she relied on the SDC and UM's to report identified issues. Interview with the Administrator, on 10/10/19 at 06:15 PM, revealed he had not identified concerns with staff performing hand hygiene during medication administration.

Based on record review and interview it was determined the facility failed to ensure a discharge Minimum Data Set (MDS) was transmitted within fourteen (14) days for one (1) of eighteen (18) sampled resident's, Resident #2. The facility discharged Resident #2 to an acute care hospital on [DATE], with his/her return anticipated; however did not submit the MDS discharge data. The findings include: Review of the policy Resident Assessment, reviewed 07/31/18, revealed the facility conducted initially and periodically comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity. The Resident Assessment Instrument (RAI) User Manual version 3.0 was used for all items coded on the MDS assessments, Care Area Assessments (CAA) development, Care Planning, MDS scheduling, submissions, modifications and Medicare regulations. The Assessment Coordinator established the assessment schedule and provided this information to each discipline. The policy further revealed a return anticipated Minimum Data Set (MDS) discharge assessment was to be transmitted within fourteen (14) days of the completion date. Review of the clinical chart for Resident #2 revealed the facility admitted the resident on 05/06/19 with [DIAGNOSES REDACTED]. Review of Resident #2's discharge MDS completed by the facility on 05/30/19, revealed the resident had been discharged from the facility to an acute care hospital on [DATE], with his/her return anticipated. However, there was no evidence the facility had transmitted the assessment as of 10/10/19. Interview, on 10/10/19 at 4:52 PM, with MDS Coordinator #1, revealed Resident #2's discharge MDS had to be completed by 06/12/19. However, the MDS Coordinator stated the assessment was not done although she had pulled a missing assessment report. She stated the importance of timely assessments was to track resident census and the building of quality measures. Interview, on 10/10/19 at 5:38 PM, with MDS Coordinator #2, revealed at times the facility had fifty (50) discharges a month and this may have contributed to overlooking the assessment. However, she stated Resident #2's discharge assessment should have been submitted by 06/13/19 and therefore was not submitted timely.

Based on observation, record review, and interview it was determined the facility failed to code the annual Minimum Data Set (MDS) accurately for (1) resident of the eighteen (18) sampled residents. Resident #46 smoked cigarettes but the MDS revealed no tobacco use. The findings include: Review of the facility policy, Resident Assessment, reviewed 07/31/18, revealed the facility must conduct a comprehensive and accurate assessment of each resident's functional capacity. Record review further revealed the assessment should include direct observation and communication with the resident, family, licensed and non-licensed direct care staff members. The assessment data was collected from the resident's medical record, interviews, and other healthcare professionals with knowledge of the resident. Observation, on 10/09/19 at 10:01 AM, revealed Resident #46 outside in the smoking area. Staff placed a smoking apron on the resident, gave him/her a cigarette, and staff lit the cigarette. Interview with Resident #46, on 10/09/19 at 9:20 AM, revealed he/she smoked four (4) times a day during facility smoke breaks. Record review revealed the facility admitted Resident #46, on 09/28/13, with [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an Assessment Reference Date (ARD) of 08/26/19, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of seven (7) and determined the resident had memory impairment. Review of the annual MDS with an assessment reference date (ARD) of 04/23/19, revealed in Section J, Health Condition, the tobacco use question was coded No, which indicated Resident #46 did not use tobacco products. Review of the quarterly MDS with an ARD of 08/26/19 revealed the tobacco use question, under Section J, Health Conditions, was blank. Review of the list of West Wing Residents Who Smoke included Resident #46. Review of the progress notes of the nurse practitioner for 02/21/19, 04/04/19, 08/13/19, and 09/10/19 revealed Resident #46 was a smoker and was educated on smoking cessation. Review of the comprehensive care plan with a start date of 09/12/14 and a goal date of 11/30/19 revealed the problem for smoking was addressed with interventions listed listed. Interview with the MDS Coordinator, on 10/10/19 at 4:45 PM, revealed she did not know Resident #46 was a smoker and the nurse's notes during the look back days did not reflect the resident had smoked. The MDS Coordinator revealed she talked to the resident but did not question him/her about smoking. She revealed Resident #46's cognition was not great. She revealed she was not sure how often a smoking assessment was completed. The MDS Coordinator revealed she usually did not look at the care plan when doing the MDS assessment questions so she was not aware that a care plan had been developed for smoking for Resident #46. She further revealed she did not know there was a smokers list available. The MDS Coordinator revealed the MDS was incorrectly coded for tobacco use on Resident #46. Interview with the Director of Nursing (DON), on 10/10/19 at 3:40 PM, revealed Resident #46 had been a smoker since admission. The DON stated Resident #46 should have been coded as a smoker on the assessment for the MDS. The DON revealed the MDS Coordinator should have known Resident #46 was a smoker since he/she had smoked from admission and had a comprehensive care plan problem for smoking. Interview with the Administrator, on 10/11/19 at 8:45 AM, revealed he expected the MDS assessments to be accurate and it was the staff's responsibility to ensure the assessments were accurate. The Administrator stated the accuracy of the MDS was what drove the comprehensive care plan.

Based on observation, record review, and interview it was determined the facility failed to follow physician's orders for one (1) of the eighteen (18) sampled residents, Resident #34. Resident #34 had orders for oxygen administered at four (4) liters (L). Observation revealed the oxygen concentrator set at three (3) [MI] The findings include: Record review of the facility policy, Oxygen Administration, revised 09/06/18, revealed oxygen was to be on and set according to the physician order. Review of the clinical record revealed the facility admitted Resident #34 on 07/22/19 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/28/19, revealed no Brief Interview for Mental Status (BIMS) assessment done under Section C, Cognition for Resident #34. Review of the admission MDS revealed under Section J, Health Conditions, Resident #34 had shortness of breath. Under Section O, Special Treatment and Programs, Resident #34 used oxygen. Record review of the comprehensive care revealed Resident #34 was at risk for respiratory complications including an intervention of resident on O2 as ordered via nasal cannula. Record review of the current physician orders for Resident #34 revealed an order, dated 09/16/19, for Oxygen at four liters (4L) per nasal cannula. Observation, on 10/07/19 at 03:27 PM, revealed Resident #34 lying in bed and requested a pain medication. Observation revealed Resident #34 with oxygen at three liters (3L) per nasal cannula. Observation further revealed Registered Nurse (RN) #5 entered the room to assist the resident. Interview with RN #5, on 10/07/19 at 3:30 PM, revealed Resident #34's oxygen should be set at two liters (2L) per nasal cannula. RN #5 acknowledged the oxygen was set at three liters (3L) but should be set at two liters (2L). Interview with Resident #34, on 10/07/19 at 3:30 PM, revealed the oxygen was to be set at four liters (4L) all the time, and maybe that was why he/she was having so much trouble breathing. Observation, on 10/07/19 at 3:30 PM, revealed RN #5 checked the oxygen saturations of Resident #34 and assessed it at ninety-seven percent (97%) but it then dropped to eight-eight percent (88%). RN #5 took the oxygen saturation device off, reapplied it, and assessed the oxygen saturation at ninety-four percent (94%) on three liters (3L). Interview with Resident #34, on 10/07/19 at 3:40 PM revealed he/she could already tell a difference with breathing since the oxygen had been turned up. Interview with RN #5 revealed, after he reviewed the physician orders, the oxygen flow rate should be set at four liters (4L) per nasal cannula. RN #5 revealed when the oxygen was not set at what the physician ordered, it put Resident #34 at risk for shortness of air, altered mental status, decreased oxygen flow to the organs and in the short term the risk would be respiratory distress. Interview with RN #5 revealed he checked the oxygen saturations this morning and it was ninety-six percent (96%) on two liters (2L) of oxygen. Interview with the Director of Nursing (DON), on 10/11/19 at 8:45 AM, revealed nurses should follow the physician orders for oxygen. The DON revealed if staff did not follow orders, there was a risk of [MEDICAL CONDITION] and could cause difficulty in breathing for residents. The DON revealed Resident #34 had [MEDICAL CONDITION] and Pneumonia. The DON revealed Resident #34 previously had orders for Oxygen at two liters (2L) and LPN #4 had been out on leave when the change in oxygen setting occurred. Interview with the Administrator, on 10/11/19 at 8:45 AM, revealed he expected staff to follow physician orders. The Administrator revealed there could be a risk of adverse outcomes when physician orders were not followed. The Administrator revealed he did not do any audits on following physician orders.

Based on observation, interview, record review and review of policy it was determined the facility failed to ensure two (2) of two (2) refrigerated scheduled medication boxes were affixed to the medication refrigerators. Observations revealed the facility gray metal scheduled medication box in the East and West Unit were able to be completely removed from the refrigerators. In addition, the facility failed to ensure the pharmacy emergency scheduled medication kit was secured within an affixed box or area. Observation revealed the East Unit medication refrigerator contained a separate pharmacy medication container which contained scheduled medications and were closed with a green tug tie's and was not in a locked box or secured area. Interviews revealed the scheduled narcotic box was not audited by staff every shift. The findings include: Review of the policy titled Controlled Substances dated 11/2007, revealed scheduled medications were to have special storage, disposal, and record keeping at the nursing care center in accordance with federal and state regulation. The facility was to have a physical inventory of all controlled medications with physical inventory conducted at the change of shift by two (2) licensed clinicians and documented on an audit record. Review of the policy titled Emergency Pharmacy Service and Emergency Kits (E-Kits), dated 05/16, revealed E-kits were to be kept secure, checked for integrity, dating, and stored in accordance with federal regulations. In addition, the charge nurse was to monitor the status of the E-kits as opened or sealed at the change of shift. Review of Unline Product Search, www.uline.com, a tug tight was a plastic pull tie to ensure lids stayed closed and the printed tie provided a number for the purpose to track the item. The tie could be removed by hand or a snip device. Observations, on 10/10/2019 at 9:10 AM, revealed Licensed Practical Nurse (LPN) #6 unlocked the East Unit medication door and then unlocked the refrigerator to gain access. A gray metal box and clear plastic box with red ties were on the glass shelf. The LPN removed the gray box and clear box out of the refrigerator and both boxes were observed not to be chained or tethered to the refrigerator. The gray box required a key for entry and the plastic box required a tug to remove the ties. Continued observations revealed the gray box was empty. Observation of the E-Kits box revealed it contained eighteen (18) tablets of [MEDICATION NAME], twelve (12) tablets of [MEDICATION NAME], and one vial of [MEDICATION NAME] liquid. Interview with LPN #6, on 10/10/19 at 9:10 AM, revealed two (2) clinical staff and the unit manager were able to access the medication room and were able to access the medication refrigerator. LPN #6 stated the gray box was able to be removed out of the refrigerator and would be able to be taken out of the medication room with the box. The LPN stated an Emergency Drug Kit (E-Kits) which contained scheduled medications was in a plastic box with two (2) ties and the LPN stated the observed E-Kits box was not affixed, tied, tethered or in a separate secured area in the refrigerator, and was able to be taken out and removed from the area. The LPN stated the facility did not require two licensed staff to be present when the scheduled E-Kits box was accessed. The LPN was unsure if the boxes were required to be secured to the refrigerator. The LPN stated diversion of the narcotics were possible since the boxes were not secured. The LPN stated if scheduled medications were not available residents would be in pain. The LPN further stated the scheduled E-Kits box was not audited every shift to ensure the box remained in the refrigerator. Observation, on 10/10/19 at 9:22 AM, revealed the West Unit Manager (UM) opened the medication refrigerator for the West Unit and a gray box was chained to the wire rack which was and observed as removable from the refrigerator. Further observations revealed the gray box was empty. Interview with the West UM, on 10/10/19 at 9:22 AM, revealed the gray box was utilized to house scheduled medications. She stated the scheduled medication E-Kits box was only located in the East medication room. She stated the gray medication box was able to be removed from the refrigerator and the room. She further stated herself and two (2) licensed staff were able to access the medication room and the refrigerator. Interview with LPN #2, on 10/10/19 at 3:00 PM, revealed the scheduled medication box in the East Unit contained ties to the E-Kits box. LPN #2 stated the tabs were pulled to remove the ties to enter the box and another colored tab was replaced to the box to secure the box closed. LPN #2 stated shift count of the scheduled E-Kits kit should occur every shift but was unsure if this was completed. She stated each nurse was able to access both medication rooms and the nurse on the East unit opened the E-Kits box with keys from the carts on the unit. LPN #2 stated the facility educated and staff were to ensure the proper securement of scheduled medication were maintained and to complete audits every shift to ensure the scheduled medication count were correct. Interview with RN #3, on 10/10/19 at 3:15 PM, revealed the LPN stated there was one (1) link type chain on the back of the East Unit medication box. She stated the box was apparently chained to something in the past. However the box was not chained now and could be removed from the refrigerator and room. RN #3 further stated the scheduled E-Kits box was placed on a shelf in the refrigerator. RN #3 further stated staff were not directed to audit the scheduled E-Kits box every shift with the count of scheduled medication with shift change. RN #3 stated both boxes were small enough to be able to be placed in an oversized purse and taken out of the facility. RN #3 further stated the pharmacy came to change out the E-Kits box when it was opened. However, the pharmacy technician did not always check for the box daily. Interview with the East UM, on 10/10/19 at 03:55 PM, revealed the gray and E-Kits boxes were not secure to the refrigerator. The UM stated staff were not instructed to audit every shift for the presence of either box remained in the refrigerator. The UM stated the facility audit tools for scheduled E-Kits box medications were not developed. The UM stated both boxes were able to be removed from the refrigerator. The UM further stated she guessed the medications were able to be diverted. However, the UM stated it was not thought of as a possibility of diversion. Interview with the Staff Development Educator, on 10/10/19 at 4:45 PM, revealed the facility scheduled medication boxes were previously secured to facility refrigerators when she was on the floor as staff. She stated when the facility switched and moved things the boxes were not re-secured. She stated staff were not required to have another person in the room when the boxes were accessed. She stated staff previously kept their purses in the medication room and they were instructed to place the purse in their car or in the locker provided by the facility because of the risk. She further stated the facility was to ensure the refrigerated scheduled medication boxes were secured to or locked in a separate area and the boxes were able to walk then the boxes were not considered secured. Interview with the Director of Nursing (DON), on 10/10/19 at 5:35 PM, revealed she felt the scheduled medication boxes in the refrigerators were adequately locked. She stated the scheduled medication box to the East and West refrigerators were not tied or secured to the unit. She stated staff's audits of the E-Kits box or the facility metal box every shift were not completed and an audit tool was not developed. She stated the pharmacy technician asked staff to check to see if the E-Kits box was previously accessed and if it was the technician would take the box out and exchange it. She further stated the scheduled E-Kits box was not placed in a locked or secured drawer in the refrigerator. She further stated as DON she was lucky diversion was not an issue she incurred at the facility. Interview with the Administrator, on 10/10/19 at 6:15 PM, revealed the knowledge of how scheduled medication boxes were to be housed in a refrigerator was obtained after the boxes were identified as not secured and through the survey interview process, He stated he was unaware of this requirement and was an administrator for twenty (20) years. He stated he saw his responsibility to the residents and staff was to have a great quality of life for residents and caliber staff to provide the care needs to the residents.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to prevent the possible spread of infection for four (4) of eighteen (18) sampled residents, Resident #12, #21, #24, and #53. Observations revealed staff failed to performed proper hand hygiene during wound care for Resident #12, #24, and #53, and failed to ensure Resident #21's urine drainage bag was not in contact with the floor. The findings include: The facility did not provide a policy on infection control. Review of the facility's policy, Hand Washing, dated 06/01/15, revealed proper hand washing included the use of a clean dry paper towel to turn off the water faucet. Review of the facility's Hand Washing Competency, dated 06/01/15, revealed the use of a dry paper towel was to be used to turn off the faucet handle. Review of the facility's Non-Sterile Dressing Change Competency, dated 06/01/15, revealed staff was to wash hands before and after removing a soiled dressing, gloves were to be worn while assessing and cleaning wounds then discarded, and hands were to be washed with new gloves applied for treatments to the wound. A date and time of the dressing change was to be placed on top of the new dressing. 1. Observation of Resident #12's wound care, on 07/26/18 at 11:18 AM, revealed Licensed Practical Nurse (LPN) #3 removed the resident's old dressing and without removing his gloves, washing his hands, and donning new gloves, completed the treatment and applied a new dressing. Interview with LPN #3, on 07/26/18 at 3:38 PM, revealed he forgot to change his gloves after removing Resident #12's old dressing. LPN #3 stated he should have removed the soiled gloves and washed his hands before he administered the treatment, in order to prevent the spread of infection. LPN #3 stated washing hands was the most important thing staff could do to help prevent the spread of germs and infections, which could make the residents sick. Interview with Assistance Director of Nursing (ADON), on 07/26/18 at 4:00 PM, revealed LPN #3 should have discarded his gloves and washed his hands before starting the treatment to prevent infection. She stated staff did not want to transfer germs to clean areas that could cause infection or illness for the residents. 2. Observation, on 07/24/18 at 9:30 AM, revealed Resident #21 had a urine drainage bag that was under the resident's chair and partially on the floor. On 07/25/18 at 12:14 PM, Resident #21's urine drainage bag was in contact with the floor while he/she was in the dining room for a meal. Observation, on 07/26/18 at 8:08 AM, revealed Resident #21 was in the dining hall and the urine drainage bag was touching the floor. As staff pushed the resident back to his/her room, the drainage bag and urinary tubing dragged on the floor from the dining room to the resident's room. 3. Review of Resident #24's Physician Orders, dated 05/15/18, revealed a wound treatment to cleanse the left foot with normal saline, apply a Puracol AG wafer, and cover with Opti-foam dressing. Observation of Resident #24's wound care, on 07/25/18 at 10:45 AM, revealed LPN #1 washed her hands and turned off the faucet handle with the wet paper towel she used to dry her hands. LPN #1 donned gloves and repositioned Resident #24's wheelchair and touched the brakes with her gloved hands, removed the soiled dressing from the left foot, did not remove her gloves and wash hands before she proceeded to irrigate and wash the foot wound, and then rested the foot on the floor without a protective barrier. LPN #1, with the same gloved hands, cut the Puracol wafer to size and placed it on the wound. LPN #1 completed the wound dressing and she did not put the date and time on the dressing. 4. Review of Resident #53's Physician Orders, dated 07/24/18, revealed a wound treatment to clean the left heel with normal saline, apply Santyl, followed by a moist gauze soaked with sodium hypochlorite solution, and then covered with a gauze dressing. Observation of Resident #53's wound care, on 07/25/18 at 2:40 PM, revealed LPN #1 turned off the faucet with the wet paper towel she used to dry her hands, donned gloves, used the television remote to turn down the volume, and then opened and handled the sterile dressings. With the same gloved hands, LPN #1 moved the bedding, removed the soiled dressing, obtained paper towels, picked up the resident's leg, and placed the paper towels under the left heel wound. LPN #1 proceeded to apply the wound cleanser and handled the nozzle of the bottle using the same gloved hands. The LPN removed the gloves, completed hand washing and used the paper towel she dried her hands with to turn off the faucet, donned new gloves, and picked up the tube of medicated cream, manipulated the outside of the tube and the cap, placed the cream onto her gloved hand, and applied the medicated cream to Resident #53's left heel. LPN #1, using the same gloved hands, placed the wet medicated dressing onto the wound and secured it with a dry dressing. Interview with LPN #1, on 07/25/18 at 4:08 PM, revealed proper hand washing included turning the water on, soap and lather hands, get a paper towel and turn the water off, and then dry the hands. She stated staff should wash hands after removing the old dressing, after cleaning a wound, and after the dressing change was completed. She further stated handling a medicated tube with clean gloves, placing the cream onto the same gloves, and applying the cream to the wound was a cross contamination issue. She stated contaminated gloves caused potential infections to wounds, could prevent wound healing, and the resident could become ill. She stated the facility had a recent in-service on proper hand hygiene. Interview with Certified Nursing Assistant (CNA) #1, on 07/26/18 2:58 PM, revealed catheter care included keeping the urinary bag off the floor to prevent infection. She stated the facility provided education on the care of urine drainage bags, and checked off all staff on the physical procedure of the care. She stated proper hand washing included turning off the faucet with a clean dry towel and it was an infection control issue if the faucet was turned off with the wet towel used to dry the hands. Interview with CNA #3, on 07/26/18 at 3:30 PM, revealed proper hand washing included after drying hands, staff used a clean dry paper towel to turn off the faucet. She stated it was important to perform proper hand washing because it protected staff and residents and prevented infections being passed throughout the facility. She stated urinary drainage bags were to be off the floor at all times, even if it had a cover. She stated all staff was responsible to prevent infections, and the facility provided in-services and required a physical observation and check off session for hand hygiene. Interview with CNA #2, on 07/26/18 at 3:10 PM, revealed after washing hands, the faucet handles were to be turned off with a clean dry paper towel, and gloves were to be removed and hands washed when gloves became contaminated, to prevent the spread of infection to the residents. She stated hand washing was the most important thing to do for the safety of staff and residents. She further stated urine drainage bags were to be off the floor at all times to prevent the residents from getting an infection from all the germs in a facility. She further stated the facility conducted frequent in-services on hand washing and infection control. Interview with LPN #3, on 07/26/18 at 2:40 PM, revealed staff was to use a clean dry paper towel to turn off the faucet after washing their hands. He stated urine drainage bags were to be off the floor at all times including when attached to wheelchairs. He stated staff was to change gloves and wash hands between steps of wound care, and after handling equipment and soiled dressings, to prevent cross contamination. LPN #3 stated proper hand washing and prevention of cross contamination were vital to prevent wound infections. He stated wound infection, pain, poor healing, and urinary tract infections were possible outcomes of poor infection control. He further stated he received training during orientation on infection control, hand washing, and proper urine tubing and bag care and positioning. Interview with the West Unit Manager (UM), on 07/26/18 at 3:05 PM, revealed staff was to turn off the faucets with a new paper towel after drying their hands. She stated staff was to wash their hands before, during, and after wound care and should have the wound supplies open and ready for use. She further stated gloves were to be changed often and after contacting a contaminated surface. She stated she monitored staff hand hygiene and aseptic technique during wound care by making rounds on the floor and observing staff. The UM stated staff was educated annually, with random in-services, and immediately if she observed improper technique when she made rounds. She stated improper hand hygiene and wound care could result in residents developing infections and illnesses. She stated the facility was not aware of any hand hygiene or wound cross contamination issues. She revealed all urinary drainage devices, with or without a dignity bag cover, were to be off the floor for infection prevention. Interview with the Staff Educator, on 07/26/18 at 4:00 PM, revealed during orientation, staff was observed for hand washing, urine drainage bag care with proper positioning, and infection control. She stated staff was observed in the classroom setting on wound care to ensure they completed the task in the correct manner and were observed on the floor by other staff during orientation to ensure infection control was followed. She further stated staff was required to complete annual in-services and received monthly training pertaining to infection control topics. The Educator stated the facility monitored staff compliance with infection control by monitoring education completed, and when improper technique was observed; staff received one on one retraining. She stated supervisors and senior staff toured the facility daily, and they had not observed issues with infection control. She stated urine drainage bags were to be off the floor at all times. According to the Educator, proper hand washing included turning off the faucet with a clean dry paper towel, and washing hands after a glove change, and when glove contamination occurred during wound care. She stated the facility had completed an in-service on proper hand washing within the last month. Interview with the Director of Nursing (DON), on 07/26/18 at 4:30 PM, revealed hand washing helped prevent the spread of infections and staff was required to complete an annual training in (MONTH) (YEAR), which included proper infection control through hand washing. She stated she monitored staff compliance by observing staff daily during rounds and during wound care sessions. Per the DON, she also made unannounced tours of the facility at night to monitor staff compliance with infection control. She stated urine drainage bags were to be off the floor, and hands were to be washed if the gloves became contaminated, to prevent infection. She stated the infection control committee had not identified trends with wound infections. Interview with the Chief Executive Officer, on 07/26/18 at 4:46 PM, revealed he completed daily facility tours, as did the rest of the administration staff under the Ambassador Program to ensure staff provided proper care and services. He stated he oversaw the facility operations, and met with managers daily and had not identified issues with infections or staff hand washing performance.